Corrective Exercise/Rehab Lower Back Pain Essentials by Anthony Carey | Date Released : 09 Nov 2016 4 comments Print Close With such large numbers of people affected by lower back pain (LBP), it is no surprise that myths and misnomers run rampant. When it comes to musculoskeletal pain, the lower back reigns as king. Approximately 80-85% of people in the industrial nations will experience lower back pain at some point in their lives. In a 2005 survey by the European Agency for Safety and Health at Work,1 24.7% of respondents reported lower back ache as a result of their work. The same report names lower back ache as the most prevalent work-related health problem. According to the US Department of Health and Human Services,2 in 2008 there were 3.4 million emergency room visits – an average of 9,400 a day for back problems. You are either working with a client who has lower back pain, has had lower back pain or will have lower back pain. LBP is generally classified as either chronic or acute. Chronic pain from any source is historically defined as pain lasting greater than three months. This definition is based on the general healing time for tissue of 8-12 weeks. An acute episode of LBP has a rapid onset and progression and is usually the result of a trauma (such as a muscle strain) or impact. What You Must Know Acute Episodes of Back Pain Respond Better to Ice Than Heat One of the predictable responses of the body immediately following an acute back episode is for the surrounding muscles to spasm or “splint” the involved area to limit motion for protective purposes. This creates a second layer of problems: the classic pain-spasm cycle. Heat is often comforting and, following an acute back injury, it can relax the spasm. However, along with the application of heat comes an increase in metabolic activity to the area, which is not desirable following an acute injury. Increased metabolic activity translates to increased swelling/edema at the site of the injury. Ice or cold application has the opposite effect of decreasing local metabolism and reducing swelling/edema. Ice will also have an analgesic effect by impairing the transmission of pain signals.3 Stretching Alone Gives a “Sugar Fix” to Back Pain When muscle tension is felt above and beyond a person’s normal “baseline,” the instinctive tendency is to stretch that muscle or muscle group. This lengthening of the muscle fibers — and therefore the embedded stretch receptors — is generally perceived as beneficial to the individual performing the stretch. As muscle tension is reduced (temporarily), local blood flow equalizes and segmental alignment improves; there is a positive result from the stretching episode. But, just like eating a chocolate bar when you are hungry, the results are short-lived. The muscle tension/tightness in the back is typically part of a more complex scenario — a scenario that will also involve the aforementioned guarding response in the spinal musculature, inhibition and/or weakness to antagonistic muscle groups and underlying motor control issues related to functional instability. Add to this any underlying issues contributing to LBP from dysfunctions distant to the lower back, and it is clear that stretching a tight back alone is an incomplete strategy. Lower Back Pain Can be Caused by Your Feet The foot, with its 26 bones and 33 joints, is the body’s interface with the ground. As such, issues with the foot will impact on the rest of the kinetic chain from the ankle to the neck. Consider the common foot abnormality of hyperpronation. Hyperpronation causes an increased anterior pelvic tilt as a result of increased medial rotation of the shank and femur. This in turn increases lumbar lordosis.4 In the case of unilateral pronation or hyperpronation, a functional leg length can occur in addition to the increase anterior tilt to the pelvis. A leg length discrepancy can cause a sacral tilt in the frontal plane followed by a compensatory scoliosis.5 In both of these cases (and there are many more) the biomechanics of the lumbar spine were impacted by the foot. Correcting foot issues with orthotics requires help from a medical provider. As exercise professionals, we should be keenly aware of the long-term neuromuscular and fascial adaptations throughout the body that have occurred over the years in response to the foot issue. Never Stretch Your Back First Thing in the Morning More specifically, avoid flexing your spine upon waking. It is a common response for people who experience stiffness first thing in the morning in the lower back to want to flex their spine. This may involve standing in unsupported forward flexion, as with touching the toes. According to spine researcher Stuart McGill, the discs are more hydrated and “full” following a night’s rest. As such, the discs are less flexible and the bending stresses are much higher, as is the risk of damage. Added to this, upon waking and without warming up or exciting the nervous system, motor unit recruitment will be slower.6 This translates to poorer eccentric control by the spinal extensors during unsupported forward flexion and greater reliance on the passive ligaments and fascia of the lumbar spine. These structures do not have the same ability to fine-tune motion of the lumbar segments, leaving the lower back further predisposed to injury in the morning. Muscle Endurance is Initially More Important than Muscle Strengthening Ask anyone exercising with a history of LBP why they are exercising and they will usually reply, “To get my back stronger.” The reality is that many people with LBP have strong backs because they overuse their backs. A common biomechanical compensation for restricted hip mobility is an increased work load placed on the lumbar spine. In terms of activities of daily living and most occupational demands, the back muscles are required to maintain low-level contractions over prolonged periods of time. Lack of lumbar endurance has been shown to be a greater predictor of LBP than lumbar strength7 and a characteristic of patients who catastrophize their pain.8 Most stability exercises should incorporate an endurance component because clients should not be attempting to contract