Muscle Medicine: The Revolutionary Approach to Maintaining, Strengthening, and Repairing Your Muscles and Joints (27 page)

INTRODUCING THE LOWER BACK

No body “hot spot” is hotter than the lower back. Take a look at the statistics. At any given moment, as much as 20 percent of the human race is thought to be suffering from lower-back pain. Over their lifetime, the vast majority of Americans will
experience at least one episode of back pain. Interestingly enough, in a majority of lower-back-pain cases, doctors are often unsure of the cause.

The lower back has its reasons for being so much trouble, juggling three demanding and sometimes conflicting jobs. The five vertebrae that make up the lumbar spine have to keep you upright while supporting most of your body weight. They have to provide some flexibility to the torso, otherwise you couldn’t twist to the side or bend at the waist to tie your shoes. And they must provide safe housing for the spinal cord and the millions of nerve fibers that link every part of the body with the command center in the brain. As we discussed in
chapter 8
, aging makes this juggling act progressively more difficult.

For most people, from the twentysomethings on up, the area of greatest vulnerability in the lower-back hardware are the disks. The disks are the “jelly doughnuts” that fit in between the vertebrae—thick fibrocartilage on the outside, gel on the inside—that act as flexible shock absorbers throughout the length of the spine. (In the knee, the protective fibrocartilage is inside the joint, the meniscus.) After age forty, the interior gel begins to dehydrate and shrink, and the exterior disk is prone to cracking, or “herniating,” which can irritate the surrounding nerves, muscles, or both.

Life dishes out plenty of abuse to the disks (see the boxes on pages 146 and 147 on protecting your lower back). After age forty or fifty, not too many people have a lumbar-spine MRI that’s suitable for framing. But medical science still doesn’t have a textbook explanation for the lower-back pain of patients who don’t have glaring joint problems, or why the same amount of visible damage causes no problems in three people but the fourth person is in agony. By now, it won’t surprise you to learn that we think the key to much lower-back pain is in the muscles.

The ligaments that run up and down the lumbar (and cervical) region play a more essential support role than the muscles. They’re strong, and outside of severe traumatic accidents, they aren’t often seriously injured, though they are a part of the standard back-trauma diagnosis. The muscles of the lumbar spine, on the other hand, are prone to fatigue and shutting down when the system is out of balance. Posture and work habits are key here. If you’re spending too much time immobile, sitting or standing, and the forces of gravity aren’t being evenly distributed through the soft tissue and the spinal hardware, you’re likely to have problems. As we discussed

IMMEDIATE TREATMENT/WHEN TO SEE A DOCTOR

Any injury or trauma in the vicinity of the spinal cord must be considered serious until proven otherwise. You need to rule out damage to the nerves or to the structures of the spinal column, including the vertebrae, the spinal cord, the spinal ligaments, and the disks. If you have any numbness or loss of sensation or progressive muscle weakness in any part of your body, or a change in your bowel or bladder function, get medical help right away. As with any joint problem, check for any signs of infection such as redness or heat or fever. If there are any, see a doctor immediately. Back pain by itself is not so serious, although it can be excruciating. In most cases, it resolves in a week or two. You may wish to work with a doctor, chiropractor, or muscle therapist to relieve the pain. If the pain lasts longer than a week or two, you certainly should.

in
chapter 4
, emotional stress often plays a role, as do out-of-the-ordinary activities that jolt the system: playing sports you haven’t properly conditioned for, carrying a suitcase on vacation, lifting heavy boxes during a house move.

The good news is that lower-back pain rooted in overtaxed muscles is usually not constant. It comes and goes, sometimes mysteriously. The better news—and it probably is news to a lot of readers—is that manual muscle therapy followed by physical therapy is an extremely effective course of treatment for most garden-variety lower-back pain. Furthermore, as muscle problems can cause spinal dysfunction and restrictions, the combination of manual therapy to address the muscle and chiropractic to realign the spine is also a valuable treatment package. That is where our emphasis lies in this chapter—on the “common backache” and not on the much less frequent cases of structural damage that may require surgery. (Every hot spot tells its own story. Some of the most common knee problems, by comparison, involve joint damage that often requires surgery.)

COMMON PROBLEMS AND CULPRITS

The erector spinae (spinal erectors) climb up the entire length of your back and are the longest muscle group in the body. When both sides of the erector spinae work together, they extend the spine from the cervical to the lumbar region, bringing the head and neck back into extension, straightening the middle (thoracic) spine, and arching the lower back. They also work eccentrically to control the spine as you bend forward. Along with the quadratus lumborum muscles, which lie underneath, the erector spinae work unilaterally to bend and twist the torso. Deepest of all are a group of small muscles, notably the multifii, that support and stabilize your lower and midback. (You strengthen those muscles when you do push-ups or abdominal plank exercises, for example.)

