Several studies have examined the relationship between the hip and low back pain with the basic assumption that suboptimal function of the hip causes compensatory mechanics of the lumbopelvic region. Alterations in soft tissue integrity resulting in shortened or stiff muscles, restricted capsular/articular mobility, and bony abnormality may cause increased load on the lumbopelvic tissues. This would be increasingly evident in activities requiring hip rotation such as golf, racquet sports, and baseball. In addition to tissue integrity and mobility, neuromuscular coordination of the hip and lumbopelvic region may also contribute to low back pain. For example, an athlete or individual may have adequate hip range of motion but altered neuromuscular control may lead to increased relative strain on the lumbopelvic tissues through the mid or early range of hip motion. This will result in a low-magnitude tissue overload that over time will lead to microscopic injury and low back pain.

The current study by Harris-Hayes et al aimed to evaluate the effect of hip range of motion and lumbopelvic-hip coordination on low back pain in participants of rotation related sports. Significant and clinically important findings from this study include:

Methods: Participants of rotation related sports with and without low back pain were examined for active and passive hip rotation range of motion in a prone position. During active hip range of motion and knee flexion in the prone position the sequencing, timing, and grading of segmental movements were recorded (i.e. coordination) for the lumbopelvic-hip region. Variables of sex, habitual and sport activity level, demographics, pain level, and Oswestry scale were evaluated.

Results:

• Hip Range of Motion and Low Back Pain: Subjects who participated in rotation related sports demonstrated a significant correlation between low back pain and hip range of motion deficit. Specifically, participants of rotation related sports with a history of low back pain had significantly less total hip rotation than those without a history of low back pain. They also demonstrated less rotation of the left hip compared to the right and considering all subjects were right handed, this may have important functional consequences and contribute to the mechanical overload of pelvic and spinal tissues.
• Coordination: Subjects with a history of low back pain demonstrated earlier lumbopelvic motion during both hip rotation and knee flexion range of motion. The early movement noted was rotation or extension and rotation.
• There was no significant difference in maximal hip lateral rotation range of motion; there was less knee flexion in the low back pain group. The participants with low back pain demonstrated greater lumbopelvic range of motion.
• Men tend to move their lumbopelvic region earlier than women, citing possible differences in early to mid range muscular stiffness (total range of motion was the same for men and women).

This study highlights the importance of evaluating functional movement patterns and coordination in addition to range of motion and traditional strength testing. Although active and passive hip range of motion may be unremarkable, careful evaluation of early to mid range stiffness in addition to the sequencing, timing and grade of lumbopelvic-hip motion will often yield important information in managing the low back pain patient.

Please send your comments, questions or discussion points to: seminars@somaticsenses.com

Marcie Harris-Hayes, Shirley A. Sahrmann, and Linda R. Van Dillen. Relationship Between the Hip and Low Back Pain in Athletes Who Participate in Rotation-Related Sports. J Sport Rehabil. 2009 February ; 18(1): 60–75.
 

The association between back symptoms and common imaging findings such as degenerative discs, facet arthropathy, herniated or bulging discs is very weak and there is no way to distinguish asymptomatic findings from symptomatic findings. There is no evidence that labeling most patients with a specific diagnosis on these imaging findings helps improve patient outcomes. Harm may be done by labeling patients causing anxiety and fears about what healthy activities are doing to the back. Imaging is also used to address health care providers fear that they may miss something that may lead to poor outcomes and malpractice suits. Defensive imaging is very common. Health Care Providers should have confidence in recent evidence-based guidelines. In high-quality, randomized controlled trials that evaluate clinical outcomes associated with different imaging strategies, the evidence is very strong and should provide health care providers with more confidence about following these guidelines. In all the studies that followed up with patients to look for missed serious conditions such as cancer, none found a single missed case. Large observational studies show a very low risk of complications once ‘red flags’ have been assessed and found to be absent.

The following quotation is taken from the British Journal of Sports Medicine (Sallis RE, 2009;43,3-4).  Are you prescribing exercise to your patients?!