their stabilizers at high levels of the maximal voluntary contraction (MVC). In his book Rehabilitation of the Spine: A Practitioner’s Manual, Dr. Craig Liebenson estimates that during the course of the day we only need to contract our spinal stabilizers at about 5% of MVC. Summary Research and clinical experience strongly supports the concept of individualized exercise prescription for those with LBP. As exercise professionals you must ensure that, prior to providing corrective exercise to clients with LBP, they are cleared for exercise by their treating medical professional and you know their health history. Fitness professionals can be instrumental in helping their client identify exasperating movements and activities and in encouraging movements and activities that facilitate function and confidence. References European agency for safety and health at work website: http://osha.europa.eu/en/publications/reports/TERO09009ENC US Department of Health and Human Services website: http://www.ahrq.gov/research/mar11/0311RA31.htm Nadler S, Weingand K and Kruse R (2004), The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain Physician, 7:395-399. Khamis V and Yizhar Z (2007), Effect of feet hyperpronation on pelvic alignment in a standing position. Gait & Posture, 25:127-134. Rothbart B (2006), Relationship of functional leg-length discrepancy to abnormal pronation. Journal of the American Podiatric Medical Association, 96(6). Gorassini M, Yang J, Siu M and Bennett D (2002), Intrinsic activation of human motoneurons: Reduction of motor unit recruitment thresholds by repeated contractions. Journal of Neurophysiology, 87(4): 1859-1866. Biering-Sorensen F (1984), Physical measurements as risk indicators for low back trouble over a one-year period, Spine, 9:106-119. Larivière C, Bilodeau M, Forget R, Vadeboncoeur R and Mecheri H (2010), Poor back muscle endurance is related to pain catastrophizing in patients with chronic low back pain. Spine, 35(22): E1178-E1186. Source: Fitpro Network Previously Published on PTontheNet Back to top About the author: Anthony Carey Anthony Carey M.A., CSCS, MES is PFP Magazine’s 2009 Personal Trainer of the Year and owner of Function First in San Diego, California and an international presenter on biomechanics, corrective exercise, functional anatomy and motor control and their relationships to pain and function. Anthony has developed the Pain Free Movement Specialist certification and is the inventor of the Core-Tex®. Full Author Details Related content Content from Anthony Carey Low Back Exercise: Separating Myth from Fact Stuart McGill | Articles Successful Corrective Exercise Programming by Anthony Carey | Videos Post-Injury Rehab Tips for Personal Trainers Paul Wright | Articles Addressing Lower Back Pain, Part 2 Justin Price | Articles Addressing Lower Back Pain, Part 1 Justin Price | Articles Lower Back Pain Essentials Anthony Carey | Articles The Core-Tex: Reactive Training & Reactive Variability Anthony Carey | Articles Successful Corrective Exercise Programming Anthony Carey | Articles Myofascial Mobility Through Strategic Movement Anthony Carey | Articles Maximizing Your Minimalist Footwear Anthony Carey | Articles Scoliosis Anthony Carey | Articles Club Foot Anthony Carey | Articles Corrective Exercise Is Functional - Part 3 Anthony Carey | Articles Corrective Exercise Is Functional - Part 2 Anthony Carey | Articles Corrective Exercise Is Functional - Part 1 Anthony Carey | Articles Spinal Fusion and Mountain Biking Anthony Carey | Articles Corrective Exercise for Excessive Standing Anthony Carey | Articles Broken Leg and Scar Tissue Anthony Carey | Articles Prehab for Hip Replacement Anthony Carey | Articles The 80/20 Principle Anthony Carey | Articles Teen Client with Cerebral Palsy Anthony Carey | Articles Knock Knees Anthony Carey | Articles Hip Replacement Anthony Carey | Articles Before the Core - Part 1 Anthony Carey | Articles Before the Core - Part 2 Anthony Carey | Articles Before the Core - Part 3 Anthony Carey | Articles Hip Pain Post Frontal Plane Exercise Anthony Carey | Articles Lateral Pelvic Tilt Anthony Carey | Articles Pars Defect Anthony Carey | Articles Upslip Downslip Hip Anthony Carey | Articles Single Leg Weakness Anthony Carey | Articles Hammer Toe Anthony Carey | Articles Treadmill Dysfunction Anthony Carey | Articles No Cartilage in Ankle Anthony Carey | Articles Sway Back Anthony Carey | Articles Concave/Convex Chest Anthony Carey | Articles Lumbar Spine Injury Recovery Anthony Carey | Articles Lumbar Disc Bulge Anthony Carey | Articles Shoulder Stinger from Rugby Anthony Carey | Articles Risks of Spinal Flexion and Rotation Anthony Carey | Articles Skier’s Achilles Tendonitis Anthony Carey | Articles Please login to leave a comment Comments (4) anthony, yolanda | 21 Apr 2017, 22:46 PM I REALLY LIKE THE THINGS U TALKED ABOUT VERY HAPPENFUL Reply Taylor, D | 08 Apr 2014, 18:33 PM Muscular Endurance in all available ROM with Phase 1 lower back stability exercises have been HUGE in returning to pain free LB Reply alexander, thomas | 02 Aug 2013, 20:23 PM Excellent article! As to the previous comment about qualifying stretching as a sugar fix. The author does do this further on in the article , basically leading you to realize that assessment first is the key. A stretch may be needed as part or even the main prescription , however our instinct to stretch due to the temporary relief may not be a good idea. It all depends on what your assessment tells you. Unfortunately most of the trainers in our culture, don't posses the training or understanding of any real assessment. Reply Sinitiere, Nick | 06 Dec 2011, 18:20 PM Nice article, with good information. I would have liked to hear you qualify a bit more when you likened stretching the back to a 'sugar fix'. This could be inherently true, or inherently false. It could be part of the 'permenant fix', or part of the 'never stretch this' list. Depending on the Mm being stretched. What if it's tonic? What if it's phasic? I realize this is a whole other conversation and a whole article could be dedicated to just that. Possibly beyond the scope of what you wanted to get into in this article. Reply Back to top