5 Yoga Poses for Persistent Back Pain

At least 80% of Americans will experience low back pain during their lifetime.  Most of these people will recover well in a few weeks.  However, approximately 1 in 10 people with back pain will develop persistent ongoing problems.  Exercise is one of the few proven treatments for people with persistent low back pain.  And no specific form of exercise has been shown to be clearly better than another.  Aerobic training, strengthening exercise, Pilates, and stretching exercises have all been proven to be effective.

Yoga is becoming an increasingly popular form of exercise across the world.  In a previous article, we discussed the benefits of Yoga for people with shoulder pain.  This article provides some background and 5 Yoga poses which we recommend for people with persistent low back pain.

Yoga is Proven Treatment for Back Pain

Research from a 2005 clinical trial shows yoga improves function and reduces low back pain.  Researchers from Washington State compared the effects of yoga, a generalized low back exercise program, and an educational booklet in 101 adults with longstanding back pain.  Both the general exercise group and those performing yoga experienced significant improvements in pain and function 3 and 6 months later.  Of note, 69% of those in the yoga group improved by at least 50% compared with 50% of those in the exercise group The Yoga program consisted of 12 group sessions lead by an instructor who incorporated 5 to 12 different poses.  Several of these poses are included in this article.

Some Background about Yoga

Yoga is a form of mind–body exercise which incorporates physical exercise with mental focus through breathing and meditation. The poses are designed to increase flexibility and strengthen your body in a controlled fashion as well as improve balance. These poses are performed standing, sitting, reclining, or inverted and may involve forward bends, backward bends, or twists. Breathing exercises link the postures together and help your mind focus.

Yoga for back pain

By combining the benefits of physical exercise with relaxation techniques, people with low back are able to exert themselves without flaring up their pain.  This can be challenging when starting any new exercise program so be sure to start slow and easy.  Select 1 or 2 of the poses below which you can perform comfortably before trying the others.

Tree Pose

This pose is much harder than it looks.  Start with your feet together and weight evenly distributed.  Bend your right knee, then reach down and grasp your right inner ankle. Use your hand to draw your right foot alongside your inner left thigh.  Stand tall with a long spine.  Press your palms together in prayer position at your chest, with your thumbs resting on your sternum.  Fix your gaze straight ahead.  Inhale as you extend your arms overhead, reaching your fingertips to the sky.  Return your palms together then lower back to the prayer position at your chest.

Perform the movement 3 times each with a slow deep breath.  Repeat the same sequence of movements standing on your right leg.  Tree pose helps improve balance and control of your core.  It achieves these goals while placing very little stress on your spine.

Warrior 1

Start with your feet together.  Step with your left foot forward bending your knee into a lunge. Keep your right leg straight behind you. Raise your arms straight above your head.  Squeeze your shoulder blades together and downward.  Lift your chin to gaze at your hands overhead. Hold your pose for 3 to 5 slow breaths and then repeat on the left side.  Warrior 1 helps improve balance, leg strength, and hip mobility.

Warrior 2

Stand in a wide position with your feet parallel and approximately 3 feet apart. Extend your arms straight out to your sides. Relax your shoulders.  Turn your left foot out 90 degrees.  Bend your knee into a lunge.  Be sure to keep your knee above your ankle and pointing over your toes. Turn your head to the left and look over your fingers.  Hold your pose for 3 to 5 slow breaths and then repeat to the other side.

Airplane

Start in a balanced tall standing position.  Lean forward slightly and lift your right leg off the floor.  Press your right leg into an imaginary wall behind you.  Lengthen your spine as you assume a horizontal position with your hips level.  Relax your shoulders down and away from your ears.  Squeeze your shoulder blades together.  Maintain your gaze down and slightly forward.  With your palms down reach your arms out to the side.  Hold this pose for 3 to 5 breaths.  Repeat the same sequence supported on your right leg.  Airplane pose helps improve balance, hip strength, core control, and hamstring mobility.

High Lunge Twist

This is one of my favorites to improve flexibility of your spine.  Like most yoga postures, there are several variations to the high lunge twist.  Each has a different “twist” to the twist.  We will cover the prayer version here.  Start from a high lunge with your left foot forward and arms overhead.  Move your hands together in a prayer at the center of your chest.  Take a deep inhale, and slightly lift your chest.  Use your exhale to engage your navel to your spine and twist your torso to the left.  Hook your left elbow outside of your left thigh. Breathe here for 3 to 5 deep breaths, and then repeat on the other side.  This is a great exercise to improve balance, core control, and spine mobility.

