Exercise Program for Low Back Pain – Part I

Exercise Post-Rehabilitation for Low Back Disorders (LBD)

 Exercise has yet to help acute low back pain (LBP) with any consistency, but is more promising for chronic LBP⁸⁰, the latter of which is a primary focus in the NIHS manual, Exercise Progression for Low Back Disorders; A Professionals Manual.

            Up to 85% of disabling LBD cases have no true pathoanatomical diagnosis^37,81, this means that most of the time the practitioner doesn’t know what they are trying to correct. This is one reason that many low back rehabilitation attempts fail. Another reason is that the low back is often treated as if it is its own entity, snuggly hidden away from the rest of the body, with the consequences of forward head posture and rounded shoulders going unnoticed.

            In reality, the lumbar spine is a shock absorber for many misalignments throughout the body, and often times posture correcting exercises that don’t directly involve the low back will reduce pain and allow proper healing of an injury without the popular but invasive lumbar exercises; these exercises can increase scar tissue formation and magnify symptoms.

            Knowing which exercises cause the most compressive forces on the lumbar spine is a key to low back rehabilitation. This is very important with disc herniations and other motion segment maladies, especially since exercise is no more proven to help LBP than the body’s natural healing process.

            The low back is different from any other body part because it requires balancing the cervical, thoracic, and lumbar spine with the lower and upper extremities. For example: If the legs or arms are too weak to lift a box, then the low back has to compensate with increased flexion and or increased contractile force, which translates to greater intra-discal pressure and chance of disc protrusions. Therefore the weakest parts of the body must be identified and corrected to ensure a long lasting recovery, even the seemingly unrelated rotator cuff muscles.

            The spinal erectors do not always need to be the primary target of exercise, in fact, they are usually facilitated while the abdominals are inhibited and in need of strengthening. Many upper and lower extremity exercises will indirectly strengthen the spine if a neutral posture is maintained throughout the different movements. This is ideal for those who have to limit their lumbar ROM and compressive forces due to instability, herniations, or acute pain.

            Care should be taken when recommending isolated lumbar spine and abdominal exercises because they tend to place the moment force directly on the low back, thus encouraging injury or re-injury.

            While stabilization training seems to be a popular way to rehabilitate the spine, it is too often done without first balancing the muscle tension and activation patterns throughout the body, which is fundamental for stability. What good is practicing stabilization exercises if the muscles are not balanced and functioning in harmony?

            For example, learning to activate the abdominals first isn’t very beneficial if one side or layer is much stronger than the other; it could actually promote spinal instability.

            In order to affect the spine’s stability, the body’s joint protection mechanisms must be efficient. They are assessed two ways¹³⁸; 1) testing the activation of the muscular corset, and 2) testing the ability to attain normal spinal curves.

            The testing of spinal position is unnecessary if the individual is unable to properly activate the abdominal corset (even if they could find a decent spine position, they would be utilizing the wrong muscles). In this case, the activation patterns are learned first, followed by the practicing of proper spinal position.

            A corrective exercise program that equalizes tension throughout the kinetic chain and teaches proper muscle activation paterns (PMAP) for the CORE muscles should be the foundation and initial stage of rehabilitation or post-rehabilitation of the low back. That being said, spinal stabilization training is essential to low back rehabilitation and should be incorporated as soon as the body is ready. Isolate, and then integrate.

 

Spinal Stabilization Training

There are three stages of spinal stabilization training and they make up the first three stages in Exercise Progression. Spinal stabilization is necessary as a first step for most people, low back pain (LBP) or not, because of the cumulative effects of deloading.

            Deloading (reduction of weightbearing and sensory input regarding gravity, i.e. sitting or swimming) tends to cause the stabilizing muscles in the body to atrophy and lose function.¹³⁸     

Spinal stability must not get confused with balance or total body stability training. Spinal stability is closely related to its overall and symmetric segmental stiffness; exercises that challenge the body on one leg or with balance devices are testing overall kinetic chain stability and balance, not spine stability.³⁷ The spinal stabilization system consists of three components;⁴⁵ (Box 10-1).

            One muscular miscue or damaged ligament can cause enough instability to promote injury if the load is enough.  In order   to   prevent   injury   due   to   spinal instability there must be extreme muscle activity.⁴⁶  

 

Box 10-1

Components of Spinal Stabilization Training Active (muscles) Passive (osteoligamentous) Controlling (neurological)

This is where a balance of muscle tension, appropriate coordination, and speed of contractions are essential in maintaining stability. The co-contraction of the abdominals is also essential to spinal stabilization.    Once passive stiffness is lacking due to structural or ligament injury, active stiffness from muscular balance and coordination becomes the only hope for stability. Active stiffness must be retrained after injuries because of the disturbed motor patterns associated with pain and trauma.

