Low Back Pain

Sports and work-related back injuries are becoming a major problem, almost an epidemic. Low back pain is becoming increasingly common in both recreational and elite athletes. Approximately 70 to 90 percent of our population suffers from low back pain or has suffered from multiple episodes of low back pain. Traditionally, health and fitness professionals have focused on isolated structures in the low back during the diagnosis and treatment of low back pain. However, from a functional perspective, the health and fitness professional must address the abnormal biomechanics (muscular and articular) and the neuromuscular deficits that create excessive compressive, translational, and shear forces throughout the lumbo-pelvic-hip complex during functional movements and cause tissue overload and injury.

FOCUS ON FUNCTION

Function has become a buzzword in the health and fitness industry.

• Function is integrated, multi-planar movements involving acceleration, deceleration, and stabilization. Active individuals must train, recondition, and rehabilitate in a functional environment to adequately develop functional strength and neuromuscular efficiency.
• Functional strength is the ability of the neuromuscular system to produce concentric force, isometric stabilization Force, and eccentric deceleration force in all three planes of movement efficiently during functional activities.
• Neuromuscular efficiency is the ability of the neuromuscular system to allow prime movers, synergists, stabilizers, and neutralizers to work together synergistically as an integrated functional unit.

The goal of integrated training, reconditioning, and rehabilitation is to provide active individuals with optimum levels of functional strength, neuromuscular efficiency, and core stabilization strength. Movement is not an isolated event that occurs from a neutral lumbar spine position in one plane motion. However, movement is a complex, interdependent series of events that involves synergists, stabilizers, neutralizers, and prime movers all working together to accelerate, decelerate, and dynamically stabilize our center of gravity over our changing base of support in all three planes of movement.

The most important link in the kinetic chain is the core. This is where all movement begins. A well-developed core allows for improved force output and neuromuscular efficiency while decreasing the incidence of overuse injuries.

Most active individuals have developed the functional strength and power in their prime movers that will allow them to become successful in a particular activity, but they have not adequately developed the functional stabilization strength or neuromuscular control of the Lumbo-Pelvic-Hip Complex to allow structural or functional efficiency. Lack of stabilization strength and neuromuscular control leads to decreased performance and overuse injuries.

KINETIC CHAIN CONCEPTS

The kinetic chain is made up of the myofascial, articular, and neural systems. All three systems work as an integrated functional unit to provide structural and functional efficiency during integrated activities. Dysfunction in any system leads to compensations and adaptations in the other systems of the kinetic chain. Adaptive, compensatory patterns develop, leading to tissue overload and injury. For example, if one muscle is weak (gluteus maximus) then other muscles (erector spinae and hamstrings) compensate in attempts to maintain force output during functional movement patterns. This is referred to as synergistic dominance. Synergistic dominance is the neuromuscular phenomenon where one or more synergists takeover function for a prime mover. In the above example, there would be increased compressive forces in the lumbar spine secondary to increased synergistic muscle activity in the erector spinae and hamstring without adequate stabilization. If one muscle is tight (psoas) than the functional antagonists (gluteus maximus, transverse abdominus, internal oblique, multifidus, and deep erector spinae) demonstrate decreased neural drive and delayed onset during functional movements. This alters the normal force couple mechanism in the Lumbo-Pelvic-Hip Complex, leading to increased compressive and translational forces. This neuromuscular phenomenon is referred to as reciprocal inhibition.

The central nervous system is the command center that controls and regulates all movement patterns. The central nervous system directs preprogrammed patterns of movement that can be modified in countless ways to react appropriately to gravity, ground reaction forces, and momentum. This is an extremely important concept to consider when designing a training, reconditioning, or rehabilitation program. The Lumbo-Pelvic-Hip Complex musculature must be trained in all three planes of motion utilizing the full muscle action spectrum (concentric, isometric, and eccentric).

Kinetic chain dysfunction is a complex interaction of all systems (myofascial, articular, and neural). For example, research has shown that following an ankle sprain, the gluteus medius and gluteus maximus demonstrate decreased neural drive. This decreases the ability to decelerate frontal and transverse plane forces at the hip and knee during functional movement patterns. Furthermore, current research has demonstrated that the transverse abdominus demonstrates decreased neural drive in active individuals complaining of low back pain. It has been established that the transverse abdominus is a major intrinsic stabilizer of the lumbar spine. The transverse abdominus is preferentially recruited during functional movement patterns to prevent rotational and translational stress in the Lumbo-Pelvic-Hip Complex. Most active individuals are unable to adequately activate the transverse abdominus during functional activities. Instead, most active individuals rely on extrinsic muscles (psoas, erector spinae, superficial abdominals) to provide dynamic stability to the Lumbo-Pelvic-Hip Complex. This synergistic dominance leads to poor posture, inadequate stabilization, decreased neuromuscular efficiency, tissue overload, and eventually injury.

A comprehensive functional profile must be established on each active individual to determine the cause of their low back pain. Muscle imbalances, joint dysfunctions, and abnormal neuromuscular control must be assessed systematically throughout the entire kinetic chain. A functional assessment must also be implemented to determine core stabilization, functional strength, neuromuscular efficiency, and power output.

CORE STABILIZATION PROGRESSION

An integrated core stabilization training program is designed to optimally recruit the muscles that stabilize the Lumbo-Pelvic-Hip Complex and develop optimal neuromuscular efficiency. Designing an integrated core stabilization-training program requires following a systematic approach. The exercises must be safe, challenging, stress multiple planes of movement, incorporate a multi-sensory environment, utilize the entire muscle action spectrum, and follow an integrated functional continuum. Proper exercise progression is important when designing an integrated core stabilization training program. The integrated continuum utilizes the following concepts for progression:

• Slow to fast
• Simple to complex
• Known to unknown
• Static to dynamic
• Correct execution to increased intensity

Increasing the intensity of a core stabilization-training program can be accomplished by increasing the proprioceptive demand or by increasing the external load. Various forms of external loading include; medicine ball's, dumbbells, tubing, bodyblade, weight vest, and the core stabilization trainer. The proprioceptive demand of the exercise can be increased by utilizing foam rolls, airex pads, dyna discs, and other unstable surfaces.

SUMMARY

It has been demonstrated that most active individuals currently suffer or have suffered from low back pain. Low back pain can inhibit an individual from leading an active lifestyle. The health and fitness professional must understand concepts of functional anatomy, functional biomechanics, functional assessment, and a scientific approach to core stabilization training.