Your Back Pain: Get Started with Yoga

There is no better time than today to get started with yoga.  Get started in your own home then consider taking classes when the time is right.  Several expert yoga instructors are available in our area (Hot or Not Yoga, The Yoga Hive). These instructors will be able to modify any pose to meet your individual needs. Some mild discomfort is expected when starting any new type of exercise.  However, with practice and mental focus you will begin to experience the benefits of improved flexibility, balance, strength, and less pain.

These 5 yoga poses are great to incorporate into your workouts.  I recommend performing them two days per week. You can cycle through each pose several times.  They will probably take you no more than 30 minutes each day. If you experience any difficulty give us a call.  We would love to help you out.

Low Back Pain in Athletes

Low back pain in athletes occurs at an alarmingly high rate.  Various studies suggest one- to two-thirds of athletes will experience low back pain during a competitive season.  Athletes are required to perform high-speed movements often with excessive loads.  Sports such as golf, baseball, gymnastics, hockey, and tennis require repetitive rotational movements that stress the bones, joints, and discs of the spine.   Repetitive rotation and extension (arching backward) with high forces at fast speeds contributes to injuries of the spine discs and bony structures.  Injured athletes must learn to control and dissipate these forces.  Thankfully, rehabilitation exercises can help the injured athlete get safely back to their sport.

Low Back Stress Injuries in Athletes

Stress reactions and stress fractures of the spine are common in young athletes.  The spine of children and adolescents are susceptible because the bones are still developing.  Spondylolysis is a crack or stress fracture in one of the vertebrae of the low back.  Most commonly, the stress fracture occurs in the fifth vertebra of the lumbar spine (L5).  In some cases, the stress fracture weakens the bone and the vertebra starts to shift or slip forward out of place. This condition is called spondylolisthesis.

Spondylolysis

In children and adolescents, this slippage most often occurs during a growth spurt.  The severity of the slippage is graded from 1 to 4.  Most athletes with grades 1 and 2 respond very well to a period of rest and rehabilitation.  The injured bone heals with rest from any repetitive rotation and extension movements involved in their sport.  Rehabilitation targets strength of the trunk muscles to help relieve stress on the healing bone.  Some higher-grade injuries may require surgery to stabilize the spine.

Research Support for a Safe Return to Sport

Athletes with stress injuries of the spine require a minimum of 3 months rest from their sport.  The severity of the injury and the nature of the sport may require longer periods of rest.  One study found excellent return to sport rates after 4.6 months of rest and rehabilitation across a number of sports.  A recent study showed baseball (54%), soccer (48%), and hockey (44%) to have the highest prevalence of stress injuries in boys.  Gymnastics (34%), marching band (31%), and softball (30%) were found to have the highest injury rates in girls.  Athletes in these sports may benefit from longer rest and rehabilitation periods.

A 2017 study from the Children’s Hospital in Columbus, OH investigated the timing of referral to physical therapy in athletes with stress injuries of the spine.  Athletes who began physical therapy sooner were able to make a return to sport 25 days earlier than those who delayed treatment.  The early physical therapy group returned to sport at approximately 3 months.  The delayed physical therapy group returned after 4.5 months of rest and rehabilitation.   These studies suggest appropriate rest and early rehabilitation foster a safe and timely return to sport.

Common Rehabilitation Exercises for Athletes with Low Back Pain

Early rehabilitation for stress injuries of the spine begins with controlling pain and normalizing mobility.  Most athletes experience a significant reduction in pain once they are removed from sports activities.  Trunk and hip strengthening exercises begin in non-weight bearing positions such as on the back, side, or all-fours position.  Athletes are instructed on how to maintain a neutral spine position to minimize stress to the healing bone.  The curl-up and heel hover are two exercises that are initiated once the athlete can control this neutral spine position.

After the athlete can maintain a neutral spine in non-weight bearing positions exercises are progressed to kneeling and standing.  The athlete is taught to control rotation and extension of the spine through exercises such as the chop and Pallof press.

Anti-extension and anti-rotation exercises are emphasized during the later stages of rehabilitation.  The strength and endurance of the trunk muscles are progressively challenged with these exercises.  All exercises should be performed with a neutral spine and in a pain free manner.

Closing Thoughts on Low Back Pain in Athletes

Low back injuries can be frustrating for the young athlete.  Appropriate rest and rehabilitation can expedite a safe return to sport.  These 6 exercises are only a sample of the types of treatments that can help.  Meet with your physical therapist and get started on the road to recovery.  Your physical therapist will continually assess your injury and progress your exercise program based on your goals.  The objective is to get you back to your sport as quickly and safely as possible.  Contact us today if you have questions about which treatments are right for you.

