Low Back Pain & Sciatica Treatment Guide

2. Copyright © 2017 by Chris Dukarski, PT, Beverly, MA 01915, info@orthowellpt.com All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the publisher, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. For permission requests, write to the publisher, addressed “Attention: Permissions Coordinator,” at the email address above. DISCLAIMER: The information provided in this book is designed to provide helpful information on the subjects discussed. This book is not meant to be used, nor should it be used, to diagnose or treat any medical condition. For diagnosis or treatment of any medical problem, consult your own physician. The publisher and author are not responsible for any specific medical or health needs that may require supervision by a licensed healthcare practitioner, and thus they are not liable for any consequences from any recommendation, to any person reading or following the information in this book.

3. | 3 Table of Contents Introduction ...............................................................................5 So then, WHAT exactly causes low back pain? .........................7 One of biggest environmental influences .................................9 So what does your spinal curves have to do with it? .................12 The 4 main causes for low back pain and sciatica .....................13 Problem #1: Lumbar disc and facet joint sprains ......................14 Problem #2: Herniated Discs .....................................................16 Problem #3: Degeneration of the spine ....................................18 Problem #4: Sacroiliac Dysfunction ...........................................21 The Recipe for Success ..............................................................24 Best Treatment Strategy ............................................................27 In Conclusion .............................................................................29

5. | 5 Introduction Many books have been written on low back pain and sciatica This book is different It has been written to get right to the point. To give you a clear understanding of the root causes of low back pain and sciatica. To give you a clear understanding of YOUR low back pain and sciatica. By the end of this book you should get 4 things: 1. A clear picture of what causes low back pain and sciatica 2. An understanding of the four main causes of low back pain and sciatica 3. A clear picture of what is causing YOUR low back pain and sciatica 4. A plan of action to alleviate your low back pain and sciatica The rest is up to you. Enjoy the read Best in health, Chris Chris Dukarski,PT

6. 6 | Low Back Pain & Sciatica Treatment Guide If you currently have low back pain or have experienced it at some point in the past… You’re not alone. 80% of people at some point in their lives will experience low back pain. What if I told you that up to 80% of Americans (including professional athletes) can have a herniated disc…but have NO low back pain. What if I told that 95% of Americans over the age of 50 have either spinal arthritis, disc disease or stenosis…but not necessarily any pain. So what is the purpose of an MRI if having a herniated disc or arthritis in your spine may just be “normal”. Is the MRI really worth the money that you’re spending on it? Or is your herniated disc or stenosis simply a ticking bomb just waiting to explode?

7. | 7 So then, WHAT exactly causes low back pain?

8. 8 | Low Back Pain & Sciatica Treatment Guide Let me explain. Genetically speaking, you are born with a specific code that you inherited from your parents. How many times have you heard “Well, my mom had a bad back too”. You can’t run away from your genes. You just need to learn how to manage things better knowing that you have a family history of low back pain. As we evolved from walking on all fours to walking upright this new orientation brought on a new set of challenges.

9. | 9 One of biggest environmental influences: The effects of GRAVITY! As we age we become all too familiar with the effects of gravity. As we stand upright, the effects of gravity on our bodies and especially on our spines becomes much more significant. Gravity has the effect of continuously pulling us down and, in most cases, pulling us forward thus causing us to slouch and to compress our spines. I’m sure you will agree, it is much easier to sit slouched then to sit straight. By the same token, it is much easier to bend over at your waist to pick something up then to engage your muscles against the effect of gravity by sticking your butt out and bending your knees in order to protect your spine.

10. 10 | Low Back Pain & Sciatica Treatment Guide The chart below shows that the amount of pressure on your discs while slouching forward with weight in your hands is more than double the pressure of that in straight standing. Holding 10 pounds out in front of you with outstretched arms becomes 100# of pressure on your spine. What most of us do not realize (until it’s too late) is that these effects are cumulative. The biggest question is not IF it will happen but….

11. Low Back Pain & Sciatica Treatment Guide | 11 When it will happen? & How it will happen?

12. 12 | So what do your spinal curves have to do with it? Structurally there are three distinct curves to a normal spine. When the position of these three curves are maintained, you optimize your ability to function against gravity. When they are not maintained, you set yourself up for injury. So what exactly happens to the spine under these circumstances?

13. | 13 LOW BACK PAIN & SCIATICA!! The 4 main causes for low back pain and sciatica are: • Lumbar disc and facet joint sprains • Herniated Discs • Degenerative problems such as arthritis, stenosis or disc disease • Sacroiliac joint dysfunction

14. 14 | Problem #1: Lumbar disc and facet joint sprains How about a quick anatomy review? There is one vertebral disc in between each vertebra in your spine. Each disc has a strong but flexible fibrocartilage exterior and a soft, jelly-like interior. Each vertebrae that the disc is attached to is made of bone. Each vertebra articulates with the next one thru your facet joints and this articulation allows motion between the vertebra. Your discs act like shock absorbers for your spine.

