Low back pain 3- Respiraton

The diaphragm plays an important role in maintaining core stability.  It serves as the "top" of the core and its activation is timed to the activation of the abdominal muscles.  We know that in many cases, individuals with low back pain have altered respiratory patterns.  Spine. 2010 May 1;35(10):1088-94. 

In fact, some people that reach a plateau in their 'typical' treatment of low back pain respond quite well to breathing exercises.  Also, other researchers have discovered that in some individuals, problems with the diaphragm (and the subsequent low back pain), are coupled to failure to activate muscles of the pelvic floor.

We now have a picture of a person with low back pain and poor respiratory patterns (primarily chest breathing rather than using abdominal breathing techniques).  This person also fails to activate muscles of the pelvic floor.  We don't think of these muscles often unless we have a problem with urination (these muscles are trained during 'potty training') but they are also activated unconsciously as we stabilize the low back. 

The overriding question is; why do these muscles fail?  To answer that, we have to know what turns them on.  These muscles are activated by unconscious pathways from the brain and brainstem.  In other words, the nervous system turns on these muscles.  "Big deal" you could ask.  All muscles are activated by the nervous system.  The point that I want to make here is that it is generally recognized by the rehabilitation community that muscles do not fail.  Instead, the neural components that activate them will fail.  In other words, muscles don't tend to get truly "weak".  They tend to get "not activated" secondary to inhibition of those parts of the nervous system. 

As we dig deeper, we learn that the lower brainstem makes you breathe.  The lower brainstem is commanded by higher parts of the brain including the vestibular system. 

In other words a poor brain causes poor breathing which causes low back pain.  This is the missing "neuro" part that I wrote about in the previous post.  To be clear, I am not talking about a brain with true degeneration as in Parkinson disease.  I am talking about a brain that works at less efficiency or has a compromised level of integrity.

Low back pain 2

When you view low back pain, you can think of it from 2 perspectives.

1.  Biomechanical causes

2.  Metabolic causes

Most research has focused on the biomechanical causes of low back pain.  Truthfully, you could spend your entire life studying clinical biomechanics as it is a complex topic.  For example, in the 1980's, we thought you just needed to get some bed rest.  In the 1990's we realized that abdominal muscles were important in the stability of the back.  In the late 90's, gluteal muscles and legs were understood as important.  In the 2000's, there was an explosion of research on muscles with fancy names like; multifidus & transverse abdominis. And only fairly recently did many practitioners start appreciating the respiratory diaphragm and muscles of the pelvic floor.

As there are many practitioners who are skilled in this approach, I won't regurgitate this body of knowledge in this blog.  For more information, check out this blog by biomechanics expert, Will Stewart.  Will does a great job highlighting the importance of assessing all components of the kinetic chain from a variety of "real life" positions.  He also emphasizes a "real life" approach to rehab and exercise.  Great stuff and hours of mind-boggling reading.

I will mention that as we've learned more about the biomechanics of the spine, we've really come to appreciate the role of the nervous system.  While the term "musculoskeletal" has been around for decades, the term "neuromusculoskeletal" has been in use for the past 10-15 years as we've come to appreciate the role of the brain.

However, for most of those past 10-15 years, the "neuro" part has not been well described.  In the next post, I'll start there with the overall goal of bringing us into the metabolic arena.  I want to show you that to have a good biomechanical system, you must have a good "neuro"  system.  And to have a good "neuro" system, you must have a good endocrine and immune system.  And to have a good endocrine and immune system, you must eat well, manage your stress, sleep well and exercise... all the things that make you healthy.

Low back pain 1

Most of the entries I post in this blog have to do with metabolic issues (diabetes, obesity, inflammation etc.).  One of the underlying themes you may have gleaned by now is the integration of body systems.  Just when we think some component of our body works in isolation, science will demonstrate an intimate connection with other components of our physiology.  For example, in the series on heart disease, we saw how things like the gut, hormones, nutritional intake, and immune system influence the health of the heart.  For the next series, I want to tackle something just as prevalent; low back pain.

When you think of low back exercises, you may think of abdominal work.  If you find a more thoughtful therapist, he may recommend exercising the gluteal muscles (variety of squats or lunges) and stretching hamstrings.  An even more highly skilled therapist will integrate respiratory exercises and activation of muscles of the pelvic floor. Perhaps your therapist also examines the broader "kinetic chain" and examines your foot, ankle, knees and hips.  We often mistake this as a very sophisticated approach toward low back pain. I will admit that this is light years ahead of where low back rehab was just a decade ago, but we still have a long way to go.  

This paper changed my life forever.  In summary; 83% of patients who had chronic low back pain were found to have low levels of vitamin D.  They were treated with vitamin D and 95% of those treated had significant improvement in their symptoms!  The authors concluded, 

"Vitamin D deficiency is a major contributor to chronic low back pain in areas where vitamin D deficiency is endemic. Screening for vitamin D deficiency and treatment with supplements should be mandatory in this setting."

This paper was published in 2003 when I was in the middle of my residency.  In those years, I spent the vast majority of my clinical time performing physical rehabilitation on patients with musculoskeletal pain.  It irked me that the hours of physical exercise that my patients were performing may have been undermined by low vitamin D.  As more research uncovered the roles of vitamin D, it became clear that even something low back pain, more than likely, involved a intimate integration of physiological systems.

We'll take a closer look in the coming weeks.