Herniated Disc: Non-Surgical Solutions

About 80% of people will have back pain at some point in their life. These odds suggest you are probably one of them. Back pain with or without leg pain is commonly due to a herniated disc in the low back. Discs are the cushions in between each of the individual bones, or vertebrae, of the spine. They are strong structures that allow our spines to move and handle loads during our everyday lives. The outer part of the disc is a durable structure with multiple layers. The inner aspect of the disc resembles more of a thick fluid. A herniated disc occurs when a small tear in the outer part of the disc results in the inner material leaking out.  Thankfully, disc herniations can be treated without surgery.

Physical therapy for disc herniation

Disc herniation is the most common cause of sciatica, in adults. Put simply, sciatica is pain that originates in the low back and travels down the leg. However, not all disc herniations cause pain in the back or down the leg. Many adults older than 30 have evidence of a disc herniation on MRI but never experience pain. I am one of them. One study showed 30% of people in their 30’s and 60% of people in their 60’s have evidence of a disc injury but experience no pain. There are many factors that determine whether or not a person will experience pain. Possible contributors include the location of the herniation, the person’s physical health, and psychological factors.

Recovery from Disc Herniation without Treatment

Disc herniations can spontaneously heal without treatment. In these instances, resorption of the displaced inner material occurs spontaneously. This can occur within a few weeks of injury or it may not be seen for several years. One recent study showed spontaneous recovery occurs in approximately 2 out of every 3 lumbar disc herniations.  Because so many disc herniations spontaneously resolve, conservative treatments are usually recommended before considering surgery. Conservative treatments include those offered by your acupuncturist, massage therapist, and physical therapist.

Evidence for Conservative Treatments

Half of the people who access the services of a physical therapist do so for low back pain. More than half of these people have conditions related to the disc. Your physical therapist will first conduct a comprehensive examination to rule out the presence of any serious problems such as an injury to the nerves or spinal cord. Whenever pain is present in the legs, the first objective of treatment is to decrease these symptoms. Disc problems are much easier to manage once the pain is localized to only the low back.

Exercise for Disc Herniations

Research shows that exercise is one of the most beneficial forms of treatment for people with lumbar disc herniations. Exercises are designed to improve the strength, endurance, and coordination of the muscles which support the spine. Also, exercises can be extremely effective at reducing pain in the legs. Very often, exercises that promote extension of the spine, also known as “McKenzie exercises” are effective at resolving pain in the legs. However, an individualized examination must always be performed in order to determine the exercise approach which is best for you.

Manual Physical Therapy for Disc Herniations

Manual therapy performed by a physical therapist is also an evidence-based and effective treatment for people with a disc herniation. Joint mobilization techniques are useful to improve mobility, promote extension of the spine, and resolve symptoms in the legs. Joint manipulation techniques may also be used to alleviate stubborn pain or stiffness from a herniated disc. It is important that these techniques are delivered by a licensed and specially-trained healthcare professional. Doctors of Physical Therapy with advanced residency and fellowship training have expertise and skill with these techniques.

What Steps Can You Take

I recently rehabilitated a 40-year old landscaper with an L4-L5 disc herniation and pain radiating from his low back to his calf.  Surgery and injections were being considered. However, after 5 weeks of physical therapy he was back to work and nearly pain free. Today he feels like a new person! Physical therapy takes patience and a commitment. There is no magic pill for resolving back pain.  However, excellent results often occur. Your physical therapist will guide you through the recovery process. Contact us today if you are suffering or simply have questions about which treatments are right for you.

Spinal Stenosis: Causes and Treatment

Spinal stenosis refers to narrowing of the space surrounding the nerves or spinal cord in the back.  Many people with signs of spinal stenosis on an MRI experience no symptoms.  Others experience pain or a deep aching sensation in the buttocks, thighs, or lower legs.  Symptoms are worse when standing or walking.  Other symptoms may include numbness or tingling in the legs and weakness of the foot or legs.  Many people have no pain when sitting or lying down.  Symptoms may be eased or completely relieved when walking leaning over a shopping cart.

Causes of Spinal Stenosis

spinal stenosis

Most people with spinal stenosis are over the age of 50.  Spinal stenosis is usually caused by normal age-related changes in the spine.  Arthritis of the joints in the spine is the most common cause.  This can be associated with degenerative changes to the intervertebral disc.  These age-related changes are normal and no different than graying of the hair or wrinkles of the skin.  In some people these changes result in pain and in others symptoms are never experienced.  It is also important to understand that the extent of stenosis on an MRI does not always match up to the severity of symptoms experienced.

