Making Sense of Back Pain
Part 1

By Leon Chaitow

One of the main objectives of this article (and Part 2 in the August/September 2006 issue) is to offer therapists ways of predicting the probable outcome of a client’s back problems.

Is this person’s backache likely to get better rapidly? Slowly? Or is it unlikely to improve as a result of manual/massage/exercise therapy?

How hardy or how vulnerable is this person? Is there evidence, and are there ways, of discovering just where this individual is on the spectrum of adaptation, compensation, decompensation (different words for describing the level of wear and tear and potential for recovery)?

There is a great deal of information that can be gathered from a combination of the person’s history and the presenting signs and symptoms, as well as from relatively simple assessments. This process does not involve making a diagnosis, but it does involve using evidence from research to predict probable outcomes. And when the probability is that someone will not get better without, say, surgery, it is worth knowing as soon as possible.

Before looking at the process of adaptation and assessment methods that can guide us to likely outcomes of treatment, it will help to set the scene by looking at the context out of which problems such as backache emerge—the internal and external influences that create the situation where an awkward movement or position can trigger an acute back pain.

Causes
When is the apparent cause of a problem only part of the real cause?

Take an athletic injury for example. The cause of a tear or strain that occurs during a sporting event might seem clear-cut. But is it? In an athletic (or any other) injury setting there is a need to consider both the event (the injury) itself and the context, including aspects of the environment and the individual’s general health status.

Crown et al. have summarized some of the key features insporting environments: “Both extrinsic and intrinsic factors can increase the risk of injury. Extrinsic factors include training errors, faulty technique, poor environmental conditions, incorrect equipment, and surfaces. Intrinsic factors include biomechanical deficiencies such as malalignment of limbs, muscular imbalances, degenerative processes, and other anatomical factors.”¹

A more complete list of additional intrinsic adaptation factors—all of which lead ultimately to what has been called decompensation —might also include nutritional imbalances, past and present pathological processes, adaptive changes to previous injury, or repetitive micro-trauma, as well as psychological factors such as anxiety.

Decompensation
Grieve has explained how a patient presenting with pain, loss of functional movement, or altered patterns of strength, power, or endurance will probably either have suffered a major injury, which has overwhelmed the physiological limits of relatively healthy tissues, or will be displaying “gradual decompensation, demonstrating slow exhaustion of the tissue’s adaptive potential, with or without trauma.”²

As this process of adaptive changes progresses, postural compensations possibly influenced by new compensation patterns of use, and further trauma, lead to exhaustion of the body’s adaptive potential, resulting in dysfunction and symptoms. This means that tissue capable of deformation will absorb or adapt to forces applied to it within its elastic limits, beyond which it begins to break down or fails to compensate (leading to decompensation). This is Hooke’s Law.³

A piece of tired elastic, frayed and ragged, has a breaking point, and if the rate of repair of tissue (muscle, ligament, cartilage, bone, etc.) fails to keep pace with the rate of damage, the end result is obvious.

Grieve rightly reminds us that attention to specific tissues that are producing symptoms often gives excellent short-term results, but “unless treatment is also focused toward restoring function in asymptomatic tissues responsible for the original postural adaptation and subsequent decompensation, the symptoms will recur.”⁴

In Part 2, we’ll examine an osteopathic assessment method that helps identify the degree of adaptation exhaustion.⁵

A Formula
When symptoms are complicated (and even when they appear simple), there is a formula I have found that helps clarify the overall picture and assists me in seeing a way forward. This is particularly true when the client’s history and symptoms are hard to understand. But as in the athletic injury example above, even when the story is apparently straightforward, getting a sense of the wider range of influences can usually be achieved if we are looking for it. I ask:

1. What genetic or acquired features (whether biomechanical, biochemical, or psychosocial) have imposed, or are imposing, adaptive demands that may have contributed to the symptoms? I cluster these together under the label adaptive load and attempt to include factors such as postural imbalances, patterns of use (that can induce repetitive micro-trauma relating to work or leisure activities⁶), injuries, breathing disorders (e.g., upper chest respiratory patterns), lifestyle (including sleep and exercise factors), nutrition, and stress levels.

