Relieve Low Back Pain | Reduce Low Back Pain | Canada's Leading Authority in Human Movement | Dev Chengkalath

“As to methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.”

Ralph Waldo Emerson

Ralph Waldo Emerson

If you plug in a google search for the causes of low back pain, you’re guaranteed to come across every type of reason that you might be suffering from this potentially debilitating condition.

Your search will no doubt return pages of results with slipped discs, weak cores, or scoliosis. Some pages may even make reference to stress, depression, fibromyalgia or other more esoteric manifestations.

While these may appear to be likely culprits, the’re often more representative of sources of pain, and not causes (go here to read more  about causes vs sources of pain).

Now at this point you’re quite possibly thinking that I have no idea what I’m talking about or that I’ve gone off my rocker.

Take a leap of faith and trust me.

I’ve worked with and learned from hundreds of people who have had every imaginable form of low back pain. I’ve spent countless hours studying the research, taking courses, attending seminars, talking to experts, and otherwise investing in my “low back pain” education.

Over this time, and as with almost everything in life, I’ve come to recognize that there are a few underlying patterns the pop up.

For lower back pain issues, the three items that keep showing up are:

1. The person suffering from the condition doesn’t know why her back hurts. Or she may have an idea, but not know what to do about it. If you don’t know what could be damaging your back or you don’t know how to change what’s hurting you, it’s pretty hard to get better, isn’t it?

This is the knowledge component.

2. The low back pain sufferer has some form of motor control issue. This can include postural faults, muscle imbalances, mobility restrictions (or it’s partner in crime, instability), and sub-optimal movement patterns.

3. Finally, there is almost always a component of de-conditioning. While this is often thought of as a lack of general fitness, this can also include a missing component of specific fitness. I’ve worked with professional athletes who were in prime physical condition, but lacked some very specific physical abilities that either put them at risk, hurt them or kept them in pain. Once this limiting step was fixed, their bodies were able to heal and performance improved.

And that, my friends, is the general recurring theme that kept showing up in the hundreds of cases of low back pain I have worked with over the years.

As with any problem, having a framework to work from helps in creating a solution. Low back pain is no different.

To this day, I don’t believe there is a one-size-fits-all solution for every type of low back pain problem. There are too many variables and too many factors that can’t be controlled.

However, following the wise insight of Ralph Waldo Emerson, I do believe that the above described general framework and it’s underlying principles will help guide each individual towards his or her own unique “methods”.

These methods will form the foundation of a successful low back pain treatment program.

Yours in movement.

Dev Chengkalath

Putting it all together: Treatment

You’ve now completed your medical history, you’ve been observed, you’ve been put through all the physical tests…

So what does it all mean?

The treatment component of the physiotherapy visit is where everything should come together and get you started back on the path to doing what you love to do, be it playing with your kids, gardening or high performance sport.

As discussed previously, the history and observation gave us the clues to set up the physical tests. The physical tests in turn gave us your baseline data; the “what you need to fix”.

The treatment is where all that information is put to good use. This is where it is processed, analyzed and converted in to a physical rehabilitation or performance program.

What exactly does this program entail?

Well, in my books, each program should cover three major aspects.

If any of these three are lacking, there is risk of perpetuating or exacerbating the injury or dysfunction.

Using a client with low back pain as the example, this is how I would potentially set up a treatment plan.

Knowledge is power

1. Knowledge: Does my client know what component(s) of his or her life is/are causing or contributing to the low back pain? Is he or she aware of how to remove some, if not most, of these or minimize their impact? Have I helped my client realize the impact of both internal and external factors (e.g. body structure as internal factor, work environment as external factor)? Basically, does my client understand what steps need to be taken consistently to resolve the issue(s)?

2. Motor Control: This is where I make sure that my client is clear on the impact of his or her daily postures and how he or she can improve/modify them. After treatment, my client should be comfortable understanding how any muscle imbalances play a role, how mobility (excessive or lack thereof) at various joints (e.g. immobile hips, hypermobile lumbar spine) may influence tissue damage and how specific movement patterns may determine repetitive stress or overuse (e.g. poor sit to stand mechanics). Not only should my clients understand these motor control areas, they should be able to teach me what they need to do to resolve them (e.g. stretches, exercises, proper movements/postures etc).

3. Conditioning: Have you ever been injured only to use that injury as your reason to stop all physical activity? Or have you had your healthcare provider tell you to “take rest” for extended periods of time? This break from exercise has the potential to lead to significant de-conditioning and further prolong healing time. Often, it is quite possible to work “around” an injury by choosing the appropriate exercises or activities to maintain or even improve overall conditioning levels while allowing injured tissues to heal!

And there you have it.

A treatment plan outline for a client suffering from low back pain. Using this outline, the details would be specific to the individual coming in for treatment. It would represent what that individual would likely have to do to work towards relieving low back pain.

Yours in movement.

Dev Chengkalath

The physical assessment: observation

Physiotherapy Medical History

In the first part of this series I outlined the importance of a client medical history. This medical history will typically highlight some, if not all, of the potential root causes and contributing factors of your low back pain.