Treatments for Spinal Stenosis

Contrary to popular belief, spinal stenosis does not always worsen.  There are treatments which can reduce pain and improve function.  Common treatments include activity modification, aerobic exercise, stretching exercise, strengthening exercise, massage, manual physical therapy, acupuncture, and injections.  Surgery is reserved when conservative treatments are unsuccessful.  The remainder of this article will discuss the role of physical therapy, injections, and surgery.

Physical Therapy

In most cases, regular exercise should be the first step in managing symptoms from spinal stenosis.  Physical therapists develop individualized exercise programs for people with stenosis.  This often includes stretching exercises for the lower back, hips, and legs.  The benefits of stretching can be accelerated by also including manual therapy treatments delivered by the physical therapist.  Manual physical therapy to the hips and low back has been shown to reduce pain and disability associated with stenosis.

Strengthening exercises for the core muscles and legs is beneficial to improve walking ability.  It is also important for the exercise program to include aerobic training.  This is usually in the form of cycling or treadmill walking.  People with spinal stenosis are encouraged to continue to walk.  Some pain with a walking program is expected and acceptable.  Your physical therapist will help you determine how much pain is appropriate.

Injections

Epidural steroid injections are used to treat back and leg pain associated with spinal stenosis.  This involves injecting anti-inflammatory medication into the epidural space surrounding the spinal nerve.  Decreasing inflammation around the nerve may alleviate symptoms into the legs.  Some people experience immediate relief of symptoms with epidural injections.  This can result in improved walking ability in the short-term.  However, research suggests the long-term effectiveness of injections is limited.

Surgery

spinal stenosis

Surgery for spinal stenosis involves removing bone around the compressed nerve or spinal cord.  This is referred to as spinal decompression surgery or a laminectomy.  Some surgeons also fuse vertebrae to prevent movement within the spine.   Complications from surgery occur in 10% to 24% of cases.   These include fracture, failed fusion, cardiac events, stroke, respiratory distress, and in very rare cases death.   Surgery can be very effective for some people.  However, research suggests there is no long-term difference between those who are treated conservatively and those who undergo surgery.

Conclusion

Symptoms associated with spinal stenosis are common in those over 50 years old.  In the majority of cases, symptoms and function can be improved with exercise, lifestyle changes, and other non-surgical treatments.  Conservative treatments should be exhausted before considering surgery for spinal stenosis.  Research shows people who complete a course of physical therapy are less likely to undergo surgery for spinal stenosis.  Talk to your physical therapist about what you can do to get back to doing what you love.

Sciatica: Causes and Treatment

Sciatica is pain caused by irritation of the sciatic nerve.  The sciatic nerve is the longest nerve in the body.  It begins in the lower back, passes through the buttock, back of the thigh, and into the lower leg and feet.

What Causes Sciatica?

Sciatica can be caused by injuries to many different structures such as arthritis to the spinal joints, muscle strains, and spinal stenosis.  The most common cause is an injury to the intervertebral disk.  The term “pinched nerve” is sometimes used synonymously with sciatica.  This is not always helpful because nerves are being pinched all day long as we move in and out of positions during the day.

What are the Symptoms of Sciatica?

Sciatica symptoms

Sciatica is a symptom.  It is not a diagnosis.  The symptoms can be felt as a deep ache or cramping sensation, tightness, sharp pain, numbness, or tingling.  Some or all these symptoms can be experienced anywhere along the course of the sciatic nerve.  Sometimes pain is worse while sitting or lying.  Other times pain is increased while standing or walking.

Who Gets Sciatica?

It is unclear how common sciatica actually is.  Estimates suggest 1% to 37% of the population will experience these symptoms at some time in their lifetime.  This variability is because sciatica is not a specific diagnosis and a universal definition is not agreed upon.  The development of sciatica has been associated with smoking, obesity, female sex, work-related factors, and poor overall health status.   It is believed that both physical and psychological factors play a role in the incidence and recovery.

Treatment for Sciatica

Because sciatica is not a specific diagnosis (sciatica is a symptom), treatment must be individualized.  Research shows inconsistent and short-lived symptom relief with treatments such as medications, injections, and surgery.  Physical therapists perform a comprehensive physical examination to determine the best course of treatment for each individual.  Common physical therapy treatments for sciatica include mechanical traction, manual physical therapy, and specific exercises.

