Ep 116 – Low-Back Pain with Dr. Ben Benjamin

Hand rubbing a lower back in pain

Low-back pain is certainly one of the most, if not the most, pressing issues practitioners will face when working with clientele. More than 70 million people visit doctors each year with low-back pain, so as an MT, knowing the what and how of working with this population can be valuable. Dr. Ben Benjamin joins the podcast to talk about his personal experience with low-back pain, common myths and misconceptions surrounding this injury, the most common causes, how to prevent low-back pain through exercise and diet, and knowing when hands-on treatment is appropriate. Dr. Benjamin relays the value of a health history intake, hands-on tests for assessment, and when to refer out.

Resources from the author:

“Keeping Clients Safe, Part One: How to Avoid Client Injuries,” Massage & Bodywork magazine, May/June 2021, page 64. www.massageandbodyworkdigital.com/i/1358392-may-june-2021/66.

“Clients Crossing Boundaries in the Treatment Room,” Massage & Bodywork magazine, March/April 2020, page 54. www.massageandbodyworkdigital.com/i/1208028-march-april-2020/56.

Author Images: 
Dr. Ben Benjamin
Author Bio: 

Ben Benjamin, PhD in sports medicine, has been practicing massage since 1963 and has been nationally recognized for his contributions to massage therapy, receiving an induction into the Massage Therapy Hall of Fame in 2010. With his years of experience as a therapist, educator, and author, Dr. Benjamin has been regarded as a voice of authority in the muscular therapy field. He was the founder and president of the Muscular Therapy Institute in Cambridge, Massachusetts, which began in 1974. Shortly after the Muscular Therapy Institute opened, Dr. Benjamin enhanced his practice by studying under Dr. James Cyriax, widely known for his pioneering work in orthopedic medicine. He has also integrated Aaron Mattes’s Active Isolated Stretching (AIS) techniques into his therapy. With a passion for helping individuals cope with and overcome pain, Dr. Benjamin has been lecturing internationally for more than four decades and written countless articles in publications such as Massage & Bodywork magazine. Dr. Benjamin is also the author of several works referenced by those educators and students in the field, such as Listen to Your PainAre You Tense?Exercise Without Injury, and co-author of The Ethics of Touch and Conversation Transformation. For more information, visit benjamininstitute.com.

Sponsors: 

This podcast sponsored by:

Anatomy Trains:  

Anatomy Trains is a global leader in online anatomy education and also provides in-classroom certification programs for structural integration in the US, Canada, Australia, Europe, Japan, and China, as well as fresh-tissue cadaver dissection labs and weekend courses. The work of Anatomy Trains originated with founder Tom Myers, who mapped the human body into 13 myofascial meridians in his original book, currently in its fourth edition and translated into 12 languages. The principles of Anatomy Trains are used by osteopaths, physical therapists, bodyworkers, massage therapists, personal trainers, yoga, Pilates, Gyrotonics, and other body-minded manual therapists and movement professionals. Anatomy Trains inspires these practitioners to work with holistic anatomy in treating system-wide patterns to provide improved client outcomes in terms of structure and function.  

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Handspring Publishing:

Handspring Publishing specializes in professional-level books for massage therapists, osteopaths, yoga and Pilates teachers, physiotherapists, and other professionals who use touch or movement to help patients achieve wellness.

Handspring Publishing’s books are written and produced to serve the professional and educational needs of health and medical professionals, musculoskeletal therapists, and movement teachers. Its list includes bestsellers like The Accidental Business Owner: A Friendly Guide to Success for Health and Wellness Practitioners by Kelly Bowers, Fascial Stretch Therapy by Chris and Ann Frederick, Fascia: What It Is and Why It Matters by David Lesondak, and the just-published third edition of Pre- and Perinatal Massage Therapy by Carole Osborne, Michele Kolakowski, and David M. Lobenstine. Handspring’s books combine attractive and accessible presentations with an evidence-based approach to writing, including referencing the latest research findings. Authors are drawn from the ranks of highly respected teachers and experts in their area of specialization including Til Luchau, Robert Schleip, Graham Scarr, Gayle MacDonald, and Carolyn Tague among others. ABMP members save 20% off regular list prices. Visit handspringpublishing.com and use discount code abmp20 to order. Shipping is free to all addresses in the United States and the United Kingdom.

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(se) Connect:

At Structural Elements, we view ourselves as Body Engineers. We evaluate the human body according to its structural integrity and establish proper balance between compression and tension elements. Through identifying patterns in the body, we are able to locate areas of compensation to treat the cause of the imbalance, not the site of pain. Our patients achieve lasting results as we reduce structural imbalances, improve connective tissue health, and reeducate movement patterns. Now, we have taken our education, operations, and communications infrastructure from our franchise company and made it available to the industry through (se) Connect.