2. What functions or systems in this individual are unable to adequately cope with the adaptive demands being imposed, and how can I help the person to improve these? I term these characteristics functionality —evidence of how normally/abnormally, or well/badly, the system is functioning. A complete assessment of these features calls for evaluation of flexibility, stability, strength, weakness, stamina, and balance—within the context of normal function. What’s loose, what’s tight, what’s working adequately, and what’s not (and why)? In other words, how well is this individual, or are these tissues, adapting to and compensating for the imposed demands of life? Simply put, what are the demands, and how well are these being coped with and what can be done about any aspects of these influences that suggest they are contributing to the patient’s problems? Why are these symptoms being manifested in this person at this time?

If the key adaptive demands can be identified (for example, overuse, misuse, or disuse) and if the patient can modify these, or if there is a way of improving the abilities of the body to adapt more efficiently (to better cope with the adaptive demands)—by improving flexibility, stamina, strength, stability, or balance—then symptoms will usually reduce or vanish as self-regulating mechanisms (homeostasis) operate more efficiently.⁷

These key approaches can be summarized in a few words: lighten the load and improve function so that the load can be better handled. The only other choice to focusing on one or the other, or both, of these areas of influence (adaptive demands and functionality) is to treat symptoms. This in itself is not necessarily a negative approach, as long as underlying causes are also being addressed and, most importantly, as long as the demands made by the treatment itself don’t further compromise the client. One of the greatest strengths of nonspecific massage is its ability to assist recovery from dysfunction (back pain or anything else) in a variety of ways—by reducing feelings of anxiety and sympathetic arousal; enhancing sleep, circulation, and drainage, as well as reducing hypertonicity; and encouraging self-regulation. In addition, when massage therapists recognize and target specific obstructions to recovery (for example, active trigger points), results are likely to be even better.⁸

But when adaptive changes, pathology, or dysfunction have advanced beyond a certain point, additional physiologically unsustainable changes are likely to lead to chronic myofascial and joint problems.

As we look through some aspects of helping clients in pain (back pain being our focus in this article), I will try to remind you of these two approaches, so that the idea of characterizing adaptive and functional features and factors in this way becomes clearer.

We will also consider in this, and the subsequent article, ways of identifying (such as the use of McKenzie-type exercises⁹) the type and degree of changes that have occurred which are causing symptoms so severe that conservative bodywork and exercise approaches are unlikely to be successful.

I hope you will find exploration of these concepts and methods a useful exercise.

Different Causes of Identical Symptoms
As a massage therapist, you are likely to attract clients who have back pain as a primary symptom. So, it is clearly in your interest to understand the possible causes of back pain, the mechanisms involved, and, wherever possible, the context out of which the client’s problem emerged.

Four people with apparently identical low-back pain symptoms might well have four completely different backgrounds to their problems. The first might have a history of repetitive micro-trauma relating to occupational (bending, lifting, sitting awkwardly, etc.) or leisure (sport, gardening, home decorating, etc.) activities, where the muscles, other soft tissues, and/or joints of the back finally failed in their attempt to adapt and went into spasm.^{18, 19} The second might have a genetic tendency to hypermobility, along with generally poor muscle tone, resulting in poor joint stability, accompanied by the evolution of multiple trigger points and a gradual increase in discomfort and chronic levels of pain.²⁰ The third individual’s emotional life might be the fundamental cause of somatization and back pain.²¹ The fourth might be demonstrating what are known as impostor symptoms, back pain that results from deeper pathology (discussed later in this article), or the individual may have incurred actual structural damage (such as a facet syndrome or herniated disc).²² In truth, all four individuals would probably benefit from massage (for different reasons) in the short-term. However, unless the context (background) is understood and where possible addressed, long-term benefit is unlikely.

