Chronic Lumbopelvic Pain - The Coccyx, Sacrum, Lumbar Spine, and Innominate.
A Little Back Story
Since 1999 I have trying to sort out my own version of chronic lumbopelvic pain. As a 15 year old student athlete I suffered an injury to what at the time I understood to be my low back. Almost 20 years later MRI confirmed that I have signs of disc herniation at L4/L5 and L5/S1 with evidence of facet arthritis coupled a history of sacroiliac dysfunction. Given my history, and these findings, one might find my long time assumption that disc injury was the root of my pain to be accurate. However, there is a good deal of evidence in the literature suggesting that disc derangement often associated with back pain may be prevalent in asymptomatic populations at a rate of up to 37% in those in their 20s and 97% in those in their 80s.(1) Such findings might suggest that psychological or neurophysiological factors may play a greater roll in chronic low back pain than derangement or injury. Yet, while researchers have suggested that the effects of intervention focused on psycho-social aspects of pain can be effective, they may result in small, short term results with mediocre evidence of efficacy compared to active physical intervention.(2-4)
When considering treatment strategies and a biopsychosocial approach to pain, both biological and psycho-social intervention must play a role. Perhaps most interesting among the factors contributing to low back pain, dysfunction, and intervention for such conditions is the interplay between the coccyx, sacrum, innominate bones, and lumbar spine. Injury, dysfunction, and pain in one of these areas can cause a cascade of interrelated symptoms and can make meaningful intervention difficult if one or more factors is missed. Through my personal history with such issues I have developed a particular interest in low back pain and low back pain patients. My clinical practice has presented with an opportunity to help a young person who, by all accounts, is well on their way to a lifetime of pain and dysfunction.
The Patient and Case
The patient is an active 15-year-old female participating in volleyball, basketball, equestrian, and track and field. She was diagnosed with a subluxed coccyx after an ice skating accident approximately one and a half years prior to beginning treatment with me as her athletic trainer. In that time she had sought care through multiple physicians, an arthritis specialist, a chiropractor, reportedly becoming nauseous after adjustment, physical therapists, and a massage therapist. Her pain is centered around her sacroiliac joints with the left being more painful than the right. She also reports tenderness in her L5 vertebrae and coccyx area as well as upper back pain in the area of T6-T10. The patient also reports intermittent cramping and spasm in her right glute and left quadriceps. Including the use of prescription pain medication and muscle relaxers the patient claims that she has been in constant pain rated on a Numerical Pain Rating Scale (NPRS) at a 6-9/10. She also reports having almost constantly interrupted sleep since her injury. She has continued to play sports and engage in activity as usual over the course of her injury despite her pain. At the time of evaluation she had largely stopped seeking medical attention for her pain. Below is a timeline of treatment utilizing a combination of treatments including but not limited to PRT, PRRT, MET, Mulligan Concept, MDT, and tape applications. The patient had been under my care prior to the beginning of data collection for a short time with limited results. In context, at the time data collection began, an NPRS of 4/10 during treatment represented a profound positive change for this patient.
Significant events corresponding to this timeline are as follows:
10/13/2017: The patient was asked if she felt that she was viewed as ‘the girl with the back pain’ and if her pain was ‘becoming part of her identity’. To both of these questions she responded ‘yes and I do not like it’. This prompted me to begin using the Tampa Scale for Kinesiophobia in order to try to gain a grasp of her understanding of her pain.
10/13/2017 - 10/30/2017: Conversation with the patient centered upon her feelings that intervention would only make her pain worse and that she felt like her pain was not well understood. I reminded her that she had, in over a year, never been below a 6/10 on the NPRS per her report of her history and in two months we were able to get her pain to a 1/10, if only briefly during treatment but that this was a sign that we were beginning to understand her pain and injury/dysfunction. I also asked the patient if she could imagine not being in pain. She responded that she could. This gave us a positive starting point from a psychological stand point. During this time the patient’s TAMPA scores reached a minimum 11/44 on the TAMPA scale.
10/25/27 - During treatment we discovered that significant pressure on the patient’s sacrum effectively rotating the sacrum along a vertical axis from left to right could significantly reduce the patient’s pain down to a 3/10, though her pain would return and/or increase immediately following treatment.