(se) Connect is the only interdisciplinary knowledge sharing platform that exists in the wellness industry. Participants gain access to treatment tools, business tools, and the ability to connect with other professionals in a variety of modalities. Through our community, massage therapists, physical therapists, chiropractors, athletic trainers, acupuncturists, and others all learn to look at the body through the same lens, which allows for rich discussions on patient care and treatment options. Our training staff brings decades of experience in massage, manual therapy, acupuncture, chiropractic, and business, and we look forward to sharing that with you.

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Full Transcript: 

0:00:00.1 Kristin Coverly: This episode of The ABMP Podcast is sponsored by Pain in the App, mobile app by Dr. Ben Benjamin. Pain in the App is a new mobile app to learn about the injury process from head to toe. Quiz yourself on the theory behind why injuries happen and what we can do about it. Dig into how specific treatments work and why. Get started on Pain in the App with dozens of free questions, then get hundreds more for only 9.99. But be careful, it's addictive. Go to the App Store or Google Play and search for Pain in the App.

0:00:36.9 KC: With se® Connect, you can learn a 15-minute comprehensive manual therapy treatment that will set you apart from other massage therapists. Se® Connect is the only multi-disciplinary platform with practice tools, business tools, and a community of practitioners speaking the same language. Check it out at network.structuralelements.com.

0:01:02.7 KC: As a massage therapist, you know that truly, the world's most beautiful machine is in your hands. You help relieve the pain and pressures that holds your client's back from fully enjoying life. The CBD CLINIC Massage Collection uses ingredients from nature to deliver strong, effective, temporary pain relief with aromatic botanicals and natural emollients like CBD. Our tiered pain products let you personalize your massage to meet each client's needs. Be your client's hero by giving them the massage treatment of their dreams with CBD CLINIC. Learn more at cbdclinic.co.

[music]

0:01:54.4 Darren Buford: Welcome to The ABMP Podcast. My name is Darren Buford. I'm Editor-in-Chief of Massage & Bodywork magazine and Senior Director of Communications for ABMP.

0:02:02.7 KC: And I'm Kristin Coverly, Licensed Massage Therapist and ABMP's Director of Professional Education.

0:02:08.3 DB: Kristin, I think you should tell our listeners about a special upcoming event.

0:02:13.0 KC: I would love to. Listeners, now is the time to run to the store, stock up on popcorn so you're ready for ABMP's movie night. Yes, that's right, movie night. On Tuesday, June 22nd, we're showing the documentary, Touched: A Massage Story. The documentary's director, Chandler Toffa, and its subject, ABMP member and Licensed Massage Therapist, Jonathan Grassi, will join us for a live Q&A session after the movie screening. This fun event is free for everyone in the profession, ABMP members and non-members, I hope you join us. Learn more and reserve your seat at abmp.com/ce-socials.

0:02:51.0 DB: Our guest today is Dr. Ben Benjamin. Dr. Benjamin holds a PhD in Sports Medicine and owned and ran a massage school for over 30 years. He studied under James Cyriax, MD, widely known for his pioneering work in orthopedic medicine. Dr. Benjamin has been teaching therapists how to work with injuries for over 35 years, and has been in private practice for over 50 years. He works as an expert witness in cases involving musculoskeletal injury and sexual abuse in a massage therapy setting. He is the author of dozens of articles on working with injuries, as well as these widely used books: Listen to Your Pain, Are You Tense? , and Exercise Without Injury. For more information, visit benjamininstitute.com. Hello, Ben, and hello Kristin!

0:03:38.4 Dr. Ben Benjamin: Hi there!

0:03:39.0 KC: Ben, we're so excited to have you back. Thanks so much for joining us. And especially for the hot topic, low back pain. This is a universal issue for not only therapists, but almost all of our clients at some point have experienced low back pain. So we're really excited to talk to you about this and dive deeper. But before we do that deeper dive, let's start on a personal note. Have you ever experienced back pain yourself?

0:04:04.0 DB: Yes, I have, you know. It's actually what got me into the field. I was studying to be a professional dancer when I jumped up into the air and came down on one foot, and life was actually forever changed. I was 13 years old, and suddenly, I had extreme, extremely severe low back pain. I could barely walk, sit or stand without intense pain, and lying down was painful. I remember my mother took me to a doctor who suggested surgery. And when my mother asked him what was wrong with me, he replied, "I don't know, but we'll find out when we get inside." This didn't sound really good, like a good idea, so we left and never went back.

0:04:43.2 DB: And a few months later, I found out about someone called the Dance Doctor because so many dances had been helped by him, and it turned out that he was not a doctor, but really, just a really gifted hands-on therapist who everybody called Dr. Kagan. And he sort of adopted me and helped me through the next, actually, 22 years of my life. Off and on, I had pretty severe back pain. He helped me, but only temporarily, and it never really went away completely.

