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There is no off switch, but there is a dimmer.

Trauma and repetitive stress are common triggers for muscle hypertonity. In the absence of neurologic disease, our brain subconsciously regulates muscle tension in response to movement or injury.  When muscles are functioning correctly, they can efficiently accomplish tasks.  Unfortunately, injury or joint dysfunction cause muscles remain hyperactive, leading to pain and compensatory dysfunction. This blog will discuss a widespread example of altered muscle output plus three practical solutions.

Watch Dr. Steele demonstrate how he manages tight lumbar muscles.  Its not difficult but it does take doctor patience, patient compliance, and proper case management.

 

Purposeful movement requires load sharing through muscles, ligaments, cartilage, and bone without overburdening any one tissue. As an example, it would be easy to assume that knee flexion requires only hamstring activation.  Knee flexion also requires eccentric load sharing by the quadriceps.  Coordinated muscle activation is an essential key to performing our daily habits, athletic activity, and hobbies.  Unfortunately, most patients pre-tax their muscles with prolonged sedentary postural stresses at work. Dysfunctional hypertonicity is the consequence of surpassing system capacity with protracted or excessive demand.

Measuring Altered Movement in LB

For the sake of simplicity, let’s consider a problem we all see daily – hypertonic lumber erectors. Hypertonic lumbar spine erectors can be either a predisposing factor or consequence of low back pain. Interestingly, these hypertonic patients hardly ever “switch off” over-loading the spine.  Increased loading with the altered load-sharing capability of other tissues creates ongoing stress and pain. (1) Pain is difficult to measure, but we can assess load sharing with the flexion relaxation response (FRR).

Flexion Relaxation Response (FRR)

During flexion of the lumbar spine, the erector spinae muscles act eccentrically to control flexion until the end range. At end range, there is a sudden decrease in muscle activity where there is load transfer to the ligamentous components of the spine. (2)

Researchers can identify a normal FRR in people without LBP. These patients seamlessly transfer load from muscles to the passive structures of the spine while maintaining the stability necessary to prevent injury. (3) Patients with LBP often exhibit over-active lumbar erectors; their muscles remain active throughout normal range of motion and at rest. (1) This inability to “turn-off” contributes to over-loading of the spine and altered load-sharing stress.

 

Now that we have a measurable problem, how do we resolve it?

FRR is a normal phenomenon associated with lumbar flexion and studies have shown that it can be absent or altered in the presence of LBP.  To reestablish a normal FRR, we need to implement three strategies:

1. Monitor Mobility

Measuring ROM is an essential part of your initial and follow-up exams.  While the specific numbers may vary from person to person, you expect to see increases in the ROM during your treatment. Patients will experience more mobility as you resolve function-limiting factors, i.e., pain, joint restrictions, muscular hypertonicity, etc.

Bonus

You should consider a directional preference for LBP patients to relate ROM losses to changes in symptoms based on position.

Click HERE to see a quick synopsis on directional preference.

2. Offer Short-term In-Office Solutions

 

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Spinal Manipulative Therapy (SMT): restoration of joint motion allows for improved load sharing by the passive lumbar spine components. SMT is often a short-term fix. (4)

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Myofascial Release: contributes to normalization of the flexion- relaxation response and also shows a significant reduction in pain and disability. (5)

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Contract-Relax and Static Stretching: may provide short-term relaxation and gains in ROM. However, the response is not permanent. (6)

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TENS: Recent research should lead you away from the use of passive modalities. While chronically hyperactive muscle tissue is a neurologic condition, external electrical devices do not provide clinically relevant changes. (7)

3. Strive for Long-term Recovery and Prevention

Spinal manipulation and muscle stretching provide increases in the range of motion and diminished pain. But of equal importance, passive in-office treatment offers a window of opportunity to educate your patients on what is causing them to overload their joints. Movement re-training, postural alteration, and ADL advice must target the etiology of spinal overload. Your obligation to the patient is to identify the reason for developing their problem.  Long-term changes almost always require workstation modifications, movement retraining, and balanced muscle strengthening/rehab to prevent ongoing overloading.

Need more proof? 

Last month, yet another study highlighted the importance of rehab for chronic LBP: 

“Fusion surgery is not better than non-operative management that includes intensive rehabilitation therapy, in terms of either function or pain.  However, fusion is better than non-operative management without intensive rehabilitation therapy.” (8)

Our job, as evidence-based chiropractors, is to solve the mystery behind our patient’s pain.  We can do this cost-effectively and efficiently if we seek out short-term in-office strategies coupled with the long-term homework solutions for ALL of our patients.

It’s easy to read that and think, “okay, doc, that’s great, but what if I don’t have the time to do that for every condition?

Trust me, I get that. Time is valuable & often limited for our profession. That’s why we created ChiroUp. We’ve done the research, we’ve compiled the best treatments possible, and we’ve put it into one easy-to-use system that allows you to relay the best patient education to every patient, every time. See how ChiroUp can save you time so that you can focus on doing what you love most. Check out our plans today!

ChiroUp Empowers

References
  1. Kim, M. H., Yi, C. H., Kwon, O. Y., Cho, S. H., Cynn, H. S., Kim, Y. H., & Jung, D. H. (2013). Comparison of lumbopelvic rhythm and flexion-relaxation response between 2 different low back pain subtypes. Spine, 38(15), 1260-1267.
  2. Zwambag, D. P., & Brown, S. H. (2015). Factors to consider in identifying critical points in lumbar spine flexion relaxation. Journal of Electromyography and Kinesiology, 25(6), 914-918.
  3. Neblett, R., Mayer, T. G., Brede, E., & Gatchel, R. J. (2014). The effect of prior lumbar surgeries on the flexion-relaxation phenomenon and its responsiveness to rehabilitative treatment. The Spine Journal, 14(6), 892-902.
  4. Lalanne, Kim et al. Modulation of the Flexion-Relaxation Response by Spinal Manipulative Therapy: A Control Group Study Journal of Manipulative & Physiological Therapeutics , Volume 32 , Issue 3 , 203 – 209
  5. Arguisuelas MD1, Lisón JF2, Doménech-Fernández J3, Martínez-Hurtado I4, Salvador Coloma P4, Sánchez-Zuriaga D5. Effects of myofascial release in erector spinae myoelectric activity and lumbar spine kinematics in non-specific chronic low back pain: Randomized controlled trial. Clin Biomech (Bristol, Avon). 2019 Feb 14;63:27-33.
  6. Magnusson SP, Simonsen EB, Aagaard P, Dyhre-Poulsen P, McHugh MP, Kjaer M. Mechanical and physiological responses to stretching with and without preisometric contraction in human skeletal muscle.  Arch Phys Med Rehabil 1996;77:373-8.
  7. Garaud T. et al. Randomized study of the impact of a therapeutic education program on patients suffering from chronic low-back pain who are treated with transcutaneous electrical nerve stimulation. Medicine (Baltimore). 2018 Dec;97(52):e13782. doi: 10.109
  8. Barrey CY et al. Chronic low back pain: Relevance of a new classification based on the injury pattern. Orthop Traumatol Surg Res. 2019 Feb 18. pii: S1877-0568(19)30030-1.

About the Author

Dr. Brandon Steele

Dr. Brandon Steele

DC, DACO

Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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