Low Back Pain and Disc Herniation

The discs located between vertebrae are vulnerable to injury, and can cause debilitating pain when injured.  Disc herniation most commonly affects the lumbar spine, but it can also occur in the cervical spine, and rarely, in the thoracic spine.

What is disc herniation?

Disc herniation is a term that refers to displacement of the nucleus pulposus of the intervertebral disc, due to injury or weakening of the external portion of the disc (annulus fibrosis).  The term “slipped disc” often refers to this type of injury, as does bulging disc.

There are four stages of disc herniation, with various degrees of displacement of the nucleus pulposus. The final stage occurs when the annulus fibrosis is completely ruptured and there is a complete loss of integrity of the external structure.

Pain occurs due to increased pressure on the nerves exiting the spinal cord. Symptoms such as pain, numbness and tingling will occur in the area that is supplied by the affected nerves.

How does disc herniation occur

Disc herniation most often occurs due to injury, sometimes from a seemingly innocent action such as bending over or twisting to pick something up. These actions of sudden flexion or rotation often cause an increase in pressure which forces the nucleus pulposus in a posterior (toward the back) direction.

Signs & Symptoms of Disc Herniation

If you’ve ever had an issue with a disc, it is an unforgettable experience.

1. Sudden, excruciating pain – into the legs and buttocks if the herniation occurs in the lumbar spine; into the arms and hands if the herniation occurs in the cervical spine.
2. Muscle spasm will occur in the injured area – this is the body’s protective mechanism to prevent further injury by immobilizing the area.
3. certain actions will increase pain and symptoms, such as bending forward from the hips, side bending, or twisting. As the action causes the pain, a therapist can tell where the bulge is happening by the pain distribution.

How is disc herniation treated?

Disc herniation is a condition that must be managed in the initial stages, with a focus on removing pressure from the affected nerves and pain control.  As the condition progresses, the focus turns to strengthening the supporting structures – if the herniation has occurred in the lumbar spine, core muscle strengthening will be incorporated into a rehabilitation program.

Massage therapy itself is not a standalone therapy for disc herniation – it can help with pain control and removing some of the excess muscle spasm. It must be noted that removing all of the hypertonicity (excess muscle tone) in the muscles surrounding the injured area is not wise – the excess tone in this case is used to stabilize the area, and if it is completely removed, the area can become very unstable and make the injury worse.

If the injury to the intervertebral disc is severe, the condition can become chronic and progress to degenerative disc disease.

For more information, please see The Anatomy of Low Back Pain.

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www.whymassagetherapy.com
All Rights Reserved.

The Anatomy of Low Back Pain

Understanding the anatomy of the lumbar spine is key to understanding and managing low back pain.

The lumbar spine, commonly called the “low back”, consists of 5 vertebrae, and is located between the thoracic spine (which articulate with ribs) and the sacrum. The vertebrae themselves are given numbers by which they are identified, for example – Lumbar Vertebra 1 = L1, Lumbar Vertebra 2 = L2 and so on.

The normal lordotic curve of the low back is known as a secondary curve, and starts to develop in infancy due to weight bearing caused by learning to sit up and walk.  The low back is especially vulnerable to injury due to its weight bearing task and mobility.

Between each vertebrae throughout the whole spine (except for C1 and C2) is a intervertebral or fibrous disc. The purpose of the disc is to provide cushioning and shock absorption from weight bearing and movement. The intervertebral disc is comprised of the annulous fibrosis and the gel-like centre called the nucleus pulposus – these structures are work together to provide the shock absorption, and are both implicated in disc dysfunction and neurological symptoms.

Facet joints are the articulating surfaces of bone between vertebrae. These synovial joints are known as “plane” joints because their flat surfaces glide over each other. These joints may become inflamed due to injury to the joint or joint capsule itself, or due to compression of the intervertebral discs, forcing them to interact in a “close-packed” position. This close packed position means that the joint surfaces are forced closer together than normal, and will irritate the bone and cartilage during movement as they contact each other and create friction.

During an acute injury, the inflamed tissue in the joints may irritate the nerve roots as they exit the spinal cord via the intervertebral foramina. Eventually, if facet irritation is untreated, bony spurs may develop due to chronic inflammation and cause spinal stenosis – a decrease in the size of the “vertebral foramen” or spinal canal.

In the case of a “bulging” or herniated disc, pressure is exerted on the nerve root as it leaves the spinal cord via the intervertebral foramina. This pinching or pressure on the nerve root will cause sharp, shooting pain, especially when the patient leans forward (flexes) from the hip.  Symptoms will present in the areas that the compromised nerves supply.

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www.whymassagetherapy.com
All Rights Reserved.

What are the Causes of Low Back Pain

Low back pain is one of the most common conditions treated by massage therapists. I have been asked by countless clients “what are the causes of low back pain?”, and I am afraid to say that there is no simple answer. The causes of low back pain are many, and it is important for clients to understand this, as appropriate treatment approaches differ as much as the causes themselves.

So common is low back pain that I decided to do a little research and try to get some statistics on it.

Here is what I found:

Back pain statistics from the Workers Compensation Board of British Columbia

From 2000 to 2004 WorkSafeBC (Workers’ Compensation Board) received over 107,000 claims for back strains

back strains account for just over 25% of all WorkSafeBC (Workers’ Compensation Board) claims.

Roughly 30% to 40% of all workplace absences in Canada are due to back pain

injuries may be caused by a single instance of overexertion or develop as a result of repeated motion over time.

Over two-thirds of back injuries are a result of overexertion

60% to 90% of the population will experience low back pain in their lifetime

More than 90% of low back pain cases have no specific cause (such as infection, osteoporosis, arthritis, etc.). In these cases the pain will usually subside without treatment in four to six weeks.