0:05:12.7 DB: And then at about 35 years old, I found a physician who knew more about these pains and injuries than anybody I had ever known in my entire life. And in the next eight weeks, he treated my back, and it was completely better, 100%. Hadn't had that happen since I was 13 years old, so it took me a long time to find somebody who really figured it out. And that was a really long time ago. And this led me to get my PhD in Sports Medicine and begin to train people all over the country in the assessment and treatment of pain and injury.

0:05:46.6 DB: Ben, are there common misconceptions about low back pain?

0:05:49.9 DB: Yeah, there are many. One misconception is that most low back pain and injury is caused by excessive muscle tension. I used to believe that. Another one is, is that working where the person feels the pain gets you the best result. A third one, a third misconception is that what is commonly referred to as sciatica is generally caused by pressure on the sciatic nerve.

0:06:13.8 KC: Okay, so let's start with that first misconception. If it's not excessive muscle tension, what is the primary cause of chronic low back pain, then?

0:06:22.9 DB: The most frequent cause of chronic low back pain is sprained sacroiliac ligaments, as well as the other ligaments in the low back and posterior pelvis. Muscles do get injured quite often. But because they have a rich blood supply, they heal rather quickly. For example, if you have a pain in your low back that goes away within a day or a few days, it's probably a muscle strain. If we're talking about chronic pain, which means it lasts for a long, long time, that's generally not caused by the muscles. People think it's the muscles because it hurts all over your back, and so it's quite natural to think of it in that way. And this is why it's so important for massage therapists and all body workers to have training in how to actually assess what's causing the person's pain, and what's the appropriate treatment. Otherwise, the client is gonna waste a lot of time and money, and doesn't receive the treatment they need to truly address their pain in a more permanent kind of way.

0:07:21.0 DB: So Ben, I'm a client and not a therapist, so my natural question is: Why don't you work where the person feels pain?

0:07:28.0 DB: You know, it sounds reasonable. Sometimes, you do, but frequently, you don't because the phenomenon called referred pain. Pain can be referred from the low back to the abdomen, the thighs, the lower legs, the feet, and often, without any or much pain in the low back at all. Now, this can be really confusing for both the client and the therapist. A number of years ago, I had an awful pain in my lateral calf, and it was really hard to believe that it was coming from anywhere else except my calf, even though I knew better from all my training and learning and stuff like that. So when you're the patient, your judgment, meaning my judgment, in that case, can be severely impaired.

0:08:10.3 DB: Now, to prove to me that it was coming from my low back and hip area, the brilliant doctor that I went to for the treatment injected me with Xylocaine only into the right spot in my hip, and the pain went completely away within 10 minutes. Now, of course, that wasn't permanent. I needed treatment in order for it to go away, but this proved to me the diagnosis was right because he injected me, it just disappeared. And it was like two feet away from where the pain was. So if you work where the pain is, you may be missing the boat because it's being referred from somewhere else instead.

0:08:42.0 KC: Let's talk a little bit more about referred pain and what that really means because I think some listeners may have a hazy understanding of what that means from massage school, but they don't really have a solid understanding, or lack, maybe, some ability to explain that to clients in a way that a client would understand. So can you tell us more about what referred pain really means?

0:09:03.2 DB: Referred pain simply means that a pain you feel is at a distance from where the injury is actually located. For example, if you have an injury in your neck, it can hurt down your arm into your hand. If you have an injury in your lower back or pelvic region, the pain can refer all the way down the leg into your foot and around to your abdomen as well. So sometimes, it only hurts in the foot and it's still coming from the low back region, so working on the foot is really a waste of time. So to be effective, you have to figure out exactly where the pain is really coming from.

0:09:37.2 DB: So Ben, what actually creates the pain, then?

0:09:40.0 DB: In most instances, the pain is caused by adhesive scar tissue. Whenever we get any type of injury, scar tissue forms to heal the area. And if the injured area heals well, the fibers really line up in the direction of movement. You feel perfectly well and the healing has taken place in what we call good alignment. However, if the healing is erratic and you end up with a matted scar, every time you move in a direction that stretches the adhesive scar tissue, the injured segment tears again and again, causing a lot of pain. And one of my teachers, Dr. Cyriax, he called this useless scar tissue because it does nothing good for you. It only creates pain. If it's lined up right, it gets you better.

0:10:24.5 KC: So Ben, clients often say, too, that they have sciatica. So does that give us useful information? It seems like often, that's a common sort of self-diagnosis based on a Google search.