“Exercise is medicine and physicians need to prescribe it! Mainstream medicine has mostly ignored research on exercise and instead the current health care system is completely enamored with procedures and pharmaceuticals. Little has been done to target behavioral factors such as physical inactivity which influence health and longevity. The scientific evidence is clear, proving the benefit of regular physical activity on prevent of Diabetes Mellitus, Hypertrophic Benign Prostatitis, Cancer (especially breast and colorectal), depression, osteoporosis, and dementia. It’s also essential in achieving and maintaining weight control. There’s a clear correlation between physical activity and all cause mortality. Exercise really is medicine and can be seen as the much needed vaccine to prevent chronic disease and premature death. If we had a pill that conferred all the confirmed benefits of exercise, would we not do everything humanly possible to see to it that everyone had access to this wonder drug? At Kaiser, physical activity is recorded as a vital sign and we believe there is no greater indicator of a patients overall health and longevity than how many minutes per week patients exercise. Last years president of the American Medical Association, Ron Davis, a preventive medicine doctor, and head of Center for Health Promotion and Disease Prevention of the Henry Ford Health System, Detroit, convinced the AMA to partner with the ACSM on an initiative called Exercise is Medicine (exerciseformedicine.org) in Nov 2007. We must encourage all patients to become more active and stay active throughout their lives. Patients should understand the risk of being sedentary and the importance of exercise in the treatment of chronic disease. We need to insist that the health care system of the world make a big commitment to getting patients active as to getting them to take meds or submit to necessary procedures.”

I recently came across an article that discusses the results of cadaver and invasive in vitro studies on foot kinematics during walking and running gait. This paper was based on a keynote presentation given at the 2009 podiatry conference in Australasia, and brings up some very important points regarding our assumptions of foot function and the prescriptions of orthoses that we make (or recieve). I will share with you the highlights of this article…the clif notes version.

There are three methods in which foot motion have been measured. The multi-segment food model, in which surface markers are used to track movement of specific bones in the foot, has been used most extensively and has inherent flaws. The skin on the foot moves independant from the bones and critically, not all bones in the foot can be measured. This leads to the incorrect extrapolation of foot motion. Unfortunately, many opinions and clinical decisions have been informed by this research.

To solve this problem two different approaches to measuring foot kinematics have been taken: 1) static and dynamic cadaver models, and 2) invasive in-vivo research. Although the results are not generalizable to the general populus, these studies have allowed us to refute several traditional ideas regarding foot function and importantly, has given us insight into the significant inter-subject variation that exists. This questions the notion that any model of foot function that uses an “ideal” foot type, alignment or movement pattern exists.

Several important findings has come from this research. I will give it to you in point form:

1. The sub-talar joint is not the only “torque converter” - in the majority of subjects the ankle joint moved more in the frontal and transverse planes than did the sub-talar joint in both walking and running. Although the range of motion in the sagital plane, in other words ankle dorsi and plantar flexion, was greater than the frontal and transverse plane motion in the ankle there was significant movement in these other planes.

2. There is significant variation in motion at the sub-talar and ankle joints indicating the ankle and sub-talar joints may work in tandem to provide the frontal or transverse plane motion required. We should certainly not prescribe distinctive roles to either as has traditionally been the case (i.e. ankle = sagital plane/dorsi-plantar flexion, sub-talar = torque converter)

3. Consistent with previous research the talonavicular joint demonstrates significant degrees of freedom and contributes signifcantly to pronation. The calcaneocuboid joint moves less but still moves as much or more than the sub-talar joint.

4. Again, there is significant variation. In one subject the talonavicular and calcaneocuboid joints displayed 21 degrees of motion in the frontal and transverse planes and in another only 5.2 and 6.0 degrees respectively. Remarkably, they both moved about the same in the sagital plane.

5. The tarsal bones move just as much and make a significant overall contribution to foot motion. These motions are invisible to the clinical eye and are consequently left out of most clinical models.