In these four examples—and there could well be dozens more, each with a different scenario leading to back pain—the long-term solutions might respectively (together with massage and soft-tissue attention to the distressed tissues) involve:

• Better body-mechanics, including ergonomics, exercise, and postural reeducation (so reducing the adaptive load as well as improving function).²³

• Improved muscle tone to compensate for hypermobile joints (so enhancing functionality).²⁴

• Attention to stress and psychological/emotional factors by a suitably licensed therapist or practitioner (so reducing the load and improving functionality).²⁵

• Medical, osteopathic, physical therapy, or chiropractic attention, possibly including symptom-oriented approaches or enhancement of functionality.²⁶

Variable or Constant Pain
The person who presents with common nonspecific backache is most often otherwise well. In such cases, the back symptoms usually vary with activity, and this suggests that biomechanical factors are the main aggravating features.²⁷

Contributing causes leading to nonspecific back pain may include poor posture, overuse, deconditioning (poor muscle tone, lack of exercise), chills, trigger point activity, and/or other factors, many of which the person with the back pain may be able to control or modify.²⁸

In nonspecific forms of backache, symptoms are usually variable and are relieved by rest and particular positions and movements (such as stretching). In contrast, the pain and other symptoms associated with more serious, nonmechanical backaches are commonly unremitting. It is therefore very important that you ask your client whether the pain is constant or varies. If the back pain varies, you need to discover what circumstances seem to bring it on or aggravate it.

It is also important to remember that uncomplicated does not mean that the pain is a minor feature. The pain of uncomplicated backache may be extreme, often spreading to the buttocks and thighs.

Back Pain Syndromes
McKenzie has suggested critical features we need to try to identify that characterize three major groups of back pain clients. To understand the differences, we need to look at the processes of centralization and peripheralization.

When someone with backache has pain that extends into the leg, this is a peripheralization of the pain (whatever the cause). If that person has treatment, performs exercises, or adopts particular positions (such as extending the low back or flexing it) that cause the pain in the lower limb to reduce—even temporarily—this is known as centralization, considered a very positive sign. (Simple methods for assessing these features will be given in Part 2 of this article.) Anything that increases peripheralization—exercise, position, manual treatment—is contraindicated, as it will slow down recovery and may significantly increase symptoms.

The three syndrome models identified by McKenzie are postural, dysfunction, and derangement (or pathological).

Postural. Both active range of motion and repetitive movements are full and pain-free, but static postures at the normal end of range cause pain. In such individuals, normal tissue is being strained by prolonged inappropriate posture. Treatment and advice should encourage better posture, good ergonomics, and the avoidance of pain-inducing positions.

Dysfunction. Active range of motion is commonly restricted in one or more directions, with local pain being felt at the end of range. Repetitive motions are also painful at the end of range (bending for example), although such movements may increase the range of motion. Causes may include chronic soft-tissue contracture or fibrosis and/or nerve root impingement/restrictions. Exercise, repetitive movement (even if briefly uncomfortable), and treatment should aim to reduce fibrosis and increase elasticity.

Derangement (pathology). Active range of motion is commonly restricted in one or more directions, with local pain being felt at the end of range. Repetitive motions produce either centralization (likely causes include discogenic changes such as herniation that are contained—that is, the annulus has preserved the material of the disc internally)²⁹ or peripheralization (likely causes include non-contained discogenic changes). Exercise, repetitive movement, and treatment should aim to avoid anything that increases peripheralization of symptoms.

In this last category, if there are no positions, movements, or treatments that encourage centralization, prognosis is poor, with unsuccessful responses likely to almost all therapeutic interventions.³⁰ It makes sense therefore to be able to assess clients with back pain to see whether simple static and/or repetitive movements produce evidence of centralization or peripheralization. (Some of these assessments will be described in Part 2 of this article.)

Causes
The majority (97 percent) of nonspecific back pain problems are triggered by mechanical factors such as a strain, an awkward movement, being in a static stressful position for too long, or the pain develops when a combination of minor stresses occur together.³¹

This does not however mean that the strain, the movement, or the stressful position are the cause of the problem—they are only the triggers. In all probability, the back pain would not have started had the person’s muscles and joints been in a less compromised situation at the time of the strain or other incident.

The most common reported causes of low-back
pain are:

• Heavy physical work.

• Bending.

• Twisting.

• Lifting.

• Pulling and pushing.

• Repetitive work patterns.

• Static postures.

• Vibrations.³²

Most of these causes, or triggers, of the onset of back pain involve poor use of the body (the adaptive load) interacting with poor stability, tone, flexibility, and balance (poor functionality). It is relatively easy to learn better ways of bending, lifting, moving, and carrying. It is also usually possible to enhance stability, flexibility, and balance.³³ It therefore makes sense for you to supply clients with suitably illustrated educational hand-outs, along with demonstrations of better use patterns and rehabilitation (for example, core-stability) exercises, and/or you might refer them to classes or tutors who can guide them appropriately.

