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Disability from lower back pain continues to be a major societal problem. The cost of care to the client with industrial back pain continues to escalate and frustrates the health care delivery system, the insurance industry (both public and private), and employers. For the client, it can be catastrophic with loss of income, reduced activities of daily living, loss of self-esteem, and dependency. The prevention of the failed lower back syndrome and the rehabilitation of its sufferers are indeed challenges.

Structural diagnostic and manual medicine practices has demonstrated a clustering of findings in clients presenting with the failed lower back pain syndrome. This cluster has been designed the “dirty half dozen.” The dirty half dozen consists of dysfunction within the lumbar spine, pelvis and lower extremities. They are:

  1. Nonneutral dysfunction within the lumbar spine, primarily flexed, rotated, and side bent (FRS) dysfunctions in the segments of the lower lumbar and thoracolumbar spine;
  2. Dysfunction  at the symphysis pubis;
  3. Restriction of anterior nutational movements of the sacral base, either a posterior (backward) torsion or a posteriorly nutated (extended) sacrum;
  4. Hip bone shear dysfunction;
  5. Short-leg, pelvis-tilt syndrome; and
  6. Muscle imbalance of the trunk and lower extremities.

This author studied 183 clients (79 men and 104 women) with an average age of 40.8 years who were disabled for an average of 30.7 months. All clients had disability with 53% working less than full-time and disabled for some activities of daily living, 42% were not working and had disability of most of the activities of daily living. Eighteen percent had pervious surgical treatment suggesting that most cases of failed lower back syndrome are a failure of previous nonoperative care. The 18% surgical failure rate is close to the national average of 15%. In these clients, the primary presentation was of back pain with some radiation to the buttock and thigh and in 38% some radiation below the knee. None of the clients presented with leg pain alone. The primary presentation was back, buttock, and thigh pain. The yielding from standard neurologic and orthopedic testing was low. Ten percent had some reflex change at the patellar or Achilles levels. Less than 5% showed evidence of significant muscle weakness. Seven percent showed some sensory loss. The classic straight leg raising with positive dural response was only identified in 2%. None had the classic crossed, straight leg raising sign pathognomonic of discogenic radiculopathy. Assessment of the dirty half dozen found 84% to have FRS or extended, rotated, and side bent (ERS) dysfunctions in the lumbar spine clustered at the L4 and L5 levels. Seventy five percent had un-leveling of the symphysis pubis. A total of 48.6% had restriction of anterior nutation of the posterior sacral base. Sixty percent of the failed surgical clients had a posterior sacral base. This high incidence leads one to consider that this functional pathology may be associated with the structural pathology or that the original symptoms were not due to the structural but the functional pathology. In the past, laminectomy was done with the client in a flattened lumbar lordosis is the goal of a spinal surgeon. Twenty-four percent showed the presence of hip bone shear with a female to male ratio of 2:1. The short-leg pelvic-tilt syndrome was found 63%. This is consistent with a number of previous studies showing two of three people with back and lower extremity disability having inequality of leg length as compared to 8% to 20% of the asymptomatic population. Muscle imbalance was found in almost all of the clients.

Only five clients (2.7%) failed to demonstrate any of the dirty half dozen. Fifty-five percent of the population showed three or more of the dirty half dozen. Despite on average 2.5 years of disability, 75% of this population returned to full employment and active activities of daily living following a treatment plan directed toward the findings.

Greenman PE: Principles of manual medicine. Lippincott Williams & Wilkins, 2003.  591-592

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