6. Consistent with previous research, there is significant mobility of the 4th and 5th metatarsals on the cuboid and cuboid on calcaneus, demonstrating the infrequently discussed lowering of the lateral arch.

7. In all subjects the foot moves less in running compared to walking, suggesting foot orthoses made for running need not be stiffer or have greater ‘control’ features.

There is one quote in this article that I found especially beautiful, so to complete this article let me finish with this:

“the data makes a mockery of any notion that a clinician should seek to alter the foot biomechanics of all patients such that their feet achieve some hypothetical mechanical model (ie. one foot model fits all feet). It is far from fitting that in the year we celebrate the 150th anniversary of Darwin’s ‘discovery’ of the essential variations in nature, that foot health professionals continue to use a clinical model of foot function which seeks to eliminate all variation between our patients. Furthermore, remaining as a ‘variation’ of nature rather than a clone of the hypothetical ‘Root’ foot type is likely to be central to a person remaining symptom-free most of their lives, since their own body will have adapted to adequetely cope with its own variations.”

I love that paragraph!
 

The successful management of many patients with musculoskeletal disorders requires an explanation of what pain is and how their disorder causes or perpetuates their pain, or in many cases how pain perpetuates their disorder. Therefore, the purpose of this article is to improve patients and practitioners understanding of how perceptions of pain impact the outcome of treatment; how diagnoses effect patients perceptions; and how effective communication of diagnoses and explaining pain can improve patient outcomes.

Well known researcher, author and lecturer, Dr. Lorimer Moseley would propose and his research supports that explaining pain can at times be more effective than ergonomic advice and rehabilitation. Further, fear of pain has been shown to change motor control and movement patterns in asymptomatic controls to that similar to patients with REAL pain. Spend five minutes in any Chiropractic office and you will surely see an array of altered motor control and movement patterns. The example of a low back pain patient standing up from a chair is my favourite. The patient first flexes their spine and bends forward until their bum lifts off the chair. With their hands on their knees they begin to inch their hands up their thighs while maintaining a completely flexed lumbar spine. Eventually their hands reach their hips and they realize they have to remove their hands from their hips in order to finish the process of standing up…this is when the look of fear comes into their eyes as they realize they have to remove their hands. They slowly remove their hands and extend their back from full flexion until they are standing upright…almost. There are two interesting points here: 1) the patient has reproduced an injury mechanism and a movement pattern that is sure to perpetuate their problem. 2) Many patients will move this way in my office and when I ask them “was that painful?” some say “no”. They say “no”?! When I ask them “if it didn’t hurt, why did you stand up like that?” they reply “I guess I am used to it hurting”, or “I thought it was going to” (i.e. fear of pain). Stress has also shown some interesting effects on motor control that is similar to patients with pain and there is evidence demonstrating an increase in muscle tone (i.e. “tight muscle”) of certain muscles in response to stress. For example, most people are well aware that the upper trapezius (commonly reported as “tight shoulders”) gets tight when they are stressed out, and research has demonstrated an increase in upper trapezius tonicity in response to stress in office workers.

Recent evidence suggests that the use of Diagnosis Based Clinical Decision Rules or Clinical Prediction Rule can significantly improve our chances of successful management of spine related disorders. A diagnosis based clinical decision rule is when a series of diagnostic indicators dictate the treatment approach. For example, a positive nerve tension test indicates success with a treatment approach that includes nerve flossing and/or nerve tension maneuvers; decreased joint mobility and joint tenderness indicates success with joint manipulation. Basically, the identification of who will benefit most from what therapy or management approach through a thorough history and examination will yield best results. It is reasonable to suggest that the lack of understanding pain or specifically, having a belief system that promotes fear and stress in response to pain will perpetuate the problem. I suggest that there are patients who would benefit most from a better understanding of pain and how it relates to their “injury” than manual therapy and/or rehabilitation alone.

So what does this have to do with “labeling patients and mistreating them”?

When we diagnose a patient with a condition, for example arthritis, how do they perceive the diagnosis? What label have we put on them as a result of our diagnosis and what label have they put on themselves as a result of our diagnosis?