0:10:36.0 DB: Yeah, it gives you some information, but it's often really misleading. True sciatica means that one of five different nerves that make up the sciatic nerve is being compressed by a ruptured disc in your back or neck. The sciatic nerve is made up of the L3, L4, L5, S1 and S2 nerves all wrapped together in a sheath that they would rarely, if ever, become compressed all together. If there is a nerve root compression, it's generally in one of those nerves, and the most common is L4 or L5. In normal parlance, the word "sciatica" is really meant to describe a pain that goes down your leg, often, into your foot. Now, this kind of pain can be caused by at least 10 different structures in the low back. When you have real sciatica with a nerve root compression, the pain is extremely severe and the person usually goes to a doctor or to a hospital 'cause it's really intense.

0:11:34.2 DB: Hands-on body work cannot make a disc stop compressing the nerve. If hands-on work does relieve the pain, it was not a nerve root compression in the first place. The person likely had a ligament injury causing pain down the leg. Hands-on treatment is often very effective for ligament injuries. Sometimes, therapists work on the ligaments by accident without actually knowing that they're doing that. I remember when I started out, I used to treat a sprained ankle for an hour or longer doing everything I could think of. People got better, often, because I accidentally hit the right spot some of the time. With the knowledge I have now, I could do the same thing or better in five or 10 minutes, just working on the injured ligament that's causing the pain.

0:12:18.4 DB: Let's take a short break to hear a word from our sponsors.

[music]

0:12:21.7 DB: Anatomy Trains is happy to announce our return to the dissection lab in-person, January 10th to the 14th, 2022 at the Laboratory of Anatomical Enlightenment in Boulder, Colorado. We are thrilled to be back in the lab with Anatomy Trains author, Tom Myers, and master dissector, Todd Garcia. Joint students from around the world and from all types of manual movement and fitness professions to explore the real human form, not the images you get from books. This is an exclusive invitation. Email info@anatomytrains.com if you'd like to join us in the lab.

[music]

0:12:58.2 KC: ABMP members get 20% off the list price on Handspring Publishing books, including Pre- and Perinatal Massage Therapy, Third Edition, Oncology Massage: An Integrative Approach to Cancer Care, and Thai Massage Dissected. Visit handspringpublishing.com to learn about these and other books. ABMP members, visit abmp.com/discounts to access your discount code to save 20% off list prices with free shipping to US and UK addresses. Find your next favorite book at handspringpublishing.com.

[music]

0:13:37.8 DB: Now, let's get back to the podcast. So Ben, what causes a back spasm?

0:13:43.0 DB: That's a great question. People are often really confused about that. A back spasm is what we call an involuntary secondary response. It's the body trying to actually help you not to hurt yourself any further. For example, if you have injured a ligament in your back, and bending to the right stretches it farther and tears it more, your back muscles will spasm in order to pull your body to the left in order to prevent you from bending in the wrong direction, which would cause more pain and more damage. Therapists often try to get rid of a back spasm by working on the muscle, and that's a really bad idea, and it actually... It's not really possible. Only for a brief time, you can, but it's gonna come back because the body automatically spasms to protect you no matter what you do, unless you take really powerful drugs that inhibit the protective response. The spasm is a signal that something is wrong that has not been addressed.

0:14:39.4 DB: So if you discover, in a thorough assessment, what is actually the cause of the spasm and treat the actual cause, the spasm will then disappear. For example, if you injure your left iliolumbar ligament, which holds the iliac bone of the pelvis to the L5 transverse process, and you try to bend to the right, your body will spasm forcefully, pulling you to the left to protect you. However, if you locate the injured ligament and effectively treat it, the spasm will not occur anymore when you bend in that direction.

0:15:11.0 DB: Since the beginning of time, human beings have developed theories to explain what's happening in their body that they don't really understand. Some of those theories are right and stand the test of time, and some of those theories are incorrect and get pushed aside when research and scientific information becomes known. Unfortunately, it often takes decades for those discoveries to be accepted by traditional medicine. It takes, for example, the discovery of penicillin. It took about 30 years to be accepted, and the person who discovered it in mold was persecuted and left out for those 30 years. And more recently, the physician who discovered that ulcers were really a bacterial infection, he was poo-pooed for years until his discovery was verified and accepted. He actually gave himself an ulcer and then cured it under observation. Unfortunately, in the field of orthopedic medicine, the assessment and treatment of musculoskeletal pains and injuries has not really kept pace with research and reality.

0:16:10.9 KC: Okay, Ben, so you have a client come to you with low back pain. Where do you start? How do you solve the puzzle to figure out what's wrong with someone's back?

0:16:19.0 DB: In order to accurately assess what's causing someone's pain in the low back, you take an extensive history to learn about the pain pattern, type of pain, and the extent of the injury and so forth. Then you do a series of tests, simple, 26 simple hands-on tests to narrow down where the injury is, what it is. This is followed by very precise palpation of the structures you identified as injured to get the exact location.