Inborn, Congenital, and Acquired Features
A major part of your client’s back pain story may relate to adaptation stresses arising from features such as:

• One leg being shorter/longer than the other—this can possibly be assisted by a heel lift or appropriate footwear, thus reducing the adaptive stress.³⁴

• One side of the pelvis being smaller than the other—this can commonly be assisted by use of a cushioned wedge, as advised by people trained in Aston Patterning.³⁵

• The upper arms being unusually short, causing the person to lean sideways when seated in an armchair—someone skilled in ergonomics should be able to offer advice regarding individualized modification of chairs.

• Unusual foot structures, such as Morton’s syndrome—referral to a podiatrist might be helpful.³⁶

• Unusual degrees of hypermobility (laxity) of the connective tissue—this can usually be compensated for by enhanced muscle tone, achieved via Pilates or other suitable exercise protocols, so improving functionality.³⁷

• Being excessively overweight—referral for
suitable exercise and nutritional advice might be appropriate.

Painful symptoms emerging from all of these examples can commonly be eased by appropriate massage. However, in none of them would the cause be dealt with by massage alone. To ensure you are assisting to the best of your ability, helpful advice or referral should accompany whatever symptom-oriented massage you may offer.

Psychosocial Contributions to Back Pain
Because something contributes to a problem does not make it the cause. It is merely one more part of the adaptive load.

A comprehensive review³⁸ of more than 900 studies involving back and neck pain concluded that psychological factors play a significant role, not only in chronic but also in the etiology of acute pain—particularly in the process of transition to chronicity.

“Stress, distress, or anxiety, as well as mood and emotions, cognitive functioning, and pain behavior, all were found to be significant in the analysis of 913 potentially relevant articles.”

Reducing these features would therefore reduce the chances, or the severity of symptoms that emerge—back ache or something else.

The most common psychosocial risk factors contributing to back pain are:³⁹

• Stress—feelings of being overwhelmed by the demands of life, time pressures, etc.

• Distress—a combination of feelings of helplessness and unhappiness.

• Anxiety—an exaggerated level of concern and fear; possibly involving catastrophizing, where the future is seen as bleak, and almost always involving altered (usually upper chest) breathing patterns that contribute to lowered pain threshold and altered muscle tone.^{40, 41}

• Depression—a profound unhappiness and sense of existence being pointless.

• Cognitive dysfunction—misunderstanding and/or misinterpretation of facts.

• Pain behavior—avoiding normal everyday activities that it is feared might aggravate the back pain problem.

• Job dissatisfaction—blaming the job for the back problem or simply unhappiness in the work situation.

• Mental stress at work or in the home—interpersonal tensions, time (or other) pressures that make working and/or home environments unsatisfying or actively unpleasant.

While massage therapy can certainly assist in encouraging relaxation and reduction of feelings of anxiety,⁴² remedies for many of these psychosocial factors are also to be found through patient education, stress management, counseling, and cognitive behavioral therapy.⁴³ So once again, along with massage, identification and appropriate referral or advice is warranted.

What Does Effective Mean?
Cherkin et al. compared massage with manipulation and acupuncture in treating back pain and found massage to be safe and superior in both effectiveness and cost-effectiveness to the other methods: “Initial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy.”⁴⁴

Cost is important. Symptom reduction is important. Safety is very important. But the question has to be asked whether effective only means reduced symptomatology, reduced cost, and safety.

It is hard to imagine that in the absence of attention to the features that allowed the back pain to develop in the first place, effective would be more than short-term, and however welcome pain-relief is, surely an aim that goes beyond this to prevention of recurrence is a more logical objective.

What About Back Pain Sufferers with Specific Pathology?
Conditions such as arthritis, a tumor, osteoporosis, ankylosing spondylitis, a fracture, inflammation, disc degeneration, nerve compression, or cord compression can all cause symptoms that mimic simple back pain.

This suggests that when you are taking the case history of the patient with back pain, if any red or yellow flag symptoms emerge (see below) you should suggest a referral to a licensed practitioner whose scope of practice allows the making of an accurate diagnosis.