Traction

mechanical traction

Traction is a form of treatment which seeks to separate or stretch apart the vertebrae of the spine.  Theoretically this might alleviate compression on a nerve in the back.  Traction is commonly achieved through mechanical devices used by physical therapists and chiropractors.  Some patients may experience temporary relief with traction.  However, the best available research suggests traction has little or no impact on long-term pain, functional status, and return to work among people back pain or sciatica.

Manual Physical Therapy

Manual mobilization or manipulation techniques are often incorporated to stretch tight joints and muscles around the sciatic nerve.   Treatment designed to improve joint mobility have been shown to be more effective than those attempting to reduce muscle spasm.  Physical therapists regularly perform manual therapy to the lumbar spine, pelvis, and hip joints for the treatment of sciatica.

Specific Exercise

Sciatica

Individually prescribed exercise is the staple treatment for patients with sciatica.  The proper exercise program can only be developed after a comprehensive physical examination is performed by the physical therapist.  Because sciatica is a symptom and not a specific diagnosis, there is no universal exercise which will help all patients with sciatica.  However, when a proper exercise program is developed, sciatica will improve or completely resolve in 90% of cases.

Conclusion

Sciatica describes pain or other symptoms experienced anywhere along the course of the sciatic nerve.  The large majority of people fully recover with conservative treatments.  Only a small percentage of people will require injections or surgery. Physical therapists incorporate manual therapy and exercise to alleviate the symptoms.  Most patients respond very well to this approach.

References

  1. Cook CE, Taylor J, Wright A, Milosavljevic S, Goode A, Whitford M. Risk factors for first time incidence sciatica: A systematic review. Physiother Res Int. December 2013:1-14. doi:10.1002/pri.1572
  2. Donelson R, Long A, Spratt K, Fung T. Influence of directional preference on two clinical dichotomies: Acute versus chronic pain and axial low back pain versus sciatica. PMRJ. 2019;4(9):667-681. doi:10.1016/j.pmrj.2012.04.013
  3. Hahne AJ, Ford JJ, McMeeken JM. Conservative management of lumbar disc herniation with associated radiculopathy: A systematic review. Spine (Phila Pa 1976). 2010;35(11):E488-504. doi:10.1097/BRS.0b013e3181cc3f56
  4. Jewell D V, Riddle DL. Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients with sciatica. Phys Ther. 2005;85(1):1139-1150.

Deadlift: Harmful or Helpful for Low Back Pain?

The deadlift is essentially a hip hinge with weight.  The hinge occurs by flexing at the hips while maintaining a flat low back.  The deadlift also involves some knee flexion but the majority of the movement occurs by hinging at the hips.  Hinging differs from stooping and squatting.  Stooping involves bending at the low back more than the hips.  Squatting involves bending at the knees more than the hips.   The deadlift is an exercise which resembles a safe technique for lifting.

The deadlift is a great exercise to strengthen your backside.  The gluteus maximus, one of the largest and strongest muscles of the body, is the prime mover when performing the deadlift.  The quadriceps, hamstrings, and low back muscles are also activated at high levels.  Adequate strength in these large muscle groups is necessary for every day function and performing sports at high levels.  The deadlift also activates smaller stabilizing muscles of the spine to a greater extent than low load exercises lying on the floor or a ball.

The deadlift sometimes gets a “bad rap”.  This is because many in the medical community have cautioned patients with low back pain from performing any heavy lifting.  It is true that improper execution of the deadlift can result in low back injury.  However, when performed properly, the deadlift is an excellent exercise to strengthen the hips and low back.  Proper instruction and coaching of the exercise should always occur for individuals with low back pain.   Most people require the help of a physical therapist or coach to learn the exercise correctly.

Should People with Low Back Pain Deadlift?

The safe answer is it depends.  However, research does show the deadlift can be very effective for strengthening the low back muscles, decreasing back pain, and improving function.  Therefore, most people with low back pain can, and should, be instructed on how to hip hinge and perform some variation of the deadlift.  This does not mean everyone with low back pain should attempt to pick up as much weight as possible from the floor.  There must be proper instruction, safe practice, and appropriate progression.

A 2015 study in the Journal of Orthopedic and Sports Physical Therapy showed both low load exercises and deadlift training resulted in similar improvements in low back pain, back muscle strength, and disability.  It was later found that people with better low back muscle endurance and lower pain levels were more likely to benefit from deadlift training.  Therefore, a wise approach is to begin with low load exercises on the floor or a table.  Once pain levels decrease and muscle function improves, progressing to deadlift training can be started.