15. Low Back Pain & Sciatica Treatment Guide | 15 Each vertebra has a distinctive shape and a distinctive orientation of the facet joints. There are two facet joints on each vertebra. The shape of the vertebra, the orientation of the facet joints and the flexibility of the discs allows for a specific amount of motion in each section of your spine. As motion is introduced to the spine, stress can be placed on any one of these structures. So how do you sprain a disc or a facet joint? The exterior one third of the disc is very highly innervated ie there are a lot of nerves. High velocity stresses and extreme loads, especially with the combination of twisting and bending forward, can actually sprain or tear the exterior of the disc. The nerves in the outer third of the disc become irritated and cause pain. The same high velocity stresses and extreme loads that sprain the disc can also sprain the facet joint. Experiments have been performed that actually cause sciatica symptoms when an irritating substance is injected into a healthy facet joint. The duration of the pain with each subsequent episode of sprain to the disc or to the facet joint can gradually increase over time. The first time may last for a couple hours but the 7th time could last a full week. This process sets into motion a progressive deterioration of the supportive structures in your spine. It can even lead to the next main cause of low back pain. Herniated Discs!

16. 16 | Problem #2: Herniated Discs So what exactly goes wrong with the disc? When pressure is imparted to a healthy disc, the pressure is equal in every direction. The potential problem with a vertebral disc is that the rear corner of the disc is the thinnest and most susceptible to injury. As you bend forward, you pinch the front of the disc and stretch the back of the disc. Over time, especially with a history of slouching and improper lifting and a history of repeated disc sprains, the rear corner of the disc can start to weaken. When you slouch or bend forward, the gel interior gets pushed backwards and can start to bulge out against the weakened disc. The evolution of a herniated disc… As the herniation progresses, it can impart a pressure or a “pinch” on the intervertebral nerves that branch off of the spinal cord. In severe cases, the disc can rupture. Each vertebral level of your spine has two intervertebral nerves. One exits each side of the

17. Low Back Pain & Sciatica Treatment Guide | 17 disc. As the intervertebral nerve becomes irritated by constant pinching, it can start to cause referred pain into your leg. Welcome to the world of sciatica…. So why is it that 80% of Americans can have a herniated disc and have NO pain? The answer to this question is very similar to something that we will talk about next when it comes to discussing why 95% of Americans over 50 have arthritis in their spine. As we go through life and deal with the constant effect of gravity on our spines, there is a slow, gradual deterioration of the supportive structures in our joints and in our discs. This gradual deterioration may or may not cause pain depending on the speed of the deterioration. Our bodies can adapt very well to these changes if they do not happen too quickly. Yes, you may have occasional low back pain due to the spraining effect that we talked about earlier, but the disc herniation may never reach the “pinched nerve” level. As a result, you can have a herniated disc that remains but does not cause pain. However, the damage has been done and the herniation is much more susceptible to the stresses of gravity and stressful activity. So beware…that herniation could increase and cause the pinched nerve associated with sciatica.

18. 18 | Problem #3: Degeneration of the spine Is this inevitable? The answer to that question is…YES. 95% of Americans over the age of 50 will develop degenerative problems such as arthritis, stenosis, and/or degenerative disc disease. The only unanswered part to that question is to what degree? As I mentioned earlier, there is a slow, gradual deterioration of the supportive structures in our joints. This gradual deterioration may or may not cause pain depending on the speed of the deterioration. Our bodies can adapt very well to these changes if they do not happen too quickly.

19. Low Back Pain & Sciatica Treatment Guide | 19 So what are the different types of degeneration? Osteoarthritis is a degenerative change in the supportive joints of your spine. It can occur in the facet joints and around the periphery of the disc. It can present as narrowing of the joints, thickening of the soft tissues around the joint or as spur formations. Degenerative disc disease is the presence of discs that have dried out and have become thinner and more narrow. This is one of the reasons we lose height as we age. Spinal stenosis is a condition in which progressive degeneration around the spinal joints can cause a narrowing of the canal that the spinal cord travels through. It can also cause a narrowing of the canal that the intervertebral nerve courses through. This can lead to a pinched nerve or a pinched spinal cord. Just because you are told by your physician that you have one or more of these degenerative changes does not mean that you are going to have pain. But what if you do? What do you do about it?

20. 20 | Low Back Pain & Sciatica Treatment Guide

21. | 21 Problem #4: Sacroiliac Dysfunction So what is the SI joint? The sacroiliac joint is a joint between the sacrum and your pelvis. There is an SI joint on either side of the sacrum. It is surrounded by very dense ligaments that provide support and allow load to be transferred through it. There is much debate as to how much motion actually occurs at the SI joint with estimates at less than 5 degrees of motion.