Grieve has described conditions that masquerade as others. He says, “If we take patients off the street, we need ... to be awake to those conditions that may be other than musculoskeletal; this is not diagnosis, only an enlightened awareness of when manual or other physical therapy may be ... unsuitable and perhaps foolish. There is also the factor of perhaps delaying more appropriate treatment.”⁴⁵

You may become suspicious that a problem is caused by something other than musculoskeletal dysfunction and seek a definitive diagnosis when:

• Misleading symptoms are reported.

• Something does not seem quite right regarding the patient’s story describing the pain or other symptoms.

• Your gut feeling, instinct, intuition, internal alarm system, alerts you; if this happens you should always err on the side of caution and refer onward for another opinion.

• The patient reports patterns of activities that aggravate or ease the symptoms that seem unusual and cause you to have doubts about the case being straightforward.

It is important to remember that symptoms can arise from sinister causes (tumors for example) that closely mimic musculoskeletal symptoms and/or that may coexist alongside actual musculoskeletal dysfunction. When there is lack of progress in symptom reduction, or if there are unusual responses to treatment, this should cause you to review the situation.

Red Flags
Red flags are signs that may be present, alongside acute back pain, and suggest that other factors than musculoskeletal dysfunction are operating. In most people, there are no obvious pathological features associated with their back pain, but:

• Around 4 percent have compression fractures (probably with osteoporosis as a background to that).

• 1 percent have tumors as the cause of the problem.

• Between 1 percent and 3 percent of people with acute back pain have prolapsed discs.⁴⁶

The red and yellow flag lists, given below, are derived from the document European Guidelines for the Management of Acute Non-Specific Low Back Pain in Primary Care.⁴⁷ Red flags suggest (but do not prove) the possibility of more serious pathology. Suspicion or recognition of red flags emerges from the person’s history and symptoms. If any of the signs listed here are present, further investigation should be suggested before treatment starts, particularly to exclude infection, inflammatory disease, or cancer.⁴⁸

• An acute back pain started when the person was under 20 years of age or more than 55 years old.

• There is a recent history of trauma (e.g., a fall or motor accident).

• Pain is unrelieved by bed rest.

• Thoracic pain accompanies the back pain.

• There is a history of malignancy.

• Prolonged use of corticosteroids (such as cortisone) is reported.

• A background of drug abuse, taking of immunosuppressive medication, or a diagnosis of being HIV positive emerges during the history taking.

• The back pain is accompanied by systemic unwellness and/or unexplained weight loss.

• There are widespread neurological symptoms, such as changes in bladder control, unexplained limb weakness, or changes in gait.

• There is obvious structural deformity, such as scoliosis.

• The back pain is accompanied by fever.

Note: it is probable that one form of massage or another would be useful for back pain relating to all or any of these signs and symptoms, but this should not be offered until the real nature of the problem has been investigated. It would be both unethical and unprofessional to delay such investigation.

Yellow Flags
Unlike the possibly pathological signs that the red flags represent, yellow flags suggest psychosocial factors that “increase the risk of developing or perpetuating chronic pain and long-term disability.”⁴⁹ Examples include:

• Inappropriate attitudes about back pain, such as the belief that back pain is actually harmful and potentially disabling or that bed rest is all that is needed rather than performing specific beneficial exercises; one of the first and most important lessons people need to learn is that hurt does not necessarily mean harm.

• Inappropriate pain behavior, for example reducing activity levels or fear avoidance.

• Compensation (the possibility of financial gain if back pain continues) and/or work-related issues (for example, poor work satisfaction and the benefit of time away from it).

• Background emotional problems such as depression, anxiety, high stress levels).⁵⁰

Summary
We’ll discuss this subject further in Part 2. For now, you might consider asking yourself the following question in relation to your patients, after ensuring that what you are treating is within your scope of practice. “Is the treatment I am offering likely to achieve one or more of these key objectives?”:

• Reducing the adaptive load (deactivation of a pain-producing, active trigger point or centralization of symptoms as discussed earlier in this article).

• Enhancing functionality (better posture, enhanced breathing function, greater mobility, reduced peripheralization of pain).

