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The Mystery of Low-Back Pain: Part III
Treatment Choices

By Ben E. Benjamin

Originally published in Massage Bodywork magazine, April/May 2006. Copyright 2006. Associated Bodywork and Massage Professionals. All rights reserved.

In the previous two articles (Part 1 and Part 2), we examined the anatomy of the low back and the various types of injuries that can occur in this area, with a particular focus on low-back ligament tears. We discussed how and why these injuries occur, how they affect the body, and how they can be accurately assessed through orthopedic testing and palpation. In this article, we'll explore a variety of options for treating low-back ligament tears, ranging from self-care and dietary changes to hands-on manipulation and injections. Fortunately, there are effective treatments available for resolving these troublesome problems.


Self-Treatment
Rest Time, the healer of many wounds, may temporarily ease the pain caused by low-back ligament injuries. Unfortunately, however, the pain frequently returns as a result of reinjury, because healing didn't occur properly the first time. Typically the injured person stops engaging in activities that cause pain, which is a good idea in the short run, but for a complete resolution of this problem most people need some professional help.

Gentle exercise. Sometimes all that is needed is an exercise program to maintain the strength and normal range of motion of the back. Forward bending, lateral stretches, and low-back exercises on all fours are often effective in mild cases of low-back pain (see Low-Back Exercises, page 108). The activity must be consistent, however, since sporadic, irregular exercise can lead to weakened structures that are vulnerable to multiple mini-injuries. In addition, any back exercise that causes pain (either at the time or afterward) should be avoided.


Medical Treatment
1. Manipulation
Manipulation often helps heal ligament strains by correcting bone misalignments that place undue stress on the ligaments. It may also tear improperly formed scar tissue, allowing the injured structure to heal more strongly with proper alignment. If manipulation does not provide some relief for a person within 3-10 sessions, it is probably not the right treatment for that individual.

2. Friction Therapy and Deep Massage
Deep massage applied to the low-back region often helps to reduce muscle tension, increase circulation, and speed the healing process. Massage therapy is most helpful when paired with transverse friction, which breaks apart pain-producing scar tissue. However, to perform friction, you must be able to contact the injured structure. The interspinous (and, in very muscular people, intertransverse) ligaments are too deep to be effectively reached by a practitioner's fingers. Therefore, if the client is injured, friction and massage therapy will be only marginally helpful, and another type of treatment will be necessary.

If a client experiences pain or limitation when bending backward (as in the extension test described in the second article), be sure to place a pillow under the person's abdomen when working on the low back, and don't use too much force. When a client lies prone on the treatment table, the low back is naturally in slight extension. Applying pressure on this area increases the degree of extension and will cause further strain to injured structures that are irritated by extension. This is why some clients feel more low-back pain after a treatment than they did before.

When performing friction therapy it's important for the practitioner to be patient and work gently, using the client as the guide. The first session is always an experiment to see how much pressure the client can handle, so the practitioner can slow the treatment down or speed it up as necessary. The client should report any pain or significant discomfort. Anything more than a slightly annoying sensation indicates the practitioner needs to lighten up. Also, the client should keep track of how the injured area feels during the week after treatment. It is normal for soreness to linger for up to 48 hours, but if it lasts any longer than that, the practitioner is working with too much force. Sometimes the tissue is so tender that the therapist needs to start with as little as a half pound of pressure.

Frictioning the supraspinous ligament. To locate the supraspinous ligaments between L1 and S1, the therapist should place the tip of their index finger on any of the spinous processes in the low back. (On the average individual, the distance between L1 and S1 is about 5 inches.) Now gently slide the finger to the next spinous process. Between these two prominences of bone lies the supraspinous ligament. The practitioner will work where the ligament is tender, either in between the spinous processes or where the ligament attaches, right on the bone at the tip of the process. The practitioner will likely use the thumb, index finger, or middle finger.

First, palpation should be used to target the precise location of the tender, injured areas. The therapist should palpate each supraspinous ligament with one or two cross-fiber friction strokes, as described in the previous article. The areas of tenderness may be in the central portion of the ligament or on the left or right edge. If pain is felt more toward the right or left side of the body, the injured tissue is likely to be located at the right or left edge of the ligament, respectively. If pain is felt right on the spine, the injury is likely to be centrally located. Pain felt all the way across the back indicates there are multiple injuries or the right and left edges, as well as the central portion of the ligament, are injured.

Once the injured areas have been identified, friction is performed at all of these sites for a total of 5 minutes, taking breaks as needed. (Over time, gradually build up to doing 10 minutes of friction.) The therapist should friction the supraspinous ligaments in an east-to-west direction, so they are moving at a 90 degree angle to the direction of the fibers.