0:16:44.2 DB: So let me take a moment to point out the difference, actually, between assessment and diagnosis, this is important. In an assessment, you ask questions to take a history. Now, you do some testing and palpation to help you figure out if the person has an injury that you can help or not. You also learn if you should refer them to a different health practitioner, if you discover that this person has a problem that you really can't help. It's too inset, too far inside the body, it's a bursae, which massage can't help, etcetera. It helps you to differentiate who you can help and have a treatment plan. So when making a diagnosis, you take a history, you do some testing, often, with the help of machines like X-rays or MRIs, and then you tell the person exactly what the injury or condition is that they have. Now, this last step is the diagnosis. This can only be done by a physician, and in some states, by a physical therapist.

0:17:38.0 KC: And knowing these assessment tests and feeling confident in your skills as a massage therapist, using them, is that what helps the therapist differentiate whether the pain is coming from a pinched nerve or muscle or a ligament that's injured?

0:17:50.2 DB: Yes. If it's a muscle, then what's called a resisted test produces the pain. A resisted test is when you ask the person to push against you and you resist that movement equally so there's no movements in space. For example, a fairly common injury is the gluteus medius muscle tear, which refers pain down the outside of the leg almost to the foot. To test for it, you have the client lie on their side, on their good side, and you have them bring their free leg back into extension about eight or nine inches, and then you have them try to lift the leg up in the air toward the ceiling into abduction. While you do that, the therapist puts their hand on the lateral ankle so the leg doesn't move at all, and so you're pushing down, they're pushing up. And if that hurts, they have a gluteus medius injury. So then, if you palpate the entire gluteus medius muscle to locate, and you find exactly, precisely, which part of the gluteus medius is injured.

0:18:46.1 DB: Now, if it's a sprained ligament causing the pain, a passive movement will be painful and often limited. For example, when someone bends forward, standing up, they bend forward or backward in this position, this will bring on the pain, and the amount of movement will be limited. For example, if they bend forward, usually, they could put their fingers on the floor. But when they have an injury, they might not even be able to get to their knees with their fingers. So then you palpate the various ligaments that are most likely stressed with this particular movement, and this could be the sacroiliac ligaments, the sacrotuberous ligaments, the sacrospinous ligaments, or the supraspinous ligaments, just to name a couple of them.

0:19:26.1 DB: If it's a low back disc that's pinching a nerve, we call that a nerve root compression, commonly referred to as a slipped disc or a pinched nerve. Now, if it's this, what's happening is there will be a number of findings when you do the testing. Certain tests will show you severe weakness. Doing a resisted test, reflexes on one side of the body will be greatly diminished, the pain will tend to be distal. For example, the pain will go all the way down to the lower leg or foot. It will only be on one side, not on both sides of the back, and there'll be likely something called asymmetrical limitation.

0:20:02.2 DB: What's that Ben? Can you go into some more detail about asymmetrical limitation?

0:20:06.0 DB: Sure. Now, this means that you can move in one direction easily, but not in the opposite direction. For example, you can easily bend forward, but you can't bend back at all, or you can easily bend to one side and hardly at all to the opposite side. What's actually happening in this situation is that bending in that direction pushes the disc against the nerve, creating increased pain so the body stops you from doing that to protect itself.

0:20:35.0 KC: And a resisted test is one of the assessment tests that massage therapists can learn and use as a tool here for this assessment of low back pain. Can you tell us a little bit more about those?

0:20:44.0 DB: Sure, it's like an isometric exercise. Now, let me give you another example in the low back. In one test, you put both of your hands right on the person's leg, just above the knee, while they're lying supine on the table. You would push down and ask the person to lift their leg up. Both the therapist and the client are giving equal and opposite force so there's no movement through space at all. That muscle should be really strong for most people. And if they can barely lift their leg against you, that would show great weakness.

0:21:15.0 DB: Now, when you do the low back testing, you test all of the major muscles in the sides, in the lower legs, the feet for strength. When you notice that the strength is dramatically different on one side of the body, then you think there might be some kind of a disc involvement, pressing on a nerve, causing sort of atrophy in the muscle, and then it becomes really weak. Another thing that you would notice would be that the pain, the weakness and the reflexes would only be on one side. Now, it's very, very rare for a disc problem to create pain on both right and left sides of the body. Pain on both sides of the body in the low back is usually from ligament problems, in most cases. Now you can have a disc on both sides, but it's incredibly rare.

0:22:00.0 DB: Which of those are the most common causes of low back pain?

