I was asked this week why I do not x-ray all of my patients. A woman asked me, "Well how do you know what's going on if you can't see it?" She went on to explain that her daughter goes to a chiropractor who takes an x-ray of all of his patients and then reviews it with them. This is a great patient education tool and it also allows the doctor to detect conditions that he or she otherwise would not find while performing an examination.
Asking why I do not practice this myself is a great question, there is such diversity within our profession that we are often faced with questions of this nature. I appreciate the diversity within our profession, it proves that we are capable of effectively treating a wide variety of conditions. I answered this woman's question by explaining that if I do not feel that imaging will change my treatment plan then ethically I cannot order the imaging. A detailed history and examination will often give me the information I need to develop an appropriate treatment plan. If it is not needed then I would prefer to treat the patient rather the image. There is also the argument that when unnecessary it is not the standard of care to expose a patient to radiation. Unnecessary imaging also comes with a financial burden, costing billions each year.
Bartoszewski, Melissa DC. "The Clinical Necessity of Imaging". Aug 2014 ACA News. <http://www.acatoday.org/content_css.cfm?CID=5527>.
Brief Anatomy Lesson:
The iliopsoas muscle group is comprised of the psoas major, psoas minor and iliacus. The psoas major muscle attaches to the vertebral bodies and discs of T12 and all of the lumbar vertebrae (L1-L5) and inserts on the lesser trochanter of the femur. The psoas minor is actually absent in 40% of people! When present, it attaches to the vertebrae and discs of T12 and L1 and in some cases to L2 as well. The psoas minor inserts on the pectineal line. The iliacus attaches to the superior 2/3 of the iliac fossa, the iliac crest, and the base of the sacrum and inserts on the tendon of the psoas major and the lesser trochanter of the femur. The action of this muscle group is hip flexion.
Why is it Important?
Dr. John Stump explains in his paper titled "America's Continued Back Attack", the increased amount of time Americans spend sitting each day and the lack of physical activity are at the root of the problem of back pain and obesity. While sitting, some of your muscles relax and some are overworked, remaining in this position for too long leads to muscle imbalance. The iliopsoas muscles become shortened and tight and can actually lose its functionality. When shortened, the muscle can pull on its attachment site in the low back, leading to low back pain.
Travell and Simons have mapped the trigger point pain referral of the psoas muscle and they have found that there are numerous locations in the psoas muscle where trigger points can refer to the low back. The most frequent complaints when a trigger point is present in the psoas muscle are low back and hip pain. The trigger points can be activated by prolonged sitting, driving and sleeping in a fetal position.
To treat the psoas muscle I either have the patient lay in side posture or face up on the table. As the patient takes a deep breath in I will wrap my fingers around the iliac crest (the anterior superior iliac spine more specifically). Once in contact with the muscle, the patient is instructed to slowly straighten their ipsilateral (same side) leg. If tolerable, the patient can slowly internally and externally rotate their hip at that time and then bring hip and knee into flexion to relax the psoas muscle. Once in a relaxed position I once again ask the patient to take a deep breath and I sink my fingers deeper into the muscle and repeat. The location of this muscle deep within the abdominal cavity results in a very different feeling while receiving treatment. It is a very odd but yet relieving feeling.
It is impossible to avoid sitting, as a society we work longer hours at our desk, we have longer commutes sitting our vehicles and we sit down at home after work more than ever before. Incorporating an exercise routine that focuses on strengthening the core and low back will have a long lasting beneficial effect. Additionally, there is a very simple practice that you can incorporate into your daily life that would help break this cycle of muscle shortening and low back pain.
The Bruegger's Relief Position is most effective when performed every 30-60 minutes. The position is achieved by sitting at the edge of the chair, with your legs slightly apart and your feet on the floor. The feet and knees should be slightly turned out and the pelvis tilted slightly forward. You should establish a slight “hollowing” of the lower back and increase its curvature (called lordosis).
Your chest should be lifted both up and out, which should allow the shoulders to settle backwards without strain. The arms are allowed to rest on the thighs with the hands facing forward. Lastly the chin is gently tucked in and the head high and facing directly forward. Open the pectoral muscles, allow for proper breathing, let the shoulders relax, and focus on gently drawing your shoulder blades down and together. Hold this position for approximately 10 seconds, relax and repeat two more times.
Stump, John L. "America's Continued Back Attack". June/July 2013 ACA News. <http://www.acatoday.org/content_css.cfm?CID=5202>
Dr. Perry, Laura. "Iliopsoas Trigger Points: Hidden Pranksters of Low Back Pain". Jan. 2013 The Trigger Point Therapist. <http://www.triggerpointtherapist.com/blog/psoas-pain/iliopsoas-trigger-points-low-back-pain/>