Wisdom Wednesday: Acute Low Back Pain – A Brief Case History

This is the first in a series of typical case histories taken from my office notes. They will appear in the Wisdom Wednesday blog slot intermittently. I hope they will give the reader some insight into managing and guiding a patient through a health issue.

A 66-year old female returns to my office for the first time in six years with complaints of acute low back pain. She has been struggling with chronic bilateral knee pain and has had a couple of orthopedic opinions on treatment ranging from medication management to total joint replacement. She denies radiating pain from the back to the legs and believes the onset is related to compensating for the knee pain. She is currently on the following medications: Atenolol, Celexa, Benacar, Zyrtec, Eliquis, Prempro, Simustatin, Armour Thyroid, Flecainide and 2 baby aspirin per day. (The average American takes 4 prescription medications daily, so this patient is taking twice that amount. I commonly see patients taking 16 different prescription medications on a daily basis).

Autogenic Facilitation (AF) was intact, using a weak left gluteus medius as an indicator muscle. (This indicates no body wide injury response by the nervous system. Her body has either resolved the injury neurologically, or there was no body wide injury stimulation to begin with - the later fits her history) Oral challenge with a mix of NSAIDS resulted in strengthening of the weak muscle. A favorable response to oral challenge with fish oil was noted. (These tests indicate that her primary inflammatory response is the production of prostaglandins despite taking aspirin daily which tends to block this pathway) Challenge of the left ilio-lumbar ligament was positive in weight bearing only, corrected by Injury Recall Technique (IRT). (This is a local injury reflex and is the most common source of ongoing neurological stimulation in low back pain) Gait assessment was intact. (Despite her contention that this low back episode is the result of compensating for her knee pain, no altered gait mechanism was indicated)

Wisdom Wednesday: GAIT MECHANISMS

The last step in the QA protocol is the evaluation for gait. The neurological organization required to walk upright is very complex. (Please review my blog “Did Walking Upright Make Humans Smart” posted on Friday, June 6, 2014) It takes most of us about a year to learn the process as infants. These neurological patterns develop from the “cross crawl” human babies use prior to walking.

Gait evaluation examines these patterns looking for distortion as it relates to structural issues. I commonly test the latissimus dorsi or “lat” bilaterally as my last step during an office visit. With the patient standing, feet even, I test for a strong latissimus dorsi with the left arm. Then the patient takes one step backward with the left foot. Now they are in a gaited position, as if they were walking. The left latissimus dorsi should now become weak if there are no abnormal gait patterns at work. The procedure is repeated on the right, looking for the muscle to weaken with the right foot back.

Did Walking Upright Make Humans Smart?

Dr. Mac Shine, a neurology researcher at the University of Sidney, Brain and Mind Research Institute and his father, Rick Shine, Professor in Evolutional Biology, have recently published a paper in Frontiers in Neuroscience.
Wednesday, May 28, 2014 (Medical News Today)

The inspiration came from watching their son/grandson learn to walk. When toddler Tyler Shine began, they observed how every step required his full attention. But as walking became routine, Tyler began to pay attention to his surroundings. He was also able to balance better, which helped free up his attention and focus on more interesting tasks. (Photo via CG-links)

They developed the idea that Tyler was transferring control of balance to “lower” parts of the brain. This released the cortex from the drudgery of routine, lower order processes, freeing it up to focus on unpredictable challenges such as obstacles.

Tyler’s father, Dr. Shine, says that at first all complicated tasks – for example driving a car or playing and instrument – take up our full attention, but they eventually become routine.

“Studies of brain function suggest that we shift the control of these routine tasks down to ‘lower’ areas of the brain, such as the basal ganglia and cerebellum,” he explains. “So, humans are smart because we have automated the routine tasks; and thus, can devote our most potent mental faculties to deal with new, unpredictable challenges.”

He and his father propose that the change from walking on all fours to walking on two legs- bipedality- was the key event in the early history of humans that prompted a change in the way we use our brains.
They postulate that the onset of walking on two legs posed “massive nerocomputational challenges” to the brain, and this drove the “rapid expansion of human cognitive capacity.”

“Specifically, the ability to rapidly ‘delegate’ well-learned behaviors into subconscious processes liberated higher neural centers to be available for flexible, ‘online’ processing fitness-relevant stimuli,” they note.
Dr. Shine says while new technology allows us to find out more and more about how the brain works by looking inside it, in order to interpret what we observe, we also need new ideas. He says he is “delighted” that his son inspired one of these new ideas.

MY TAKE:
This novel look at neurological and evolutionary development fits many of the patterns I see everyday in the clinical setting.

Eighty percent of my new patients have an ‘injury reflex’ upon entry. This neurological imbalance impairs higher areas of the brain with aberrant input from a site of former injury. Once corrected, improved neurological function is noted in both the brain and spinal cord.

Injury Reflex Technique (IRT) works by stimulating the lower brain centers and the injury site simultaneously. This has a ‘rebooting’ effect, much like erasing the memory buffers in a computer when you turn it off and back on again. Much like a computer, the nervous system is now free to function without the glitches that caused the computer to freeze initially.

Stimulation of the lower brain centers is most often performed by quick dorsiflexion of the ankles. This stimulates the rich neurological bed in the ankles associated with walking. Having the patient in weight bearing, with the feet firmly on the floor is also used to reinforce these same walking neurological patterns.

Checking for an IRT reflex is the first thing I perform with each and every patient. The last thing I check, after any evaluation, is the gait mechanism. This looks for altered neurological patterns associated with walking. Once any imbalance in gait is corrected, I know I have restored function of the nervous system to the best of my abilities.

THE BOTTOM LINE:
What these researchers have postulated may be an over simplification of a very complex process, but their theory has merit. I look forward to more novel ideas and approaches to the human body.