A Case of Low Back Pain Treated with Cranial Therapy and Spinal Manipulation
A 35-year-old man shown to a chiropractic clinic complaining of severe pain in the lower back (pain radiating down the anterior and the lateral aspects of the upper left leg). Though the pain was bilateral, the pain was quite severe on the left side. The patient briefed about an accident that he had met with about two years ago that was followed by hospitalization for almost a week. Traumatic injuries and symptoms included severe neck and back pain, and was experiencing these symptoms since then. Post-traumatic radio-logical examinations revealed an abnormality in chronic L4-L5 facet and left sacroiliac joint. However, there were no signs of fractures or any nerve injury. Lower back pain was often triggered by continuous sitting, walking, cycling, rigorous physical exertion, and so on. Physical therapies including good posture habits and moderate exercise improved the pain.
The most likely diagnosis of this presentation is
- Spinal Injury
- A Slipped Disc
- Low Back Pain
Low back pain (LBP) is a very common ailment affecting almost 80% of the population at least once in a lifetime. It is often accompanied by other symptoms, including radiating pain towards the lower limb muscles, decreased movement and strength of muscles and has also been reported to trigger sensory decline. Low back pain majorly affects L4-L5 and 1st sacral vertebra which is a passage of peripheral nerves of the lower limbs.1 However, in almost 10% of patients, the primary origin of the pain is not found in the spine or surrounding region.2 When muscles are shortened for a long period of time, they trigger muscle atrophy, and causes stiffness of the joints thereby leading to reduced range of motion. 1 Risk factors for LBP are enlisted in Table 1.3
Exercise remains a mainstay approach in chronic low back pain (CLBP) management with its ability to reduce the risk of future back injuries, improve joint flexibility and movement and the muscle strength.4 Evidences also supports the benefits of the Craniosacral therapy in CLBP patients.2
Initial examination included a physical exam to look for stiffness, posture abnormalities and range of motion, which revealed a lower right rim of the ilium compared to the left side, lower right shoulder and bilateral pes planus. Range of motion was notably decreased. Kemp’s test shown to be positive on the left. The reflexes of S1, L5 and L4 were asymmetrical. The pin prick technique was used to examine Dermatomes in the legs, which was found to be normal. Palpation of the spine showed a restricted movement at T3-T8 on both sides, at L4-5-S1 on the right and L5-S1 on the left in right rotation. Further, the Yeoman’s test revealed a dysfunction in the sacroiliac (SI) joint. Results from neurological and orthopedic examinations were normal. Therefore, L4-L5 facet dysfunction caused due to trauma and left SI dysfunction was confirmed.
Based on the detailed exam, an addition of Cranial treatment along with the chiropractic treatment plan was considered. A technique of a Cox flexion-distraction with lateral flexion was undertaken which involved a flexion movement of the lumbar spine while holding the spinous process of L5. In addition, other high velocity-low amplitude techniques were applied to treat the abnormalities in the pelvis and the lumbar spine region and Trigger point therapy to the left gluteal musculature. Symptoms were significantly improved with this treatment approach and he was able to resume most of his daily activities. To avoid recurrence, physio-therapeutic training on practicing different types of recommended exercises was given. A bone scintigraphy was performed after 11 months of trauma, showing a lesion on the right sphenoid region, which was then treated using the Sacro-Occipital Technique (SOT) sphenoid lifting technique.
Conventional treatments for LBP have limited benefit in improving overall quality of life. Thus, complementary and Alternative Medicine (CAM) therapies have emerged as an important choice in the treatment of low back. The most prevalent CAM therapies for back pain include spinal manipulation, acupuncture, and massage. Spinal manipulation therapy uses a high-velocity, low-amplitude manual thrusts which is believed to displace and deform the tissues and adjust the anatomical orientation. Evidence has proven the impact of spinal manipulation on primary afferent neurons from paraspinal tissues, the motor control system, and pain processing.5 According to Cecchi F et al,6 spinal manipulation provided better short and long-term functional improvement, and more pain relief than physical therapy. In this case, low back pain was significantly improved after the cranial techniques. Fischer and colleagues represented a strong association of craniomandibular dysfunction with complex regional pain syndrome with decreased range of motion in the hip joint. According to the authors, the central nervous system acts as a bridge to pass on information between the temporomandibular joint and the rest of the body.7
The final outcomes of this case suggest that, adding Craniosacral therapy to spinal manipulation may be helpful to treat the symptoms of LBP.
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Wayne Powell, and Simone F.C. Knaap. Cranial Treatment and Spinal Manipulation for a Patient With Low Back Pain: A Case Study. J Chiropr Med. 2015 Mar; 14(1): 57–61.
Gouveia N, Rodrigues A, Eusébio M et al. Prevalence and social burden of active chronic low back pain in the adult Portuguese population: results from a national survey. Rheumatol Int. 2016 Feb;36(2):183-97.
Rainville J, Hartigan C, Martinez E, et al. Exercise as a treatment for chronic low back pain. The Spine Journal. 2004; Volume 4 (Issue 1): Pages 106–115.
Furlan AD, Yazdi F, Tsertsvadze A. Complementary and alternative therapies for back pain II. Evid Rep Technol Assess (Full Rep). 2010 Oct;(194):1-764.
Cecchi F, Molino-Lova R, Chiti M. et al. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Clin Rehabil. 2010 Jan;24(1):26-36.
Fischer M.J., Riedlinger K., Gutenbrunner C., Bernateck M. Influence of the temporomandibular joint on range of motion of the hip joint in patients with complex regional pain syndrome. J Manipulative Physiol Ther. 2009;32(5):364–371.