Muscle IQ Blog
Chris Knudsen, DPT
At Muscle IQ Physical Therapy in Provo, Utah, WE LOVE TREATING LOW BACK PAIN. And, we work hard to achieve a successful recovery for all our patients. The most common problem we treat is low back pain. More often than not, our patients come to us after suffering for years with low back pain. We have developed what we feel is the best physical therapy system for treating chronic back pain. This blog will discuss what I believe are three very important factors that are necessary in a rehab program in order to ensure the highest rate of successful outcomes for our chronic back pain patients.
The National Institutes of Health (NIH) define chronic back pain as “... pain that continues for 12 weeks or longer…” Their website also states, “In some cases, treatment successfully relieves chronic low back pain, but in other cases pain continues despite medical and surgical treatment.”
Prevent or Reverse Fibrogenesis
It is not readily apparent what factors differentiate those who recover from chronic back pain and those who do not. That is why success rates for recovery from chronic low back pain varies so much. Is there something going on in the low back that increases the likelihood of back pain becoming chronic? A recent study looked at the differences in the deep muscles of the low back between acute back pain surgery patients and chronic back pain surgery patients. What did they find? The biggest difference between the two patient groups was the growth of fibrous tissue, or fibrosis, in the deep muscles of the low back. What was their conclusion?
“...increased efforts should be made to prevent or reverse fibrogenesis to improve patient function in this population.”
Restoring Normal Muscle Response
Every patient with chronic low back pain will also present to our clinic with back muscles that do not work right. There are muscles we find in the low back that do not respond or contract like they are supposed to during certain testing. Normal muscles will respond quickly and solidly to this testing, however, the back muscles in a patient with chronic back pain will respond slowly, weakly, or will not turn on at all. When a muscle does not respond the way it is supposed to this is called muscle inhibition.
What causes muscle inhibition?
The spinal cord is in constant communication with every muscle in the body. Every muscle maintains a certain level of tone (muscle tone) even when at rest because of this communication from the spinal cord telling the muscle what to do. When an outside force is applied to a body part the muscles will want to contract to respond to that force. This is a reflex. It is what happens when the body is healthy.
When people have chronic back pain the spinal cord knows that the back is not healthy and it does not allow the muscles to contract fully. The spinal cord tells the muscles “Do Not Contract” in response to the outside force. As long as the spinal cord thinks there is a problem with the back it will not let the muscles contract fully. At Muscle IQ we perform testing on our patients that reveals which muscles are being told “Do Not Contract”. We do testing to see where the problem is originating from. In order for these muscles to contract fully again we must treat the problem area until the spinal cord is no longer worried about that area. Once the correct area has been satisfactorily treated the spinal cord will allow the muscle to contract more fully again, restoring the normal muscle response (in medical language: restoring normal spinal cord excitability and reducing muscle inhibition).
To treat chronic low back pain effectively we must restore normal muscle response. To do this, we must:
Identify the weak muscles (muscle inhibition) through muscle testing
Identify the area causing the weakness
Treat the problem area
Re-test, looking for restoration of normal muscle response
Preventing and Reversing Fibrosis
So, one thing that is different about low back pain that has just come on recently (Acute) and low back pain that has lingered for a long time (Chronic) is the thickening of the tissues (fibrosis) in and around the low back muscles; hardening of the fascia in and around the muscles. I see this and feel this all the time in my low back pain patients. It sometimes presents as a hardened area, or trigger point. Sometimes it presents as a long band of hardened tissue that is shown by the patient as they are indicating where they feel their pain. It can also feel like a general tightening of the entire surface in an area in the back, or a hardened layer. At Muscle IQ our treatment is guided by the Fascial Distortion Model, which is a perfect fit for the treatment of this aspect of chronic back pain. (See our website for a full description www.MuscleIQ.com )
A successful outcome from chronic low back pain cannot happen without identifying and treating the fibrotic changes (fascial distortions) in the low back that occur with chronic back pain. In my next blog I will discuss the second aspect that is necessary in treating chronic back pain; restoring normal muscle response (restoring normal spinal cord excitability and reducing muscle inhibition).
Reconditioning the Back Muscles
Everyone who has chronic low back pain will have de-conditioned muscles. Muscle de-conditioning occurs when muscles are not used as much as they should be or as often as they had been previously. The most common example in cases with chronic low back pain is when normal activities are avoided because of pain. Prolonged decreased activity leads to de-conditioned muscles. Pain also seems to play a role in de-conditioning. What makes de-conditioned muscles different from healthy muscles? My goal is to write things in a way that can be easily understood, even when the subject I am writing about is complicated. I like reading studies that are written in “Research Speak” and translate them into normal English.
In a recent study, scientists state:
“Muscular disuse is defined as the response to decreased usage, leading to a reductive remodeling of the tissue(1), accompanied with a shift from slow to fast myosin isoforms muscle phenotype(2), markedly decreased force output(3) and fatigue resistance(4), lower neural activation(5), reduced metabolic supply due to capillary rarefaction(6), and a diminished local oxidative capacity.(7)”
So what does this mean in normal English?
De-conditioned muscles have the following problems:
The normal tissue repair speed is slower
The actual muscle fibers switch from one type to another; from “slow twitch” to “fast twitch”. Slow twitch muscle fibers are necessary for posture and protection. De-conditioned muscles are less protective against new injury.
The muscle is less powerful.
The muscle fatigues faster.
Decreased nerve communication between the muscle and the nervous system, making the muscle not contract as fully.
Decreased blood flow inside the muscle. Blood brings the nutrients to the muscle tissues that are needed for continued work and repair processes.
The de-conditioned muscle cannot process oxygen as efficiently.
In a patient with chronic low back pain it is vitally important to understand that the back muscles are not normal. They will not respond the same way to normal exercise routines that someone would do at a regular gym or following an exercise video at home. You need a program specifically developed for the current condition of your back muscles. The back needs a thorough test to see the current force capabilities of each back muscle.
Back Muscle Strength Testing
At Muscle IQ we have state-of-the-art medical exercise machines that you will not find anywhere else in Utah County. Each of our chronic back pain patients receives a thorough strength test of their back muscles using the David Spine Concept machines. (Get more details at (http://www.muscleiq.com/DavidMachines.html)
This testing allows us to fine tune a specific exercise routine for chronic back pain patients that provides the proper weights, repetitions, and movements in a safe and controlled position that is exactly what is needed for Reconditioning the Back Muscles. The weights need to be light. The exercise needs to be high repetition. The movement needs to be pain-free. These are the best conditions for achieving the change that is needed. This is what is needed to help modify the deconditioned muscle into healthy muscle. This change takes time. The muscle needs to be worked for several weeks in this manner in order to eliminate the 7 factors above that describe a chronic back pain muscle.
This is very important. This is why many (if not most) chronic back pain patients never fully recover. The pain returns. The problem comes back. It takes skilled care, in a professional environment, with the right treatments and the right exercises to have any chance of solving the chronic back pain problem.
At Muscle IQ we provide a unique approach to solving the chronic back pain problem:
Treat the Fibrotic Changes (Fascial Distortions) in the low back.
Restore Normal Muscle Response
Recondition the Back Muscles
If you want to get rid of your chronic low back pain give us a call at 801-310-0851 and check us out at MuscleIQ.com for more information.
Key Words: Low Back Pain, Chronic Pain, Fascial Distortion Model, David Spine Concept