Addressing Lower Back Pain, Part 1

Environmental Changes and Lower Back Pain

Over the past century, our environment and activities of daily living have changed dramatically. Prior to the advent and availability of modern staples such as automobiles, televisions, computers and stationary bikes, people spent much of the day engaged in varying types of physical activity and movement. Such technological advances, however wonderful as they may be, mean that most people now spend the majority of time sitting down. When seated, the butt and hips are behind us (supported by a chair or seat) and the entire spine bends forward into a rounded and flexed position. The gluteal muscles do not have to work to support the hips and spine as the chair does all the work. Therefore, when required to stand up, the glutes are not strong enough to push the hips forward to form a quality base of support for the spine. In addition, the thoracic spine (mid to upper back), which has a natural slight forward curve, suffers from prolonged seated positions (Price, 2006). After long periods of sitting, this forward thoracic curve can become excessive, thereby causing this part of the spine to lose its ability to arch backward and assist in standing erect.  

These hip and upper back dysfunctions mean that the responsibility for lifting the torso upright falls mainly on one structure in the body, the lumbar spine. There is a natural curvature in the lumbar spine designed to lift the torso upward (Kendall, et. al., 1993). But, when used exclusively to achieve and maintain upright posture, the lordotic curve can become excessive.  Over time, excessive lumbar extension can cause disc degeneration, nerve root compression and wear and tear to all structures of the lumbar spine and surrounding soft tissues.

Muscle Dysfunction and Lower Back Pain

When seated, the hips are bent (flexed), the top of the legs are closer to the torso, and the glutes are mostly inactive. Obviously, this position can cause the muscles and soft tissues at the front of the hips (namely the hip flexors) to become tight and restricted. Consequently, when we begin to stand up, these soft tissue structures are so inflexible and tight that the hips have a hard time pushing forward (i.e., extending) to enable us to stand up straight. (This is the case with any group of muscles acting upon a joint.  The muscles on one side have to let go in order for the muscles on the other side to contract).  Therefore, this tightness in the front of the hips can prevent the glutes from activating and being able to do their job to push the hips forward (Golding & Golding, 2003).  This pattern of dysfunction becomes a “which came first - the chicken or the egg?” scenario. Is excessive extension in the lumbar spine caused by weak glutes or tight hip flexors? The answer does not matter. Both variables must be addressed to enable the hips to extend so that the lumbar spine does not have to arch excessively to keep us upright.

Client Awareness Activity

There is a very simple activity that you can do with your clients to help them become aware of how they may be using their lower back too much to help keep their torso upright and thereby over stressing the structures of the lumbar spine.  Ask the client to stand against a flat surface such as a door or wall. Instruct them to stand with their back against the wall with heels, buttocks, shoulders and head touching the wall. Place your hand, palm down, on the wall and slide it behind the lower back (see Picture 1). 

Now ask the client to pull their shoulders back to the wall and make a note of any increase in the arch in their lower back.  An increase in the space between their lower back and the wall may mean that they are unable to extend their upper back to the wall when you asked them to pull their shoulders to the wall.  This lack of extension in the upper back will only serve to place more stress on the structures of the lumbar spine as it has to make up for the lack of extension in the thoracic spine.  Do this activity several times to help your client become aware of the compensation patterns in their own body. 

Exercises to Help Alleviate Lower Back Pain

Where the lumbar spine, hips and tops of the legs come together is a very important articulation in the body that enables us to stand, walk, run and play. If there is a dysfunction in this area, then other muscles (like those of the lower back) work harder to splint the area and keep it stable. This is why so many people experience a “tight lower back”; the lumbar erector muscles have to work twice as hard to make up for weaknesses elsewhere in the body (e.g., the glutes or the thoracic extensors). By simultaneously strengthening muscles surrounding the lower back and stretching others, the lumbar spine muscles can be taught to release and thereby reduce excessive lumbar lordosis.

The dome shape of the BT makes it perfect for performing exercises for the lumbar spine while lying in a prone position. It posteriorly tilts the pelvis and flexes the lumbar spine, reducing tension to the lumbar erectors. Furthermore, the air inside the BT dome can be used as resistance during active stretching exercises to contract and relax a group of muscles by pressing into the dome surface. This contract/relax technique mimics the way muscles react to real life movements and allows the body respond to specific stretches more effectively. Using the BT in this way makes it an ideal tool to utilize when trying to alleviate back pain caused by excessive lumbar lordosis.

Below you will find four exercises to help address the muscles of the lumbar spine that are affected by the compensation patterns highlighted above.  In the next article in this two part series you will learn exercises to stretch and strengthen those structures in the thoracic spine that need addressing to help alleviate lower back pain. 

Gluteal Activation Lift

This exercise “wakes up” the gluteal muscles responsible for extending the hips. This will help you or a client get the hips under the torso when standing, thereby reducing the compensatory excessive arching of the lumbar spine.

• Movement Directions: Lie face down with center of the hips over top of the BT dome as seen in Picture 2. Posteriorly tilt the pelvis to decrease the arch in the lower back. Lift one leg off the ground about 3 to 6 inches without arching the lower back as shown in Picture 3. Return leg to ground. Perform 10 repetitions on both legs.