            Spinal stability requires different muscles and tissues to “take up the slack” with every change of position. It also requires different amounts of tension that are directly related to the task at hand. This takes a lot of practice to permanently groove the patterns into the conscious and eventually subconscious neurological system as well as erase any pain and injury induced patterns.

            Some of the more important stabilizing muscles are the multifidus, transverse abdominus, internal oblique, diaphragm, pelvic floor muscles, latissimus dorsi, and the quadratus luborum.           

             There are three main stages to spinal stability training, see box below; these three stages progressively incorporate the three stages of motor control learning, which are⁴⁷;

 

1.      Kinaesthetic awareness

2.      Conscious control

3.      Subconsious control

 

Stage one of spinal stabilization training introduces new and improved simple neuromuscular patterns that can be quite difficult for the beginner or those in pain to feel or gain kinaesthetic awareness of.

            These populations must be supervised closely at first in order to detect any compensation, such as the abdomen “puffing out” instead of tightening or the superficial spinal erectors arching the low back instead of the multifidi activating with no resulting movement in the spine.

            The practitioner or individual should place their hands on the back and abdomen or use additional feedback methods to ensure proper muscular coordination and positioning. 

            Postural alignment during these exercises should be viewed form the side and anteriorly or posteriorly whenever possible, otherwise it is easy to overlook any right vs. left iliac crest and 12^th rib height discrepancies if only the common side observation is used.

            Without a foundation of corrective, isolated, and segmental exercises, stabilization training is essentially building a strong house (global muscles) on a weak foundation (segmental muscles and the joints) that will always be limited by structural and neuromuscular imbalances.

            It is obvious when someone has a nice house with a weak foundation by looking at an accomplished athlete with low back problems. They can often perform very difficult stabilization exercises with ease but only by utilizing the mobilizing muscles; this is due to muscular imbalances and poor training and eventually leads to wear and tear followed by pain and injuries.

            Therefore, total body or advanced stabilization exercises should be introduced after posture is more balanced, segmental strength is gained, and PMAP is learned. Isolate, and then integrate.

            Stage two focuses on engraining the newly learned activation patterns into the neuromuscular system and progressively incorporating the global stabilization system into weightbearing movements.

            While speed is a priority in stabilization contractions, it cannot be trained for until the appropriate positions are learned and practiced at a slower pace. Then speed can be the focus by using labile surfaces and other techniques. Endurance is also essential to stabilization and is most often best trained by performing the exercises until exhaustion while maintaining proper alignment.

            A great way to safely train to exhaustion is to perform the most difficult exercise possible for as long as possible and then immediately switch to an easier stabilization exercise that is similar until proper form is

no longer possible. This is continued down the line of exercises until the person is exhausted. Training of this sort is called “peeling back”, and according to Craig Liebenson⁴¹,

“Finding the patient’s limit and peeling back is the art of spinal stabilization.”

            Spinal stabilization training should work up to at least 30 minutes of exercises that challenge the various positions possible by the spine if lasting and functional results are desired. Repetitions are not the goal, fatigue is, and thus time is a better gauge for improvement and keeping track of performance.

            Stage III involves the entire muscular system with an emphasis on open chain movements and the development of the larger muscles in non-weightbearing positions. Exercises from Stages I and II are incorporated as well in order to fully integrate both systems.

 

Stages of Spinal Stabilization Training

Stage I      Activation of Local Stabilizers   ·     Learn individual muscle activation patterns (especially multifidus, gluteus maximus, and transverse abdominis) and integrate them into awareness of proper static posture, progress from 1) lying 2) sitting 3) standing; do not advance to Stage II until proper form can be held in all three positions for 10x 10 seconds. ·     Simple and isolated strengthening exercises are focused on segmental muscles that balance postural stresses (only if a neutral spine can be maintained) in the body to effectively pull the spine into a more even stiffness, in other words, enhance stability. ·     In general, utilize active stretches for the hip flexors, pectorals, and upper abdominals to strengthen the gluteus maximus, scapula adductors, and thoracic extensors respectively.   Stage II      Integration of Global Stabilizers ·     Incorporate the PMAP learned in Stage I into closed chain weightbearing (compression) exercises, i.e. squats and lunges, overhead press, etc. ·     Engrain proper form with daily repetitions. ·     Posture correcting exercises are still used.   Stage III      Integration of Mobilizers ·     Utilize more functional open and closed chain exercises at higher speeds to involve the mobilizers. ·     Posture correcting exercises are still used.

 

* Contact NIHS for info on referrences and the manual. chris@thenihs.com

 

 

 

 

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