• Easing symptoms without adding to the client’s adaptive burden (how sensitive and vulnerable, and how far along the road to decompensation, is this individual?).

• Working with the body’s self-repair, self-regeneration, and self-healing processes (see items 1, 2, and 3 above).

• Taking account of the whole person, the context, and not just the symptoms—judging as best possible current degree of exhaustion and susceptibility, with a rule-of-thumb guideline that the more complicated the condition, the more vulnerable the individual, the less that should be done therapeutically at any given time.

• Dealing with causes where possible.

• Doing no harm.

Leon Chaitow, ND, DO, MRO, is a practicing naturopath, osteopath, and acupuncturist in the United Kingdom, with more than forty years of clinical experience. He is a prolific writer and has published more than sixty texts. Chaitow is the editor of the Journal of Bodywork and Movement Therapies . He regularly lectures in the United States as well as Europe and was until his retirement in 2004 a senior lecturer at London’s University of Westminster, where he remains an honorary fellow. In 1992 he became the first person in the U.K. to be appointed as a consultant naturopath/osteopath to a government-funded National Health Service practice, a position he still holds. Contact him at www.leonchaitow.com.

Notes
1. L. Crown, J. Hizon, and W. Rodney, Musculoskeletal Injuries in Sports: The Team Physician’s Handbook (St. Louis: Mosby, 1997), 361–370.
2. G. Grieve, Modern Manual Therapy (London: Churchill Livingstone, 1986).
3. C. Bennet, Physics (New York: Barnes and Noble, 1952).
4. H. Johansson, “Influence on gamma-muscle spindle system from muscle afferents stimulated by KCL and lactic acid,” Neuroscience Research 16, no. 1 (1993): 49–57.
5. G. Zink and W. Lawson, “An osteopathic structural examination and functional interpretation of the soma,” Osteopathic Annals 7, no. 12 (1979): 433–440.
6. A. Hodson, “Too much too soon? The risk of ‘overuse’ injuries in young football players,” Journal of Bodywork and Movement Therapies 3, no. 2 (1999): 85–91.
7. H. Selye, “Confusion and controversy in the stress field,” Stress 1, no. 2 (1975): 37–44.
8. E. Ernst, “Massage Therapy for Low Back Pain: A Systematic Review,” Journal of Pain and Symptom Management 17, no. 1 (1999): 65–69.
9. R. McKenzie and S. May, The Lumbar Spine: Mechanical Diagnosis and Therapy (Waikanae, New Zealand: Spinal Publications, 2003), 553–563.
10. G.B.J. Andersson, “The epidemiology of spinal disorders,” in The Adult Spine: Principles and Practice 2nd ed., ed. J. W. Frymoyer (New York: Raven Press, 1997), 93–141.
11. Grieve, Modern Manual Therapy .
12. R. Deyo and J. Weinstein, “Low Back Pain,” N England J Medicine 344 (2001): 363–370.
13. Grieve, Modern Manual Therapy .
14. S. Bigos et al., “Acute Low Back Problems in Adults,” Clinical Practice Guideline Number 14 (Rockville, MD: Agency for Health Care Policy and Research publication no. 95-0643, Public Health Service, U.S. Dept. of Health and Human Services, 1994).
15. Deyo, 363–370.
16. Andersson, “The epidemiology of spinal disorders,” 93–141.
17. X. Luo, R. Pietrobon, and S. Sun, “ Estimates and patterns of direct health care expenditures among individuals with back pain in the United States,” Spine 29, no. 1 (2004): 79–86.
18. Nannini et al., “The Centennial Olympic Games and Massage Therapy: The First Official Team,” Journal of Bodywork and Movement Therapies 1, no. 3 (1997): 130–133.
19. R. McKenzie, The Lumbar Spine: Mechanical Diagnosis and Therapy (Waikanae, New Zealand: Spinal Publications, 1981).
20. N. Hudson et al., “Diagnostic associations with hypermobility in rheumatology patients,” British Journal of Rheumatology 34 (1995): 1157–1161.