This medical history gives us the foundation upon which to structure the next component of our physiotherapy assessment: the physical exam. This is where we can test and observe how your body moves, works and functions both as isolated parts and in unity as a whole. This is where we can figure out if you have any mobility issues, postural dysfunctions or biomechanical faults. Using this information then helps us figure out how we can work collaboratively (that’s right, you have to be an active participant for this to work!) to resolve them.

The physical assessment can be broken down in to two components:

1. Observation
2. Physical Testing

In today’s blog post, we’ll be focusing on observation.

Observation of your movement and postures starts from the minute you step in to the clinic. While it’s listed under the physical exam, this component can actually take place before, during, and after the medical history. In fact, I’ve secretly followed clients out to their cars (and corrected how they get in and out of them!) to see how they move without knowing they’re being watched.

Here's looking at you.

We physiotherapists like to watch how you move, if you have any compensation patterns, how you hold your body, how you shift your weight, how you walk, how you remove your jacket, and a host of other seemingly ordinary activities.

All of these can give us clues as to the cause and/or the source of your low back pain (see my post on “cause vs source” for more information). All of these can give us clues as to how we can help you fix them!

For example, a client who winces or has difficulty bending forward to remove her shoes tells us that her body doesn’t like flexing forward, all without saying a word. In fact, even how she bends forward furnishes useful information on potential movement issues.

Slouched Sitting Postures: Over time can lead to injury.

The client who who resists twisting while removing his suit jacket let’s us know he isn’t a fan of rotation. This information will allow us to set up further tests during the physical testing. Again, without saying a word.

The client who sits on the examination table, slumped and slouched, with shoulders rounded forwarded and chin protruding gives us an idea of his body awareness and the types of postures he likely adopts for long periods of time during the day.

This is but a small sample of how these vital bits of information that can be garnered without a word spoken.

As you can see, observation is one of physiotherapy‘s most powerful tools. It directly impacts and influences what physical tests we’ll choose and ultimately what interventions we’ll apply to help you relieve you low back pain, get you back to function and performing optimally.

Stay tuned as next week I’ll break down the physical testing component of the physical exam.

Yours in movement.

Dev Chengkalath

While sitting and standing (think squatting) may seem like the most rudimentary task, it’s by far the most improperly executed activity that most of us do everyday.

Don’t believe me?

Take a look at the next person beside you, or within eyesight, to sit down (I’ll go over the standing part in tomorrow’s post).

Slouched Sitting Postures: Over time can lead to injury.

I’m not just saying have a cursory look.

Rather, I’m asking you to actually observe them going through the full cycle of this basic human movement.

What do you see?

If you look carefully, you’ll see some very interesting applications of physics at work.

Gravity in all its glory will accelerate those gluteals at 9.81 meters per second squared until the firm (or plush) surface of whatever seating receptacle becomes a barrier to any further downward gravity-assisted movement of the buttocks.

And this is usually where it gets really interesting.

For those of you out there who don’t spend your days observing people and how they move, you might not notice or even care. But for the rest of us physical therapy types, this is fascinating.

This is where imprecise compensatory repetitive motions come into play.

As soon as those glutes start their heavily gravity-assisted travel towards the seat, the “plop” is almost inevitable. You know the plop I’m talking about. It’s that free-fall into the chair when muscles are turned off and gravity does all the work.

Now as soon as those glutes hit the seat and no further downward motion takes place, for most people (and especially those with low back pain) there is a subtle loss of  lumbar spine stability.

What does that loss of stability look like?

Well, this loss of motor control can be seen with the posterior tilt of the pelvis (think of this as tucking your tailbone underneath yourself) coupled with the rounding of the lower back and the forward carriage of the head (see above photo for slouched spine postures and forward head/neck position).

This wouldn’t be so bad if it were corrected right away. In fact, this correction is imperative to relieve low back pain!

Ideal Sitting Posture: Easy to find, hard to hold.

However, the major issue is that once this slouched posture has been achieved, it tends to be maintained thus becoming a prolonged posture (which coincidentally  is one of two components of overuse tissue trauma, the other being repetitive motions).

So how do you fix it?

In tomorrow’s post, I’ll go through a detailed breakdown of the sit  (and then the return to standing) and how you can fix it using the three part approach outlined in my previous post re-capping the causes of low back pain.

Yours in movement.

Dev Chengkalath

If you’re a low back pain sufferer, I’m sure you’re well aware by now about the lack of consensus on what truly causes your pain.

I wish I had a simple, easy answer for you, but I don’t. In fact, most medical professionals, physical therapists included, just don’t know. And the reasons for this are many.

We, as humans, are extremely complex beings and pain is one of our most complex experiences.

That being said, here’s a recap of what I believe to be the 3 major causes of low back pain. When fixed, this is where you’ll find your low back pain relief:

1. Lack of knowledge: This includes not knowing what movements, postures or positions put body tissues at increased risk of trauma or injury.

2. Motor control issues: This includes issues related to posture, muscle imbalances, mobility and movement patterning.

3. De-conditioning: This includes issues related to being unable to tolerate physical activity or physical stressors.

No matter what the source of the pain, the cause of the pain will almost always fall into the above three categories.

Over the next few posts, I’ll go through a disc-bulge related low back case study and work through the above steps.

Yours in back pain relief.

Dev Chengkalath