Osteopath Gareth Milner
''An Osteopathic Treatment for Lower Back Pain''
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Treating patients who suffer from Lower Back Pain is an Osteopath's bread and butter. In a typical Clinic day as an Osteopath, around 10 of 15 people consult us for our Professional Expertise, to remove or palliate their lower back condition.
This Blog Post will go into how an Osteopath clinically treats Lower Back Pain as well as briefly going into the causes of Lower Back Pain and how to self treat the condition.
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The photos in this Blog are from my treatment of 28 year old Rafel Capel, an Osteopath himself. Rafel's history of musculoskeletal issues included degeneration of his lower lumbar spine discs as well as right knee pain. His medical history included Asthma as a child. He is a keen footballer, playing as a goalkeeper. After a thorough Case History, Osteopath Gareth Milner started with a Postural Analysis, observing his body from the side, rear and from the front. Osteopaths look at the whole, and just because Rafel was experiencing some lower back symptoms, this does not mean Gareth would focus solely on observing his lower back and pelvis. ​As Rafel did not experience neurological symptoms (like pins & needles in the leg or foot, weakness in the legs, sciatica shooting pain etc.) a neurological examination was not indicated and therefore not performed. After the observation Gareth assessed his whole musculoskeletal system for its position, muscle tone and size, and any signs of swelling etc. In the photo to the left Gareth is assessing the position of Rafel's pelvis, contacting his Posterior Superior Iliac Spines (who named that part of the Pelvis with that name?!).
The image to the right shows the pelvic iliac bones (left and right) and the middle pelvic bone, the sacrum. In Rafel (which is generally the case for most people), his left pelvic bone was tilted posteriorly (like on the image). An increased tone in his left hamstring muscle was the direct reason for this pelvic bone torsion, most likely caused by some spinal nerve irritation from his degenerative lower lumbar spinal disc. Gareth moved down to look at his lower limb anatomy, with the pronation (flat foot) of his right foot the most clinically important observation, with the affect this foot position was having on his right knee, a location of some pain for him. Gareth moved up his spine to check for curvatures, feeling each spinal level for the muscle tone.
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​From Gareth's initial assessment it was clear that his right foot and right knee were joints that would need to be manipulated in future treatments which would not just reduce the knee pain symptoms but would help maintain a good alignment in his hips, pelvis and lower back.
​In his spine his most clinically relevant areas to manipulate were his mid thoracic spine (T7-10) and his lower neck (C4-C6). View the final image in the left photo gallery detailing the Vertebral Column. Apart from physical traumas (like diving to stop a goal); his physical job; effects of stress on the body etc. these spinal areas were very much stiff and biomechanically dysfunctioned because of his history of Asthma. When we check the movement of the pelvis, we do an Osteopathic Test called the 'Rising Thumb Test'. This involves contacting the pelvis (shown in the first 2 photos in the left photo gallery) and checking the movement of the thumbs when the patient bends forward. We also do the same with the patient seated on the clinic bench.
With Rafel's pelvis, Gareth's left thumb was rising both when he stood and bent forward, as well as when he was seated and bent forward. Overall (keeping it simple for this Blog), this means that he had a very 'stuck' left sacroiliac joint. This was noted on his case history file, to be consulted once the Orthopaedic and Osteopathic Assessments were completed. Rafel was then asked to lie down on his back, supine on the clinic bench.
Gareth then performed the SLR Test (Straight Leg Raising), which is defined as a neural tension test that can be used to rule in or out neural tissue involvement as a result of a space occupying lesion, often a lumbar disc herniation. It is one of the most common neurological tests of the lower limb. ​​With patients who have a lower lumbar disc herniation or prolapse, pain would be experienced down the leg, commonly a shooting or burning pain.
No symptoms like this for Rafel, just some normal tension in this hamstrings. Gareth then checked the position of his pelvic iliac bones (shown in the photo below) as well as the mobility in these joints. It was evident that his left pelvic bone was stuck in posterior rotation, a true somatic dysfunction for his body (in the past when Osteopathy first started in Kirksville, USA by Andrew Taylor Still, the phrase 'Osteopathic Lesion' was first used for what is now commonly called by Osteopaths a 'Somatic Dysfunction').