The muscles of the lower back are balanced by the muscles of the front of the trunk— agonist and antagonist. The more important role of the abdominals is not to flex the trunk but to act as a spinal stabilizer and rotator. The rectus abdominis, which flexes and stabilizes, runs straight up from the pubic bone to the rib cage. (It’s divided into segments that are visible if you’re especially fit and lean—the “washboard abs” look.) The external obliques run diagonally to either side of the rectus abdominis. Assisted by the internal obliques, which run diagonally beneath them, these muscles flex the trunk and aid in side-to-side and twisting movement, as well as supplying core support. The transversus abdominis muscle is the deepest muscle of all. It acts like a girdle of support and assists in breathing.

All of the muscles of the lumbar spine are considered “postural.” They’re constantly firing in small, subtle ways to maintain the proper alignment of the spine. When the iliopsoas, a powerful muscle group that flexes the hip and the trunk, tightens up, it can pull the spine forward. The erector spinae and core muscles are forced to overwork to maintain the position of the spine, leading to back pain and spasms, which can refer pain away from the area.

WHAT GOES WRONG, AND HOW TO FIX IT

Mostly Muscular

Chronic Lower-Back Pain

Dr. Ted Schwartz, a forty-year-old neurosurgeon at Manhattan’s prestigious New York Presbyterian Hospital, had endured chronic back pain since he was in medical
school. He’d studied his own MRI and could see nothing about the structure of his lumbar spine that looked unusual. He wasn’t even a candidate for an anti-inflammatory injection near a disk, much less the spinal-fusion operation (removing a damaged disk and fusing the vertebrae together) that he had performed on hundreds of his patients. Dr. Schwartz assumed the problem was mostly muscular, but nothing in his surgeon’s toolbox seemed to fit the situation, and his sporadic attempts to address it with back-stretching exercises had gone nowhere. Meanwhile, standing in the operating room for hours on end had become so painful, it threatened to short-circuit his surgical career. “I’ve always been very skeptical of any nontraditional treatments for back pain,” he says, “but I didn’t have a lot of good options.” After three twenty-minute manual therapy treatments over two weeks, Dr. Schwartz was out of the woods. “That was three years ago, and my back pain hasn’t been bad on a chronic basis since,” he says. “Now I stretch every morning, and if I get a flare-up, I’ll take Aleve.” Regarding the treatment itself—Dr. DeStefano manually

PROTECT YOUR LOWER BACK

Don’t lean forward from the hips and lock your knees when you’re doing standing activities such as washing dishes, vacuuming, shaving, etc.

Avoid twisting your trunk around when you’re bending and lifting, such as when unloading laundry or reaching for something in the backseat of a car. Whenever possible, turn your entire body around, and avoid lifting with your back muscles.

When you’re lifting heavy objects, lift with the hips and legs, not the back. Keep your back straight, bend at the knees, and keep the heavy object centered and close to your body.

Avoid carrying suitcases or heavy shoulder bags, which stress one side of the back. Rolling suitcases and backpacks are the way to go.

Don’t drive in a stretched-out position with your seat reclined. Sit straight and tall— you shouldn’t have to reach for the steering wheel. On long car trips, take rest/stretch breaks.

On plane, train, or bus trips, pack a small pillow or rolled-up towel to place behind your lumbar spine or neck.

released tightness in the abdominal muscles and the psoas muscle in the front of the trunk and the erector spinae muscles in the lower back—Dr. Schwartz is grateful but not all that curious. “If it worked, it worked,” he says. “To this day, I’m not sure I can explain why.”

Picture the spine as the mast of a sailing boat stabilized and balanced by wire stays. The wires in the rear of the mast are the back muscles, the erector spinae group. The opposing set of wires in front are the abdominal muscles and the psoas. Remember that muscles, or muscle groups, have to work together: an agonist fires as an antagonist relaxes. For you to bend backward at the waist or move your trunk side to side, those ab and psoas muscles have to lengthen and the back muscles have to contract. To come back to neutral or to lean forward, it’s the reverse. If any of these muscles are fatigued and not properly responding, your sailboat mast, or spine, will be out of balance and you’re going to feel it. Yet all too often in the treatment of lower-back pain, the front muscles are ignored. The attitude is “Hey, you’ve got back pain; let’s get to work on those back muscles!”

Why Ted Schwartz was more vulnerable to back pain than most of his colleagues, neither he nor we know. But the hours of unrelieved standing had chronically irritated and fatigued the back muscles. Sitting glued to your office chair at work can be just as harmful in a more insidious way. (See the box below on making your office more back-friendly.) Over time, the sitter settles into a rounded-shoulder, slumped-forward position in the chair. The muscles in the front of the torso, especially