21. W. Hoogendoorn et al., “Systematic Review of Psychosocial Factors as Risk Factors for Back Pain,” Spine 25 (2000): 2114–2125.
22. G. Grieve, “The Masqueraders,” in Grieve’s Modern Manual Therapy: The Vertebral Column 2nd ed., ed. J. D. Boyling and N. Palastanga (London: Churchill Livingstone, 1994).
23. J. Porterfield and C. DeRosa, Mechanical Low-Back Pain: Perspectives in Functional Anatomy , (2nd ed.), (Philadelphia: WB Saunders Co., 1998): pp. 1–22.
24. L. N. Russek, “Hypermobility Syndrome,” Phys Ther 79, no. 6 (1999): 591–599.
25. W. Hoogendoorn et al., “Systematic Review of Psychosocial Factors as Risk Factors for Back Pain,” 2114–2125.
26. L. Giles, 50 Challenging Spinal Pain Syndrome Cases (Edinburgh: Butterworth-Heinemann, 2003).
27. G. Waddell, The Back Pain Revolution (Edinburgh: Churchill Livingstone, 1998).
28. K. Lewit, Manipulative Therapy in Rehabilitation of the Motor System (London: Butterworths, 1999).
29. M. Laslett et al., “Centralization as a Predictor of Provocation Discography Results in Chronic Low Back Pain, and the Influence of Disability and Distress on Diagnostic Power,” Spine 5, no. 4 (2005): 370–80.
30. A. Aina, S. May, and H. Clare, “The Centralization Phenomenon of Spinal Symptoms—A Systematic Review,” Man Ther 9, no. 3 (August 2004): 134–43.
31. Deyo, 363–370.
32. Andersson, “The epidemiology of spinal disorders,” 93–141.
33. L. Chaitow, Maintaining Body Balance, Flexibility and Stability (Edinburgh: Churchill Livingstone, 2004).
34. M. Kuchera and W. Kuchera, “Postural Considerations in Coronal and Horizontal Planes,” in Foundations for Osteopathic Medicine , ed. R. Ward (Baltimore: Williams & Wilkins, 1997).
35. J. Aston, Aston Postural Assessment Workbook: Skills for Observing and Evaluating Body Patterns (San Antonio: Therapy Skill Builders, 1998), 194.
36. C. Frey, Current Practice in Foot and Ankle Surgery (New York: McGraw-Hill, 1994).
37. R. Keer and R. Grahame, Hypermobility Syndrome (Edinburgh: Butterworth Heinemann, 2003).
38. S. Linton, “Review of Psychological Risk Factors in Back and Neck Pain,” Spine 25 (2000): 1148–1156.
39. W. Hoogendoorn et al., “Systematic Review of Psychosocial Factors as Risk Factors for Back Pain,” 2114–2125.
40. P. Nixon and J. Andrews, “A Study of Anaerobic Threshold in Chronic Fatigue Syndrome,” Biological Psychology 43, no. 3 (1996): 264.
41. L. Chaitow, D. Bradley, and C. Gilbert, Multidisciplinary Approaches to Breathing Pattern Disorders (Edinburgh: Churchill Livingstone, 2002).
42. T. Field, “Massage Reduces Depression and Anxiety in Child and Adolescent Psychiatry Patients,” Journal of the American Academy of Adolescent Psychiatry 31 (1992): 125–131.
43. J. Moore et al., “A Randomized Trial of a Cognitive-Behavioral Program for Enhancing Back Pain Self-Care in a Primary Care Setting,” Pain 88 (2000): 45–153.
44. D. Cherkin et al., “A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain,” Annals of Internal Medicine 138, no. 11 (2003): 898–906.
45. G. Grieve, “The Masqueraders,” in Grieve’s Modern Manual Therapy: The Vertebral Column.
46. R. Deyo, J. Rainville, and D. Kent, “What Can the History and Physical Examination Tell Us About Low Back Pain,” Journal American Medical Association 268 (1992): 760–765.
47. Royal College of General Practitioners, Clinical Guidelines for Management of Acute Low Back Pain , (London, 1999).
48. Ibid.
49. M. Van Tulder et al., European Guidelines for the Management of Acute Nonspecific Low Back Pain in Primary Care (Melbourne, Australia: Proceedings of 5th Interdisciplinary World Congress on Low Back and Pelvic Pain, 2004), 56–79.
50. N. Kendall, S. Linton, and C. Main, Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain (Wellington, New Zealand: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand, 1997).

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