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Andrew Taylor Still (pictured far left) believed that Osteopathy was a necessary discovery because the current medical practices of his day often caused significant harm and conventional medicine had failed to shed light on the diagnosis and effective treatment of disease.
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Gareth then asked Rafel to turn onto his front, in the prone position. As shown in the images below Gareth checks his pelvic position again, and the position of his lumbar spine vertebrae, as part of an Orthopaedic Assessment, checking for any tenderness or pain and any abnormalities in positioning and structure. All was normal from an Orthopaedic point of view. From an Osteopathic perspective his 3rd lumbar down to his 5th lumbar erector spinae muscles felt 'hard', 'dry', 'ropey' which suggests they are chronic in their mobility dysfunction
Shown below ... there are a lot of back muscles, aren't there? Like all Osteopathy students Gareth Milner learnt them all, their origin, insertion and nerve supply. Countless hours of revision, but very enjoyable study.
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Gareth's assessment of Rafel was complete with his individualised Treatment Plan quickly formulated. Gareth would manipulate Rafel's L5/S1 facet joint with a High Velocity Thrust Manipulation; mobilise his sacroiliac joints; mobilise his Thoracic Spine (due to the stiffness created by his Asthma); release his neck muscles focusing on his right trapezius/ shoulder as well as his diaphragm and right piriformis. Let's get cracking! (excuse the pun).
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The Osteopathic Treatment for Rafel started with lower back muscle cross-fibre massage/ inhibition (pictured to the right). This prepping of the soft tissues has always stuck in Gareth's mind from the great Peter Blagrave (pictured below left), who taught (amongst others) Gareth Osteopathic Technique.
Gareth always remembers chatting to him about his dogs in the practical Class breaks. A lovely man and an awesome Osteopath. Rest in peace Peter Blagrave.
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Rafel's left Quadratus Lumborum muscle was one of the reasons his left sacroiliac joint was stuck/ locked up/ not working, so Gareth performed some Neuromuscular Technique to this muscle (shown below), basically sticking your thumbs into the trigger points (the knots) of the muscle.
This was also followed by some gentle but effective, rhythmic oscillatory movement, initiated up the spine from the pelvic contact (shown below). A nice, pleasant to receive commencement to the Osteopathic Treatment.
Rafel then moved into the sidelying position on the treatment plinth. As his lumbar spine was bent backwards, his body's compensation to his tight hip flexors from kicking footballs, Gareth mobilised his lumbar spine in flexion (shown below left), gently stretching the muscles and mobilising his lumbar facet joints. Gareth then moved onto mobilising Rafel's lumbar spine in side bending (shown below middle). As a Director of a Manual Handling & Musculoskeletal Disorder Risk Management Business, good posture is always a focus for Gareth. For Osteopaths though performing good postures all the time is not possible, and back pain can be part of the job for Osteopaths. Rather ironic that, isn't it?
With the lower back nicely warmed up, muscles stretched and joints more mobile Gareth decided to manipulate Rafel's L5/S1 facet joints with the technique Osteopaths are famed for, the High Velocity Thrust Manipulation. To watch this view the Osteopathy video above at 3 minutes 33 seconds.
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In an Osteopath's hands, High Velocity Thrusts (HVTs) are extremely safe. We learn these extremely effective techniques over 4 undergraduate years and then learn to master them through our clinical practice. Gareth is a big fan of specific and expertly performed HVTs, but he is also mindful they are just a mere screwdriver in the box of tools. They don't define Osteopathy.
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In the left image the 2 facet joints between the L5 (5th lumbar) vertebrae and the boney sacrum are shown green. Most lower back pain is due to simple mechanical dysfunction of these facet joints, with the muscles in spasm pulling the joints and bone out of alignment.
Osteopaths come along and simply puts things back into their anatomical alignment. Simple really. If you are interested in Human Biomechanics and how the lower back functions, then after this, give Gareth's Blog Post titled ''Human Biomechanics - Kept Simple'' a read, available via our Blog page. Click the TAB at the top of the website.