Deadlift Progressions

It can be challenging for some individuals to learn how to properly hinge at the hips without bending at the spine.  Physical therapists use different corrective exercise approaches to teach the proper movement pattern.  Only after mastering the movement pattern is weight added.  The basics of the set up for the deadlift include a hip-width stance, soft slightly bent knees, shoulder blades back, and a chest-up position.  Your chest should be above your hips, and your hips above your knees.  The movement is initiated by extending the hips with a flat back.

Below are 5 exercise progressions for the deadlift.  There are many others which are considered when designing an individualized program.  The specific exercises prescribed depend on the individual’s current levels of strength, mobility, function, and their goals.

 

 

Closing Thoughts

 People with low back pain cannot fully function in everyday life without lifting objects from the floor.   Physical therapists can teach people how to properly lift.  Deadlift variations are ideal for this purpose.  Research shows people with low back pain can safely and effectively perform the deadlift.  For many people with low back pain, the conventional deadlift is not the best choice.  Most people require modifications.  Your physical therapist can perform a physical examination and then prescribe the exercise which is best for you and your goals.

Hip Manual Therapy Improves Low Back Pain

Research shows range of motion restrictions of the hip are associated with low back pain.  People with low back pain have less hip rotation range of motion compared to people without low back pain.  It is also common for people with low back pain to have side-to-side differences in hip rotation range of motion.  For example, one hip may rotate a total of 75 degrees, and the other hip only 60 degrees.  Hip mobility restrictions can be due to stiffness in the joint capsule or muscles which cross the joint.  Restricted hip mobility due to joint stiffness is best treated with manual therapy performed by a physical therapist.

Hip internal rotation restrictions are closely linked to low back pain.   This movement involves rotating the thigh inward towards the midline of the body.  This hip must internally rotate when the leg is behind the body during the normal gait cycle.   If this motion is unavailable at the hip, the movement must then occur at the spine.  Hip internal rotation must also occur when performing any type of pivot or change of direction when walking.   Many sports activities, such as swinging a golf club, require large amounts of hip rotation.  If the motion is not available at the hip, the spine must compensate.  This often results in abnormal movement and stress to the structures of the low back.

Proven Benefits of Hip Manual Therapy

A 2017 study published in the Journal of Evaluation in Clinical Practice investigated the effects of providing manual therapy and exercise targeting the hips in people with low back pain.  Half of the participants received treatment to the spine only.  The other half received treatment to the spine and hips.  The group who were treated with manual therapy and exercise targeting the hips were more satisfied with their treatment.  They also reported greater improvements in pain and disability compared to the group who only received treatments to the spine.

Hip Manual Therapy Techniques

Three hip joint mobilization techniques were utilized in the previously mentioned study.  Examples of these techniques are included below.   Manual therapy techniques are individualized based on findings from the physical examination.   All mobilization techniques are performed without pain.  Only a mild stretching sensation is felt by the patient during these treatments.  Immediate improvements in hip range of motion occur in most cases.  However, in order for these improvements to be sustained, home exercises are prescribed.

Closing Thoughts

There is no one magic treatment for low back pain.  Abdominal and low back strengthening exercises can be effective.  However, the best results usually occur when multiple treatments are combined and patients are taught to self manage.  Treatment focused only on the spine is often only partially effective.   The low back and hips are very closely linked.  Outcomes are improved when treatments are also directed to the hips.  In order for results to be sustained, an exercise program targeting hip mobility and hip strength are also included.

 

 

Hip Weakness Contributing to Your Back Pain?

Have you tried all types of low back exercises for your lingering back pain?  You might want to have your physical therapist take a look at your hips.  Your hips and low back are closely linked through multiple shared muscles.  Therefore, motion at the spine, pelvis, and hips occur together.  Poor movement at one of these areas creates compensations at the others.  This is because of the common muscle attachments.  Often, rehabilitation exercises targeting the abdominal and low back muscles result in only partial resolution of low back pain.  The missing piece may be addressing weakness of your hip muscles.

Proof There is a Link between Hip Weakness and Back Pain

Weakness or poor endurance of the glutes has been associated with low back pain in athletes and non-athletes.  Women with persistent back pain have smaller glute muscles compared to those without back pain.  Female athletes with back pain show side to side differences in hip strength.  This predisposes them to poor movement patterns and injury.  Chronic back pain in men is associated with weakness of the glutes, elevated body weight, and tenderness in the low back region.  Weakness of the glute muscles is often present in people who are limited in their ability to stand because of low back pain.