0:22:02.6 DB: Well, the greatest percentage of chronic low back pain injuries, it's from the ligaments. Now, there are 13 different ligaments in the low back and pelvic region that are very commonly injured, and another 10 or so ligaments that are sometimes injured as well. And when ligaments are injured, that can cause pain for decades, unless they are appropriately treated. At least 70 million people visit their doctor each year for low back pain just in the United States. And that's like one in every five people in the whole country.

0:22:34.0 DB: Now, this is because most health professionals don't know what to do with people who have low back pain, so it doesn't require surgery. Disc issues that are severe often require surgery. However, many physicians who take a more conservative approach suggest the patient wait. Because what happens is the disc degenerates and the pain gradually disappears, and usually, that takes about 12 to 15 months. But if it's severe, you're probably gonna have surgery. But if you can hold on, they recommend you not get it. The disc material that is extruded from the protective cover slowly disintegrates and is reabsorbed by the body, in most cases.

0:23:14.0 DB: Now, there is one lumbosacral injury that is exclusively due to a muscle that's damaged, but this is much less common than the ligament injuries. Massage therapists are usually blown away by the fact that once they've had enough training and experience in treating ligaments, they see their clients get better at a greater rate.

0:23:36.0 KC: So Ben, you mentioned that low back pain can be pain for decades. So I know everyone listening, myself included, I'm guessing Darren, would like to avoid that. We would not like to sign up for pain for decades. So what are things that we can do that everyone can do to prevent low back pain?

0:23:52.6 DB: Definitely. There are many things that people can do to keep their low backs and their entire body healthy. Now, human beings used to be really active, working physically every day to survive. And in the modern world, people spend most of their time being fairly passive, sitting or standing for hours every day, but not really using their body to the full extent. Therefore, exercise becomes a very important part of maintaining a healthy body and a healthy low back. Some types of exercise are very helpful and healthy and health-giving, while others are very destructive. A good exercise program should be done at least three times a week, and should include strength-building, stretching, coordination and balanced exercises.

0:24:38.3 DB: When people overdo strength-building or stretching, they often hurt themselves. Strength must be built slowly and deliberately, and does not have to be painful. The "no pain, no gain" philosophy is just based on ignorance, and in most cases, will eventually cause injury and irreversible damage. Unfortunately, most people don't know that because many in the sports and exercise world espouse that philosophy. As a result of the "no pain, no gain" philosophy, most athletes play in pain for their entire career, and they have it when they retire, often, to their detriment and being able to live. You can't effectively build strength or stretch once in a while, also. You have to do it two or three times a week, at least.

0:25:24.3 DB: And there's an entire method that's called active-assisted stretching that therapists can provide their clients with to get them started on a good stretching program. This involves the client doing most of the work and the therapist assisting at the end of each stretch for just a brief few seconds. Stretching for long periods of time, if done forcefully, can lead to injury. It takes two or three days of study and a lot of practice to become skilled at active-assisted stretching. Clients love it, and often decide to take an hour of stretching and an hour of massage because they like it so much. I get a stretching session at least once a week myself.

0:26:01.0 DB: Another important factor in keeping your low back healthy is what you eat. Many people don't wanna have this conversation because they like what they eat. Eating poorly leads to weakened immune system and diminished healing capacity. People in the western world, especially in the United States, eat really poorly. Now, if you look at what some people shopping carts, you go to the department of the supermarket and you look, you can see 50% to 70% or more of the food in their cart is junk food. Eating a balanced diet is impossible if you're eating junk food or unhealthy food throughout the day. Some clients embrace this kind of change. I always take a food history of every client because it can be really important in their ability to heal from their injuries. If diet is a factor, I refer them to a nutritional therapist or a doctor to work with them over time to change how they eat.

0:26:56.1 DB: So Ben, I speak for all listeners: What do you consider junk food and unhealthy food?

[chuckle]

0:27:01.5 DB: A lot of things. A lot of things, a lot of things. Junk food is food, generally, that tastes good that has no nutrients that your body needs, and that also has destructive effects on your body's health. Now, this includes anything with refined sugar in it, which has zero nutritional value. Foods containing high amounts of fat, white flour, too much salt. It includes candy, cakes, cookies, soft drinks, canned foods that are loaded with sugar or corn syrup. These foods do nothing good for you. They just compromise your health.

0:27:35.8 DB: Now, eating fat is also is very important, but has to be the right type of fat, not the kind of fat that encourages your body to eat more and more and more. Good fats in food are what gives actually satisfaction from eating. Without good fats, you wanna keep eating.

0:27:52.0 DB: So salt is also important, but again, the right amount and the right type. Cheap, dyed-white, iodized salt that you see on most tables is unhealthy, whereas, for instance, organic Celtic salt is really important for your health. The right amount of this salt is vital for your health and function of your nerves, your muscles, and to also maintain normal blood pressure.