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From learning what Rafel did away from his Clinical Practice, Gareth used this information as well as his Osteopathic findings, to treat other relevant musculoskeletal structures. With the amount of goal kicking he does, Rafel's hip flexor muscles were tight both sides. There are numerous techniques to stretch/ release these muscles and in this first treatment for Rafel, Gareth used the gentle, but effective inhibition of his Psoas muscles, applying the contact in Rafel's abdomen as shown below.
One of the first Osteopathic Techniques Gareth learnt at the European School of Osteopathy in the year 2000 was the 'GOT' which incorporated articulations across the body from the feet up to the neck. This technique (shown to the left) Gareth remembers getting it into his mind about which way you had to move the hip and what your hand contacts (on the pelvis) did at the same time.
For those of you interested in studying Osteopathy view the European School of Osteopathy's website on www.eso.ac.uk
Gareth loved his 4 years at the European School of Osteopathy. Learning a remarkable Profession in the Garden of England! You can see Gareth at his Graduation Ceremony (above right) on the far right of the middle row, wearing a light blue shirt.
Although most of an Osteopath's clinical assessment is finished before the treatment starts, Osteopaths are always assessing as they go along.
Did that technique work? Is the joint moving better? Is it aligned right? Has it affected another area enough that I now don't have to treat?
In the top left image Gareth assesses the mobility of Rafel's right hip, specifically its rotation. There was minimal internal rotation of this right hip, due to contracture (shortening) of his right piriformis muscle. The piriformis muscle is deep in the buttock and one of the ways to release it is basically to stick your elbow in the belly of the muscle. Not fun to receive, but effective. In the bottom left image Gareth applies Neuromuscular Technique monitoring if the muscle is releasing and if Rafel is happy with the pain level his elbow in the tight muscle causes.
To finish the treatment focus on his lower back and pelvis Gareth applied traction, individually through both legs. A nice technique to have performed on you, decompressing the lower back, an area that gets a lot of compression, the bipedal mammals we are (i.e. standing on 2 feet) as well as these days the compression on the 5th lumbar disc we receive daily from sitting and working at a desk with a computer.
​So far the treatment had taken 15 minutes with the focus on the lower back and pelvis. As Rafel wasn't experiencing much lower back symptoms, Gareth worked holistically across his body mobilising his Cervical (neck) and Thoracic Spines (mid back) as well as releasing his diaphragm (the most important breathing muscle), the trapezius and neck muscles. The treatment finished with a High Velocity Thrust manipulation at the 4th level of his neck. Anatomically if you have somatic dysfunction of this part of the neck, you then can have dysfunction of the diaphragm and vice versa.
You can watch Gareth manipulate his Wife Emma's neck in both the supine (lying on back) and prone (lying on front) positions in the Osteopathy Explainer Video above in this Blog. This Video featuring another European School of Osteopathy Graduate Helen Bonetti is another great demonstration of our magical Profession.
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Presented in this Blog Post, this is very much traditional Osteopathy, its roots, where it came from, and IT WORKS! There are other styles, techniques, theories and these are all great. These include Visceral and Cranial Osteopathy which without doubt have their place in this great clinical practice. These days Osteopaths have embraced other treatment modalities, including Electrotherapy (Interferential and Ultrasound) and Dry Needling which again have their place in clinically treating the patient.
To wrap up this Blog Post Gareth gives you his 10 Top-Tips for preventing Lower Back Pain. If you suffer from Chronic Lower Back Pain practising these Top-Tips will reduce the symptoms and keep your spine more mobile. More information can be found on Gareth's Blog ''Self Help for Your Back Pain''.
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1. Perform Stretching Exercises every day for 20 minutes
2. Join a Pilates Class or buy yourself a decent Pilates DVD
3. Have regular Osteopathic Treatment. Find an Osteopath
4. Have a regular Massage. Deep tissue is most effective but may be too strong for some.
5. Bath a lot or even better still get a hot tub!
6. Practice deep breathing exercises with meditation. Gareth recommends www.calm.com
7. Drinks lots of mineral or filtered water. Aim for as much as possible. Hydration of spinal discs is paramount.
8. Practice good posture at the desk, and have it maximised with best practice Display Screen Ergonomics.
9. Perform Optimal Manual Handling Technique and Practices.
10. Perform light Weight Training 2 times per week, as well as the Stretching and Pilates routine mentioned above.
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Thanks for reading.
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