As DC's, treating low back pain is our staple. Obviously, we treat much more than low back pain, but many people come to us for this complaint. A recent JAMA study found that low back and neck pain had the highest amount of health care spending, with an estimated $134.5 billion. The second leading cost was other musculoskeletal disorders, followed by diabetes.(1) Interestingly enough, another JAMA study broke down the expenditures even further and found that even though only 1.2% of patients received surgery, they accounted for 29.3% of total 12-month costs. Furthermore, this study also found early imaging led to greater expenditures as well. (2)
LBP has many potential pain generators, causes, and history, but ultimately most LBP is the end result of dysfunction above and below the lumbar spine. This paper focuses on how the hips play a crucial role in helping patients with low back pain.
The lumbar spine has many potential pain generators, including the muscles, the facets, the ligaments, and the disc and nerve roots. Your initial assessment should be aimed at determining the pain generator and whether it can be alleviated. For example, if extension movements increase the person's LBP, then stressing the facets should be part of the exam to make a logical conclusion and treatment plan around decreasing pressure on the facets, which would be loaded in extension movements. In this example, your treatment would want to include distractive manipulations to open the facets and not extension based manipulation. Home care could consist of spine safe flexion based movements. However, if repetitive extension based end-range loading decreases peripheral symptoms and flexion movements or flexion based provocation movements increased peripheral symptoms, you would avoid symptom inducing flexion movements and add extension based active care into your plan.
However, many lumbar spine issues are the result of poor function above and below that area, and the hips are a big player in lumbar spine dysfunction. The assessments mentioned above are critical and should not be downplayed, but it should also be pointed out that this is mostly initial treatment while function is restored above and below the problem area (based on the assessment), which is the focus of treatment. The efficiency of the musculoskeletal system is shared motion throughout our joint system while allowing for maximal movement with the least amount of energy expended. In a nutshell, this means getting motion from our transitional areas (thoracolumbar spine, hips, foot/ankle, cervicothoracic junction) while stabilizing those core areas or areas in between (lumbar spine, mid-cervical spine, knee, shoulder).
An essential part of treating low back pain lies in our assessment of the hip. Here are 5 tests that may help you more effectively treat low back pain.
Along with these tests, you should also palpate the iliofemoral joints and thoracolumbar area for restrictions. Lumbar spine issues are almost always due to a lack of shared motion in the thoracolumbar spine and dysfunction (hyper or hypomobility) in the hips. The lack of shared motion and the compensatory activation of compressive muscles (erector spinae, posterior fibers of the quadratus lumborum, psoas, etc.) leads to excessive and repeated forces being fed into the lumbar spine. This leads to breakdown of the discs and compressive loading of the facets.
Based on these tests, you will be better able to formulate a treatment plan that incorporates more manipulation and soft tissue release (decreased internal rotation, modified Thomas test) or more stabilization/functional rehabilitation.
Corey Campbell, DC
MPI Vice President
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