Hip Flexor Stretch

The hip flexors are one of the main muscle groups responsible for flexing the hips. These muscles can become very restricted and tight in people that arch theor lower back excessively. By contracting the gluteal complex on the back of the hips while stretching the hip flexors, hip flexor muscles are released more effectively.

Picture 4	Picture 5

• Movement Directions: Put right knee on the BT dome with the left leg forward and left foot positioned flat on the ground as shown in Picture 4. Posteriorly tilt the pelvis by using the abdominal muscles and gluteal complex to bring the pelvis up and forward (i.e., “tuck the tail under"). Check that the right glute is contracted. Raise right arm to increase stretch to hip flexors (front of the hip) as seen in Picture 5. Maintain posterior tilt and gluteal contraction for the duration of the stretch. Hold position for 20 to 30 seconds on each side*.
• After holding the hip flexor stretch for a few seconds, relax glutes and try to pull the knee that is resting on the BT dome toward the front leg. Keep knee in contact with the BT dome and use it as resistance. So, hip flexors are now contracting while pushing down and forward into the pliable, dome surface. After a 2 to 3 second contraction, relax hip flexors and engage glutes again while posteriorly tilting pelvis. This contract/relax technique will greatly increase the ability of hip flexors to release so the hips can move more easily forward into extension. Perform the contract/relax sequence for 2 to 4 repetitions on both sides.

*If your or your client has trouble keeping the pelvis posteriorly tilted and glutes activated during either version of the stretch, simply go back to the first exercise (see “Gluteal Activation Lift”) to facilitate the required movements and muscle activations.

Contract/Relax Rectus Femoris Stretch

The rectus femoris is the only quadriceps muscle that originates from the front of the pelvis. (The other three quadriceps muscles originate from the top of the leg.) So, it also acts as a hip flexor muscle. As a result, most people who arch their lower back too much also have a tight rectus femoris muscle.

Picture 6	Picture 7

• Movement Directions: Same as the “Hip Flexor Stretch,” put right knee on the BT dome with the left leg forward and left front foot flat on the ground as demonstrated in Picture 6. Lift the right foot and hold it behind you in line with the center of the buttocks as shown in Picutre 7. Using abdominal muscles and gluteal complex, “tuck the pelvis under.” Check that the right glute is contracted. You should feel a stretch in the right leg and hip. After holding stretch for 2 to 3 seconds, push down (i.e., “kick”) right foot into right hand to contract the rectus femoris. Hold contraction for 2 to 3 seconds before relaxing the rectus femoris and pulling the right foot closer toward the butt to increase the stretch. Perform contract/relax sequence for 2 to 4 repetitions on both sides.

If you or your client has trouble keeping the pelvis posteriorly tilted and glutes activated during either version of the stretch, simply go back to the first exercise (see “Gluteal Activation Lift”) to facilitate required movements and muscle activations.

Toe Touches with Pushdown

The lumbar erector spinae muscles that lie on either side of the lumbar spine are largely responsible for arching the lower back. As such, these muscles become tight and restricted in clients that arch their lower back excessively to try to stand erect. The opposing muscle group of the erector spinae is the rectus abdominus which is responsible for flexing the spine. Contracting the rectus abdominus while stretching the lumbar erectors facilitates the lower back muscles to release.

Picture 8	Picture 9

• Movement Directions: Stand behind the BT, as shown in Picture 8 and reach down so that both hands are flat on the dome surface. Bend knees if you or your client has trouble reaching down that far. Gently push down into the BT dome as demonstrated in Picture 9. This engages the rectus abdominus muscle and releases the antagonist muscles of the erector spinae. Hold stretch for 3 to 5 seconds, return to starting position and repeat.

By utilizing the exercises above and encouraging your clients to stand up throughout the day to practice extending their hips and extending their thoracic spine, you can help them alleviate lower back pain.

References

1. Golding, Lawrence A. and Golding, Scott M.  Fitness Professionals’ Guide to Musculoskeletal Anatomy and Human Movement.  Monterey, CA: Healthy Learning, 2003.
2. Gray, Henry.  Gray’s Anatomy.  New York: Barnes & Noble Books, 1995.
3. Kendall, Florence P., McCreary, Elizabeth K. and Provance, Patricia G. Muscles: Testing and Function. Philadelphia, Lippincott Williams & Wilkins, 1993.
4. Myers, Thomas.  Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. Edinburgh, Churchill Livingstone, 2001.
5. Price, Justin.  “A Step-by Step Guide to Corrective Exercise Program Design”.  Lenny McGill Productions, 2008.
6. Price, Justin.  “A Step-by Step Guide to the Fundamentals of Corrective Exercise”.  Lenny McGill Productions, 2006.
7. Price, Justin.  “A Step-by Step Guide to the Fundamentals of Structural Assessment”.  Lenny McGill Productions, 2006.
8. Price, Justin.  “A Step-by Step Guide to the Understanding Muscles and Movement”.  Lenny McGill Productions, 2008.
9. Schamberger, Wolf.  The Malalignment Syndrome: Implications for Medicine and Sport. Edinburgh: Churchill Livingstone, 2002.
10. Taylor, Paul M. and Taylor, Diane K. (Eds.).  Conquering Athletic Injuries.  Champaign, IL: Leisure Press, 1988.
11. Whiting, William C. and Zernicke, Ronald F.  Biomechanics of Musculoskeletal Injury.  Champaign, IL: Human Kinetics, 1998.