It is unclear if hip muscle weakness is the result of disuse or a cause of low back pain.  In either case, exercise targeting the hips is required to restore strength and proper movement.  Many people with weakness of their hip muscles overuse their low back muscles.  Overactive low back muscles leads to fatigue, pain, and abnormal movement. This results in a viscous cycle where abnormal movement results in more pain; and more pain worsens the poor movements.

LBP hip weakness

A 2015 study in the Journal of Physical Therapy Science compared the effectiveness of low back and hip strengthening exercise to low back exercise only.  The group of people who exercised both the low back and hip muscles showed significantly greater improvements in back strength, balance, disability, and pain.  Another study in the Journal of Back and Musculoskeletal Rehabilitation also showed better outcomes in people who performed exercises for both the low back and hip muscles.  The following 5 exercises were included in the study. Try these to get you started.

Clamshell

The clamshell strengthens your gluteus medius muscle.  Begin by lying on your side with your hips bent.  The knees are also bent and your feet are kept together.  A resistance band can be placed around your thighs just above your knees.  Start by rotating your top hip to bring your knees apart.  Hold this position for 2 seconds and then return to the starting position slowly.  Remain lying completely on your side with one hip stacked on top of the other.  Allowing your pelvis to roll backwards is the most common mistake.   The clamshell is a great exercise to start with because it requires minimal activity of low back muscles.

Side-Lying Hip Abduction

Hip abduction strengthens both the gluteus medius and maximus.  Begin by lying on one side with your bottom hip and knee bent.  Your top knee remains straight.  Maintain your top hip in a neutral or slightly extended position with your toes pointed forward.  Point your toes forward to orient your hip in slight internal rotation.  This increases gluteus medius activity.  Initiate the movement by lifting your top leg about 30 degrees.  Hold this position for a count of 2 seconds and then slowly lower your leg to the start position.  Ankle weights can be added for resistance once 15 proper repetitions are performed.

This exercise activates the gluteus medius to a greater level than the clamshell.  However, it is also more challenging to perform correctly.  Similar to the clamshell, it is important to remain completely on your side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake.  Also, as the muscle tires, your leg will drift forward into hip flexion.  It is important to maintain your leg lined up or slightly behind your trunk and upper body.

Quadruped Hip Extension + Knee Flexion

Begin on your hands and knees.  Position your shoulder directly over your hands.  Position your hips directly over your knees.  Maintain a neutral spine position throughout the exercise.  Initiate the movement by bending one knee to 90 degrees.  Next, lift your heel up towards the ceiling keeping your knee bent.  Hold this position for 2 seconds then return to the starting position. Lower your leg back down before repeating another repetition on the same side.  Avoid arching through your low back.  Complete the desired number of repetitions on one side before beginning with the other leg.

Cook Hip Lift

Begin lying on your back with your hips bent and feet lined up with your shoulders.   Flex your hip by holding one knee to the chest.  It is helpful to place a small towel roll or ball in the crease of your hip.  Lift your toes off the floor and perform a bridge from one leg.  Avoid excessively arch your low back.  Be sure to achieve the bridge position by extending through your hips. Hold this position for 2 seconds then return to the starting position.  Lower the body back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with your other leg.

The positioning of your hips during this exercise facilitates a neutral pelvis and low back position.  This is helpful for people with low back pain.  However, this also increases the challenge to your glute muscles compared to a standard bridge. Raising your toes makes you press your heel into the ground as you lift your hips. This facilitates the glutes and hamstrings.

Lateral Step Down

The step down exercise begins with your hands on both hips standing with one leg on the side of a step or 8-inch high box.  Maintain balance on 1 leg and slowly squat to lower your heel of the other leg toward the floor.  Gently tap your heel and return to the starting position.  Maintain your trunk in an upright position.  Avoid leaning to the side or waving your arms.  Your knee should not move forward past your toes.  Also, your knee should remain over your toes so it does not cave inwards.  Perform 8 to 10 slow and controlled repetitions before switching sides to your other leg.

Closing Thoughts

It is important to exercise your abdominal, low back, and hip muscles to fully recover from an episode of low back pain.  These muscles do not function in isolation.  Not addressing muscles imbalances often leads to recurrent episodes of pain.  These 5 exercises address common hip muscle imbalances in people with low back pain.  Exercises should be individually prescribed based on a physical therapist’s examination of your movement and strength.  Additional individualized exercises integrating multiple muscles with functional movement patterns are often beneficial to help you achieve their goalsContact us if you would like help getting started.