22. 22 | Low Back Pain & Sciatica Treatment Guide The likelihood of trauma or pain arising from the SI joint is much smaller than the aforementioned conditions. 15-20% of the population may experience SI pain. The biggest causative factor for SI pain is after a forceful trauma to the pelvis such as bracing yourself for impact in a car accident or landing hard on your leg. A shifting of the pelvis can occur during pregnancy as the ligaments of the pelvis relax for childbirth or with the hypermobility associated with a history of dancing or gymnastics. SI pain can also result from the degenerative changes mentioned earlier that impact the ability of the SI joint to transfer load from the legs through the pelvis.

23. Low Back Pain & Sciatica Treatment Guide | 23 The next question is what do you do if you have low back pain?

24. 24 | The Recipe for Success So what is the first step to alleviating your pain? The first step is to answer the necessary questions to determine exactly what the source of your pain is. There is a typical presentation to the 4 main causes of low back pain. Lets begin. #1: Lumbar disc or facet joint sprain 1. Is your pain localized to your low back? 2. Did you perform any high velocity or high load activities? 3. Do you have infrequent episodes of sciatica? 4. Has your pain been more episodic and induced by activity? 5. Is your pain quickly alleviated with anti-inflammatories and icing? If you answered YES to these questions, then you could have a case of lumbar disc or facet joint sprain. #2: Herniated Disc 1. Do you have a sharp, pin-point pain that starts in your low back and courses down your buttock into the back of your leg?

25. Low Back Pain & Sciatica Treatment Guide | 25 2. Do you ever experience a lateral shifting of your pelvis? 3. Is your pain increased with activities such as forward bending, lifting, prolonged sitting, coughing and sneezing? 4. Do you typically feel better moving and walking? If you answered YES to these questions, then you could have a herniated lumbar disc. #3: Degenerative Changes such as arthritis, stenosis or degenerative disc disease. 1. Do you have broader and more generalized aching symptoms in your back and into your leg? 2. Do you experience an increase in pain with standing and walking? 3. Do you find yourself hanging over a grocery cart while shopping? 4. Does sitting improve your symptoms? If you answered YES to these questions, then you could have a degenerative condition such as spinal stenosis. #4: SI Joint Dysfunction 1. Does your pain usually start in the area of the SI joint and then wrap around to the outside of your thigh to your groin? 2. Were you recently in a car accident or a fall onto an outstretched leg? 3. Do you have a history of pain during pregnancy? 4. Do you have history as a dancer or gymnast? 5. Does one of your legs feel heavier or longer than the other one?

26. 26 | Low Back Pain & Sciatica Treatment Guide 6. Do you have difficulty putting on your socks or shoes on your painful side? 7. Do you have an increase in pain sitting for long periods of time, rolling in bed or getting out of your car? If you answered YES to these questions, then you could have an SI joint dysfunction. What next?

27. | 27 Best Treatment Strategy EDUCATION Knowledge is Power! You’re first step in recovery is understanding your condition and understanding the best way to treat it. The second step is realizing that if your pain is reproducible, it is probably reducible. So lets give you a plan of action to reduce it and alleviate it once and for all. Step #1: Go to You Tube and search Best 3 Strategies Low Back Pain You can also access the link at www.orthowellpt.com and click on Special Program. Click Best 3 Strategies. My videos will explain the Best 3 Strategies to treat low back pain. The content of these videos is applicable to ANY of the aforementioned causes of low back pain. You need to create a foundation to heal and these videos will provide that.

28. 28 | Low Back Pain & Sciatica Treatment Guide Step #2: Go to You Tube and search Best 3 Strategies for Low Back Pain You can also access the link at www.orthowellpt.com and click on Special Program. Click Best 3 Strategies. The Best Exercise for each main cause of low back pain will be presented in each of the videos on my Best Exercises playlist. Best Exercise Disc Sprain Best Exercise Herniated Disc Best Exercise Stenosis Best Exercise SI Joint Dysfunction

29. | 29 In Conclusion Low back pain is a treatable and curable condition. Can you change your genetics? NO. But you can manage the influence of the environment upon it. The first step is understanding your condition. The second step is following a recipe for success with an effective plan of action. The third is looking for a qualified physical therapist if you are not successful in resolving your pain with steps 1 and 2. Give me a call at OrthoWell Physical Therapy if you need my help. Beverly, MA 978-522-4199 Newburyport,MA 978-462-2700 info@orthowellpt.com Best in Health, Chris Dukarski,PT

30. Chris Dukarski, PT is the owner of both OrthoWell Orthopedic & Sports Physical Therapy and WalkWell Foot Orthotics in Beverly, MA and Newburyport, MA. He has over 25 years of experience treating orthopedic and sports conditions with an emphasis on biomechanical analysis and the fabrication of custom foot orthotics. He graduated summa cum laude from Wayne State University in 1990. He has extensive post graduate and continuing education experience that can be read on his website at www.orthowellpt.com. His passion for sharing his insights and educating his patients is evident in his blog postings and website at www.orthowellpt.com. He continues to investigate orthotic, bio-mechanical, and treatment through self-study and continuing education. His enthusiasm and expert knowledge has enabled Chris to create a dynamic team of physical therapists that will maximize your results in minimal time.