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Massage Today
August, 2013, Vol. 13, Issue 08

A New Model for Low Back Pain and Dysfunction

By Dale G. Alexander, LMT, MA, PhD

In my 33 years of clinical experience, it has been my observation that chronic low back pain and spinal dysfunction are one of the most prevalent contributors to human suffering and reduced quality of life. I was truly surprised when my research discovered that 95% of all spinal surgeries occur at L4-5 and L5-S1.1

So, how might we enhance our capacity as massage therapists and bodyworkers to assist people with these ailments? One way is to have an expanded and clearer understanding of the anatomical variables that have clinically shown themselves to be related to the persistence of these problems. Let's explore a few of the anatomical relationships that are structurally and physiologically related to low back function. The understanding of these relationships have assisted me in helping many.

In 1987, Dr. Jean-Pierre Barral, DO and Frank Lowen, LMT, an amazing anatomical artist, detailed that the mesenteric root suspends the small intestine from two lumbar vertebrae: the anterior bodies of L2, the disc between and L3.2 If the balanced suspension of the small intestine is spasmed, might this mean that the 20 to 25 feet of the small intestine could be a variable influencing the chronic nature of low back dysfunction?

A year earlier, in my first muscle energy technique course with Dr. Richard MacDonald, DO, he proposed two exceptionally useful concepts of how biomechanics function in the human body. First, that the feet, ankles, knees and hips are all designed to carry weight. Secondly, that from the SI joints on up through the kinetic chain of the axial skeleton, the transfer of weight is designed to go through the joint spaces of the respective facet joints in the cross-crawl pattern of walking, "without loading the bones or their discs." Thus, these facet joints were theorized to function as a relay team, passing the baton of force through their respective joints spaces, thereby creating momentum and decreasing effort after the first few steps of forward motion.

low back pain - Copyright – Stock Photo / Register Mark However, in the presence of spinal motion dysfunctions affecting this baton hand-off, the forces of standing and movement shift from being channeled through the joint spaces and instead become "load bearing" especially to the lumbar vertebrae and the sacrum. This osteopathic theory also suggests that such shifts add compression to the discs and distorts the motions of the facet relationships, often compressing the exiting spinal nerves. Could this be a factor in the frequency of sciatica with its nerve roots beginning at L3 with contributions from L4, 5 and S1?

Over the course of my early clinical practice, the understanding and practical application of these concepts had served me very well for many years. Then, another important clinical discovery occurred that broadened the scope and depth of my understanding of how low back dysfunction occurs and so often becomes a chronic problem.

One day in 1996, an 11-month-old infant was brought to the physical therapy clinic where I was working in Eastern Ohio. The presenting problem was that an infant was developmentally beyond the time when humans naturally begin to crawl. As the infant had a deformed head, neurological reasons were suspected as the reason. After a thorough examination by the head PT, I was asked to evaluate the infant boy and after checking his GI track and palpating his iliopsoas muscles, I was holding his knees and feeling through his femurs into his hip sockets and suddenly there was an audible sound that was a cross between serial clicks and multiple soft pops. My brain flashed an amazing number of sensory pictures through my hands into my visual cortex and I turned to the head PT and softly said, "I wonder if this little boy's femoral heads just recaptured their sockets?"

Three days later, his mother called the office with great excitement that her son was crawling "up a storm" and was actually trying to walk. My subsequent clinical experience has correlated the prevalence of posterior subluxation(s) of the hip and the anterior subluxation of the shoulder joints. A recent article in my Massage Today column describes these in more detail.3 However, in summary, the principle is that when one or both hips sublux, the weight bearing and the transfer of the forces of standing and movement are shifted to the SI joints and the lower lumbar segments.

My clinical experience suggests that low back pain and dysfunction often follow. Shoulder subluxations may also participate in perpetuating such dysfunctions via the latissimus dorsi myofascial fibers.4 Now consider that the mesenteric root of the small intestine has become taut for many possible gastrointestinal reasons including chronic stress. Further, consider that the ability of L3 and then L2 is unable to make the baton pass of the forces of standing and movement up the kinetic chain. Which lumbar segments are going to carry the load? The answer is almost invariably L3, L4, 5 and S1. Maybe it is not a surprise that the discs of these segments and especially that of L4-5 and L5-S1 discs so frequently bulges or herniates.

Another revealing anatomical caveat from Dr. MacDonald's functional anatomy courses was that for women, the iliolumbar ligament extends from the posterior superior iliac spine (PSIS) to L5 and L4 whereas, for most men, it connects only to L5. You can reflect on the clinical frequency of occurrence between men and women presenting with an obvious low back side shear pattern. My experience is clearly more males than females.

So, please stop and consider how often this pattern may have exhibited itself in your clients. Unstable support from below... and a blocked ability to distribute the forces of standing and movement along the full length of the axial skeleton... concentrates these forces to bounce back down toward the most common segments associated in low back pain and dysfunction episodes... L3-4-5-S1.

A key concept of the Inside-Out Paradigm is that distribution of forces is an essential component of understanding how the body balances itself in response to traumatic mechanical distortions and in response to neurological viscero-somatic reflex arcs which use the spinal cord to express their distress and/or the onset of pathological changes. Many models of evaluation and treatment imagine that the human body is a system of guy-wires. My clinical experience suggests that many more variables need to be considered as outlined in this article. No model is complete, including this one.


  1. The Management of Lumbar Disc Disease,
  2. Dr. Jean Pierre Barral, DO and Frank Lowen, LMT, Visceral Manipulation class notes 1987-1993.
  3. "Freeing the Heart: Protection of the Hip and Shoulder Joints," by Dale G. Alexander, LMT, MA, PhD, Massage Today, June, 2013, Vol. 13, Issue 06. 
  4. Dr. Richard MacDonald, DO, Functional Anatomy Courses, The Upledger Institute, 1988-1989.

Click here for more information about Dale G. Alexander, LMT, MA, PhD.


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