In the health care industry, injuries due to patient handling (lifting, transferring, or repositioning) account for about 35% of all accepted time loss claims and for about 40% of claim costs.

So, that’s all fine and well, but while “back strain” appears to be the most common cause of low back pain, and quite a generic term, there are other causes of low back pain. It is very important to identify the cause and contributing factors to low back pain for successful treatment, otherwise clients may just end up wasting time and money.

Falling into each of these 4 broad categories, which I am going to name as causes for low back pain, are several different conditions which I have seen in my practice.

Low back pain cause – Muscle fatigue or strain

Also referred to as a “pulled muscle”, this happens when muscles are overused or is weak. Muscles can also be torn from an injury, and of course, the more serious the damage, the longer it will take to heal …

This is also the primary participant in “soft tissue injuries” – the effects of which insurance companies have lead people to believe are minimal. The reality is that soft tissue injury, and the chronic inflammation which may accompany the more severe injuries, often take longer to heal than the ballpark figure in the insurance tables. However, I digress …

Pain can also be caused by an imbalance of muscle development, or a lack of “extensibility” or “stretch” of the muscles. This is very easy to see, for example, in athletes who may overuse and overdevelop one muscle group. This muscle imbalance is stressful for the body and may cause pain and spasm in the opposing muscle group as the body tries to maintain homeostasis. This lack of balance can lead to “mechanical dysfunction” of the joints of the back (see below). Muscle imbalance, can, however, be treated at home if you know what to do.

Low back pain cause – Joint and bone dysfunction

This type of back pain is often referred to as “mechanical back pain” or “mechanical joint dysfunction” when referring specifically to the joints. What this means is that a joint is not able to move as it is meant to, either from injury to the bone or joint, or hypertonicity of the surrounding muscles (hyper meaning ‘too much’, tone means the amount of tension in the muscle). Unfortunately, this can lead to several other issues and can be a self-perpetuating cycle if left untreated, often causing seemingly unrelated problems.

Of course, bones and joints can also be affected by fractures, breaks, arthritis and a multitude of other conditions which is well beyond the scope of massage therapy to diagnose and in some cases, treat. Massage therapy can, however, be used to alleviate symptoms and assist in recovery.

Low back pain cause – neurological

Low back pain from a neurological source can be a result of a variety of triggers, all of which are related to either the intervertebral disc, spinal cord, or the “nerve roots” as they exit the spinal cord. This type of pain can be excruciating and very debilitating, as anyone with a “slipped disc” will tell you. (this is a bit of a misnomer, and will be addressed in upcoming articles). This type of low back pain usually presents as symptoms in the area which the affected nerve root supplies, so the location of the symptoms is really dependent on the nerve root “level” where the injury or restriction happened. (and often the level of the injury is determined by the presentation of symptoms.) Pain which occurs in one area but originates from dysfunction in another area is called “referred” or “referral” pain.

Low Back Pain – Neurological from Bulging, or Herniated, Disc

Low back pain cause – visceral referral

In some cases pain can be a result of a dysfunction or infection of an internal organ. This happens because the “nociceptors” (pain receptors) of an organ are irritated and the pain is either felt in the skin or tissue which is superficial to (or just above) the organ, or in a classic “referral pattern”. Pain caused by visceral dysfunction can be quite severe.  A classic example is low back pain in the lumbar area which may wrap around a persons front, or extend down the sides of the thighs and into the groin.  This is a referral pattern of the kidneys, and should never be ignored.

Remember, most low back pain is a result of muscle weakness or imbalance. However, if you are not aware of any activity or cause of the pain, the pain is severe, or if the pain has been present for any length of time, I would urge you to see a physician immediately to rule out anything more serious than a muscular cause for the pain. You may also want to check out more information I have found on WebMD.

© Copyright 2009
www.whymassagetherapy.com
All Rights Reserved.

Massage Therapy and Anatomy – C1, C2 and Arthrology

Question of May 8, 2009 – The C1 and C2 vertebrae are considered “atypical”. Why is this, and explain how the 2 vertebrae relate to each other.

C1 and C2 are considered “atypical” cervical vertebrae because their form and function differ from the other 5 cervical vertebrae.

C1, also known as the ‘atlas’, is a circular ring of bone, which consists of anterior and posterior arches and 2 lateral masses. On the superior surface of the lateral masses are the superior articular facets, on which sit the occipital condyles. This allows for a “nodding Yes” motion of the head. On the posterior surface of the anterior arch is the facet for the odontoid process of C2. (see below).

There are no intervertebral discs between C1 and C2.

C2, also known as the ‘axis’, is somewhat similar to other cervical vertebrae, except for the presence of the “dens” or odontoid process – a bony protrusion which projects upward and articulates with the anterior arch of C1. (it is held in place here by the transverse ligament which attaches on both lateral masses of C1). The axis allows for rotation of the head, as in shaking your head “no”

How is this relevant in Massage Therapy? – This is a very vulnerable part of the body, so understanding the anatomical structures in the area is necessary in the case where a therapist may have clients with a WAD injury (whiplash associated disorder). Clients who may have had a bad slip, fall or accident (car or otherwise) in which acceleration/deceleration occured may have the potential for instability in this area. It is important, ergo, for the client’s physician to give a green light for massage therapy treatment, and then for the therapist to proceed carefully.

Question for today (easier today)

What does the term arthrology mean?

Massage Therapy and Anatomy – Curves of the Spine

Response to question of April 19, 2009

Q: How are the movable vertebrae connected? In addition to movement, what other significant role do they play?

A: Intervertebral discs connect movable vertebrae, and they are also responsible for shock absorption.

Today’s Question:

Q: What are the 4 spinal curves present in the adult spine? Of these, which are considered “primary” curvatures, and why are they known as this?