10/26/2017 - 10/30/2017: The addition of an inferior shear force during sacral mobilization reduced the patient’s pain to a 1/10 with a post treatment NPRS of 4/10 that would last for up to an hour. Later movement in the form of prone extension and extensions with rotation were added with the patient's pain remaining at a 0-1/10 during treatment.
10/30/2017: Basketball season began causing an increase in the volume of conditioning (running) the patient engaged in and elevating pain significantly throughout the patient’s experience. This prompted a conversation regarding pain as an output from the brain rather than an input from the body. This was explained as her brain and her nervous system over-reacting to a previously traumatic event or injury. The patient was able to grasp this concept and the notion that it did not mean that it was 'all in her head' but rather a perception of danger on the part of her nervous system to a previously very real threat that may or may not remain to some degree. Also at this time the decision was made to re-introduce therapeutic exercise with careful attention to regression and progression in order to find a barrier to entry post treatment for movement that would not immediately return or significantly exacerbate her pain.
11/7/2017: The patient was able to utilize multi-segmental trunk flexion with L innominate posterior rotation and L to R sacral pressure to relieve symptoms to a 1/10 during treatment with continued relief gradually increasing to a 4/10 post rehabilitative exercise.
11/15/2017: A joint re-evaluation between myself and my clinical student, based on some of his readings regarding treatment and evaluation of lumbopelvic pain, uncovered a right rotation fixation of the 5th lumbar vertebrae. A potential driver missed in my initial evaluation. Throughout a combination of evaluation and old/new treatment to address the coccyx (PRRT), sacrum (Mulligan and MET), and 5th lumbar (Mulligan), the patient experienced relief of post practice symptoms to a 4/10 but with a number of physical markers to indicate that dysfunctions were being addressed comprehensively. A return to the previous treatment of innominate rotation with Mulligan Concept into multisegmental spinal flexion reduced the patient’s pain to a 1/10 though her pain was elevated to a 7/10 during the following school day.
11/16/2017: After practice the patient reported with a maintained 7/10 pain throughout the day and basketball practice. A quick treatment based re-evaluation revealed that he sacrum was no longer stuck in right to left rotation along a vertical axis and was significantly more mobile. This was confirmed with a negative Gillet's test. The multisegmental flexion with innominate rotation Mulligan mobilization with movement was applied and the patient’s pain fell to 0/10. the innominates were taped with the L into posterior rotation and the right into anterior rotation. During my documentation period, my clinical student and I continued to converse with the patient for over 30 minutes. As she began to leave I asked her for a number, a common practice with this patient. Her response was an incredible smile while holding up a closed fist and saying 0. She then turned and skipped down the hallway. It appeared we had found the combination of treatments with which to begin resolving this patient’s chronic lumbopelvic pain.
11/17/2017: Speaking of barriers to entry with therapeutic exercise, we have bypassed this idea in grand fashion. The patient took part in team strength and condition with no increase in symptoms having a day long period of time including practice and strength and conditioning with an maximum NPRS of 3/10.
11/20/2017: "Trampoline parks are not good for SI joint pain" This was the quote from my patient as she entered the Athletic Training facility Monday afternoon. I was apparently still treating an active 15 year old who having 0/10 pain for the first time in nearly 2 years resumed being an even more active 15 year old. Mulligan mobilization with movement and tape application as described above immediately reduced the patient’s pain to 0/10 with regression to 1/10 after both practice and strength and conditioning. It became apparent that even after a significant setback we were on the right path.
As of 12/3/2017: The patient now goes full days without pain only suffering increases in pain with significant contact on the basketball court, she is a hustle player, picture a tiny Detroit Pistons era Dennis Rodman, that can be quickly addressed. While this is an ongoing case, these results are quite exciting.
References
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36:811–16
Pincus T, McCracken LM. Psychological factors and treatment opportunities in low back pain. Best Pract Res Clin Rheumatol. 2013;27(5):625–35.
Ramond-Roquin A, Bouton C, Gobin-Tempereau AS, Airagnes G, Richard I, Roquelaure Y, et al. Interventions focusing on psychosocial risk factors for patients with non-chronic low back pain in primary care--a systematic review. Fam Pract. 2014;31(4):379–88.
Petersen T, Laslett M, Juhl C. Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC Musculoskelet Disord. 2017;18(188). doi.org/10.1186/s12891-017-1549-6