0:28:15.6 DB: Unhealthy foods include things that are grown with chemical sprays that are carcinogenic. Another issue is the extensive use of antibiotics in raising animals for food. 80% of the antibiotics used in the United States are given to cattle. Cattle are meant to eat grass, but when they're in feed lots, they feed them grain and corn that makes them sick. They know they're gonna get sick. So they feed them antibiotics regularly, almost every day, to help them get fat and not die. So I would never touch meat that is not organically-raised. And that means if you go to a restaurant, almost any restaurant, you're getting vegetables and fruits with chemical sprays on them, and meats that are loaded with antibiotics. That's why I cook for myself. And there are many other things that one can do to maintain your health, but let's stop there. I could go on for a long time, you can probably see that.

0:29:08.0 KC: Okay, so let's make a shift from talking about what we eat to how we treat. Let's talk about our treatment plans. How long does it typically take to treat a client with low back pain?

0:29:18.4 DB: Well, it totally depends on what's damaged, how long it's been injured, and the health of the individual, and how committed the client is to the treatment. First, you have to establish that they have something that you can treat. So let's say if it's a ligament or a muscle injury, you can usually treat it successfully, unless the damaged structure is deep inside the body. For example, if someone has a sacroiliac ligament injury that's near the surface of the body, hands-on treatment is usually very effective. So if the sacroiliac ligaments that you're trying to treat are two inches inside the body in its deeper layer, hands-on work is not gonna do anything. You can only do the posterior sacroiliac ligaments. So in this case where it's deeper, the person needs a treatment like injection therapy that can treat ligaments that are in the deeper layers of the body, and it could be other treatments as well.

0:30:11.0 DB: If the injury is recent, hands-on treatment required would likely be over in a month or two, depending on how severe it is. However, if the person has multiple ligament injuries, which is extremely common, or injuries that have been there for 10 or 20 years, treatment's gonna take much longer, usually, four to six months. And as I mentioned earlier, there are about 13 ligament injuries that are very common in the low back and pelvic area that can be reached with hands-on work, and the person would have to be very compliant with doing very simple exercises every single day. Now, these exercises create a pull on the ligaments that makes new healthy scar tissue fibers form in the correct alignment. And if it's a gluteus medius muscle injury, which can be extremely painful as well, how that often refers down the leg, treatment would usually take maybe a month or two. Again, if some of the injured fibers are quite deep, they might not be able to be reached by the hands, in which case, you wanna refer them for an auxiliary treatment.

0:31:11.0 DB: Ben I ask this next question sitting in my chair, which I normally do for almost eight hours a day as I'm working. What puts the most stress on the low back? Is it standing, sitting, walking?

0:31:22.7 DB: So actually, of those three, what puts the most pressure is sitting. Sitting puts a lot of pressure on the ligaments and discs of the low back. When you stand or walk, the weight is transferred and distributed throughout your body, including your legs. When you sit for extended periods of time, especially if you're sitting in a posture that's a kind of a slump, all the pressure goes on to the low back structures. Worse than that is lifting something really heavy at an inefficient angle, like you're bending forward, and you try to lift something. That's not great. Now, for those who sit most of the day, it's doubly important that they get up, they move around frequently, like every 45 minutes. Get up, walk around for five minutes. That's a good thing to do to prevent that sort of thing.

0:32:08.0 KC: Ben, this conversation has really raised my awareness, and I'm sure listeners, too, of ligaments and the role that they play in low back pain, and we're probably looking and thinking about them in a different way. So let's talk a little bit more specifically about them. So do different injured ligaments create different patterns of pain in someone's low back area?

0:32:27.0 DB: Yes, many of the ligaments have distinct referral pain patterns, and this gives you a clue as to actually what they are. For example, the iliolumbar ligament refers pain across the top of the ilium on the same side, into the groin and genital on that side, and into the lateral hip and down the lateral thigh as far as the knee. The sacrotuberous ligament connects the ischial tuberosity, the bone that you sit on, and the lateral edge of the sacrum. Now, this ligament, when it's injured, refers pain down the back of the thigh, the back of the calf, and if it's severe, into the heel of the foot. So when pain is in the back thigh, the sacrotuberous ligament can really easily be confused with a hamstring injury so you have to be able to test both of them to differentiate which one it is.

0:33:14.8 DB: Ben, what about taking medications? I know a lot of people rely on that as a way to relieve low back pain. What are your thoughts there?