Frictioning the iliolumbar ligament. Finding the iliolumbar ligament can be very challenging. This ligament is located just inside the superior edge of the anterior lip of the posterior iliac crest. It is attached to the anterior superior surface of the ilium, approximately an inch lateral and superior to the posterior superior iliac spine (PSIS). Because the female pelvis is wider and more shallow than the male pelvis, the position of the attachment relative to the PSIS differs a bit between the sexes (slightly more lateral for females, slightly more superior for males). When people stand with their hands on their hips, each thumb is usually either right on the ligament attachment or very close to it. The superficial portion of the iliolumbar ligament is accessible to the finger, but the deep portion is not. Fortunately, the superficial portion is where most of the injuries occur.

The most efficient position for frictioning the iliolumbar ligament is for the practitioner to stand at the head of the table on the same side as the area where they'll be working. The client's head is turned away from that side if the head is not in a face cradle. The practitioner will lean over the client's upper body and place both thumbs on the crest of the ilium, facing each other, approximately one inch lateral and superior to the PSIS. They will move their thumbs laterally, while simultaneously pressing down on the ilium (inferiorly) and pressing toward the floor (anteriorly). Then they release the pressure, move back to the starting position, and repeat the movement. This frictioning is continued for 2 minutes. (Over time, gradually increase the duration of frictioning to 5 minutes.)

3. Exercise
The low-back exercises described in the sidebar (link at the top of the page in the right margin) place repeated tension on the ligaments of the low back and sacral area. They prevent the reformation of adhesive scar tissue that has been eliminated through friction treatment and help the treated tissues heal in the presence of movement. After a few sessions of frictioning, practice sitting forward bends. A week or two later, start forward bending from a standing position. Then, after another week, introduce leg up forward bends (appropriate only in cases of iliolumbar ligament injury). None of these exercises should cause any pain.

4. Craniosacral Therapy
Craniosacral therapy is often effective in treating low-back pain caused by ligament strain. Practitioners of this modality use light touch to assess the functioning of the craniosacral system -- the membranes and cerebrospinal fluid (CSF) that surround and protect the brain and spinal cord. They then use gentle manipulation to release any restrictions in this system. Craniosacral therapy treats the low back indirectly; it helps restore a healthy balance in the entire body, which allows the ligaments to heal more efficiently and stay strong. This very gentle treatment takes time and patience and is effective only when performed by a highly skilled practitioner.

5. Diet
There is a profound connection between good nutrition and a healthy body that is free from injury, or that at least heals quickly when injured. Without good eating habits, the entire fabric of the body's tissues becomes weakened and depleted. We all know individuals who are not very old or out of shape, but whose bodies seem to be falling apart. They have not one injury, but many. They are constipated or have other digestive problems. They often feel they don't have enough energy, and they have no idea why. They may have headaches, difficulty sleeping, and pain in many areas of the body. Their muscles feel either too taut or lifeless. People who have a wide range of these sorts of symptoms frequently suffer from severe nutritional depletion.

To address problems caused by a poor diet, consider a skilled practitioner who can assess any nutritional deficits and prescribe an eating program tailored to your body, lifestyle, and schedule. One-size-fits-all diets don't work for most people over the long term. Eating healthfully must be a sustainable, lifelong commitment. While a healthy body can tolerate a little candy, soda, or fried food now and then, a constant onslaught of unhealthy foods will create vulnerability to injury and slow down the healing process. Clients who improve their eating habits generally heal much more quickly than those who do not. Make a connection with a good nutritionist, naturopath, or physician who specializes in nutrition. Having a good referral option for nutritional counseling will enhance the effectiveness of your work.

6. Injection
Proliferant injections are very effective in eliminating pain caused by strained, scarred ligaments. This treatment is recommended when more conservative methods have failed. Proliferants stimulate the production of new ligament cells. This strengthens the underlying structure of the ligaments, healing existing tears and helping to prevent the recurrence of injury. Proliferant therapy also tightens ligament fibers and is therefore the most appropriate treatment when ligaments are stretched and lax.

Proliferant therapy for the low back includes six basic steps. The procedure outlined in Proliferant Therapy for the Low Back (see sidebar) represents the highest standard of treatment, refined over five decades of practice. Performing these injections safely and effectively requires a very high level of skill on the part of the physician.

The proliferant keeps working for up to nine months, with the most accelerated growth occurring in the three to seven days following each injection. As the new tissue forms, the ligament fibers become up to 40 percent stronger. Injection therapy has a very high success rate when performed by a highly skilled practitioner, but as with any treatment, it is not effective for every individual.


Conclusion
In this article, we have examined a broad range of treatments for low-back ligament injuries. The best option for any given individual will depend on a variety of factors, including the person's preferences and available resources, as well as the severity and precise location of the injury. With a thorough understanding of low-back anatomy, assessment, and treatments, you'll be able to make educated choices about your care.

Ben E. Benjamin, Ph.D., holds a doctorate in education and sports medicine. He is senior vice president of strategic development for Cortiva Education and founder of the Muscular Therapy Institute in Watertown, Mass. He has been in private practice for more than 40 years and is the author of Listen to Your Pain, Are You Tense? and Exercise Without Injury. He can be contacted at bbenjamin@cortiva.com.




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