0:33:22.2 DB: Medication taken once in a while when an injury is quite painful can be useful. But pain medication is temporary and should be used judiciously. Pain is an awful thing, especially chronic pain. It depletes you of energy, and even rational thought, if the pain is severe. It can rob you of peace and enjoyment in your whole life. Now, people often get desperate, and this, in part, is what's led to the opioid crisis. Most physicians don't know how to diagnose or recommend effective treatment for the majority of musculoskeletal pain and injuries, especially the low back. And therefore, people take powerful opioids and other drugs because it gives them real relief for brief periods of time. They don't begin knowing that they risk becoming addicted to opioids, and they have a high likelihood of dying because it was prescribed by a doctor, so they think it's okay. So opioids and drugs, in general, are not the best treatment. I'm not against medication taken briefly when the pain is very severe, but it's not the answer. The answer is finding out exactly what is causing your pain and applying the most appropriate treatment. They exist.

0:34:31.0 KC: Let's talk about the most appropriate treatment. In your opinion, what's the best treatment for low back pain?

0:34:36.2 DB: It's difficult to describe the best treatment without actually knowing what's wrong, but I'm gonna give you a treatment based on the severity and type of injury. The first thing is you have to be skilled at doing a thorough assessment of the low back. So without knowing what's actually wrong, you might be performing a treatment that's not gonna do anything. So assessment is a skill that every massage and bodywork therapist should have, but unfortunately, most do not. Massage therapists could be the beacon of hope for millions of people with low back pain. Now, of course, any massage and bodywork will often give temporary relief, but if you understand the actual cause of the person's injury, you will know exactly what treatment will get them permanently better, and if that's possible or not.

0:35:19.5 DB: If it's an injured ligament with adhesive scar tissue that's on the superficial posterior part of the back or pelvis, then friction therapy is the treatment that I would use first. I would combine this with daily exercise, which strengthens and helps to align the fibers as they're healing. If it's a muscle injury, which is usually the gluteus medius muscle, I would apply friction therapy, myofascial therapy and massage. If it's a ruptured disc, which is compressing a nerve root, the client should immediately see a surgeon and see if waiting is a good option, along with getting some treatment to relieve it a little bit and some medication to ameliorate the pain. If the pain was so severe that the person couldn't stand up or walk, surgery might be the best option. If a person has an L4 nerve root compression with what we call foot drop, you would seriously consider surgery 'cause you don't wanna lose the function of your foot. Now, if you have a disc that creates tingling in the perineal area, as well as diminished function in your bladder and excretory functions, this is a dangerous condition and requires immediate surgery to the S4 nerve root.

0:36:30.5 DB: So the answer depends on what's injured and how severe it is. If it's an injury to a ligament deeper in the body, like the deep sacroiliac ligaments or the sacrospinous ligament, or if the ligament has resisted effective treatment, I would recommend what's called proliferant injection therapy. A proliferant is a very simple medicine that stimulates the body to strengthen and tighten the ligaments. When ligaments become distended and loose, either because of their genetic make-up or through an injury, the body is much more prone to injury. Proliferant injections help to stabilize those ligaments and joints, and are very effective as treatment. Unfortunately, there are not many doctors that are skilled in these types of injections so you need to search carefully to find the ones who are. And you can call me, anybody who's listening, can call me for information about that, if you'd like.

0:37:21.0 DB: Excellent! Ben, as we draw this podcast to a close, is there anything else you'd like to add on today's subject?

0:37:26.9 DB: Well, the most important thing in this profession is doing what you love and doing it well. If you really like working with the fascia, study that and get really good at it. If you're interested in correcting alignment, you might study Alexander Technique or Feldenkrais Method, in addition to being a massage therapist. If you like working with people to alleviate pain, as I do, then study the effective assessment and treatment of injuries so that you are avoiding guesswork, and help your clients see lasting results.

0:37:56.0 DB: We wanna thank our guest today, Dr. Ben Benjamin. To find out more information about Ben, visit benjamininstitute.com. The ABMP Podcast is produced by the team at Associated Bodywork & Massage Professionals, ABMP, a professional membership organization supporting massage therapists and body workers. Membership includes liability insurance, free continuing education, and the award-winning Massage & Bodywork magazine. Go to abmp.com to learn more about becoming a member. Thanks, Ben. Thanks, Kristin.

0:38:26.0 KC: Thanks for joining us, Ben.

0:38:26.4 DB: Oh, thank you.

0:38:30.0 KC: Members are loving ABMP Five-Minute Muscles and ABMP Pocket Pathology, two quick-reference web apps included with ABMP membership. ABMP Five-Minute Muscles delivers muscle-specific palpation and technique videos, plus origins, insertions and actions for the 83 muscles most commonly addressed by body workers. ABMP Pocket Pathology, created in conjunction with Ruth Werner, puts key information for nearly 200 common pathologies at your fingertips, and provides the knowledge you need to help you make informed treatment decisions. Start learning today. ABMP members, log in at abmp.com and look for the links in the Featured Benefits section of your member home page. Not a member? Learn about these exciting member benefits at abmp.com/more.

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