5 Fundamental Low Back Exercises

People with low back pain have poor control and coordination of their spine muscles.   Pain shuts down the muscles in your low back.  This leads to atrophy (loss of muscle size) and poor movement.  The lumbar multifidus muscle plays an important role in restoring normal spine movement.  People with low back pain have atrophied multifidus muscles.  Fatty tissue replaces lost muscle.  People with longstanding low back pain on only one side of the back, show loss of multifidus muscle size and fatty infiltration on only the painful side of the back.  Thankfully, low back exercises can help.

low back exercises

Low back exercises restore control and coordination of the smaller muscles in your low back.  Basic exercises are initially used to target the lumbar multifidus and other deep muscles of the back.  Perform all exercises in a slow and controlled manner.  Don’t rush.  Normal breathing should always be maintained.  Generally, higher repetitions (10 to 20) are recommended in order to promote muscle endurance.  This is consistent with how these muscles function in everyday life.   The following 5 exercises  are fundamental for anyone looking to start a low back exercise program.

Lumbar Multifidus Activation

This is the most basic of low back exercises.  Begin on all fours with one knee placed on a small pillow or foam Airex pad.  Position your shoulders over your hands and hips over your knees.  Maintain your spine in a neutral position.  Slowly lift your knee from the floor.  Your thigh and hip should move straight up.  This small amount of rotation is controlled by your multifidus.  Hold this position for 2 to 3 seconds then slowly lower your knee back to the floor.  Your foot stays in contact with the floor during the exercise.  To progress the exercise, elevate the foot with the knee or increase the hold time to 10 seconds.  Perform 10 to 20 repetitions on each side.

 2-Leg Bridge

Begin by lying on your back with your hips flexed and feet lined up with your shoulders.  Perform the bridge by lifting both hips from the floor.  A common mistake is to excessively arch the low back.  Hold the bridge position for 2 to 3 seconds then return to the starting position.  Lower your body back down in a slow and controlled manner.  Perform 10 to 20 repetitions for multiple sets.

Be sure to achieve the bridge by extending through your hips.  If you lack mobility in your hip joints or hip flexor muscles this may lead to compensation through the low back.  This can be corrected with manual therapy and hip mobility exercises.  You can also try bringing your feet slightly closer together and your knees slightly wider apart.  This will allow you to achieve greater hip extension range of motion.

Bridge + March

You can progress the standard bridge in many ways.  This progression involves an alternating march.  Perform a standard bridge and hold the top position.  With your hips elevated from the floor, lift one foot 2 to 3 inches.  Hold your foot off the floor for 2 to 3 seconds before lowering.  Without lowering the hips down to the floor, lift your other foot in the same fashion.  Lower your hips back down to the floor to complete the first repetition.  Maintain a level pelvis as one foot is lifted from the floor.  This requires activation of the glutes, hamstrings, and low back muscles.   Perform 10 to 12 repetitions on each side for multiple sets.

Bird Dog

Start on your hands and knees with your back flat.  Your shoulders are directly over your hands.  Your hips are directly over your knees.  Slowly raise your left arm and right leg until they are horizontal with your trunk.  Maintain a straight line with your trunk, upper extremity, and lower extremity.  Avoid trunk rotation.  Also, do not allow your back to sag or arch.  Hold this position for 2 to 3 seconds.  Then repeat with your right arm & left leg, alternating sides with each repetition.  Increase how long you hold each rep to 10 seconds if you want to make it more challenging. Perform 10 to 12 repetitions on each side for multiple sets.

Modified Side Plank

Lie on your side, with the knees comfortably bent.  Prop up on your elbow bearing weight through your forearm. Lift your pelvis up from the surface so the only contact is through your forearm and lower leg.  Do not go beyond the neutral position (your body is in a straight line). Do not allow your body to rotate forward or backward.  Hold this position for 2 to 3 seconds, and then gently relax down to the starting position.  You can make it more challenging by holding the position for 10 seconds. Perform 10 to 12 repetitions on each side.

Closing Thoughts on Low Back Exercises

Low back exercises often target the lower abdominals, hips, and pelvic muscles.  Some refer to this as the “core”.  However, it is important to realize that alleviating or preventing low back pain requires an exercise program beyond simply training your core.  Once basic low back and abdominal exercises can be performed correctly, progression is needed.  Only exercises that integrate the smaller and larger muscles of the trunk with the extremities (advanced core exercises) will restore full function. Your physical therapist can help you develop the best approach for you.  Contact us if you have questions about how to get started.

Low Back Pain: Get Started with Abdominal Exercises

Low back injuries usually do not occur from one single incident or event like lifting a heavy box.  Instead, most back injuries occur from small incremental stress or load applied over time.  Sitting slouched for prolonged periods at a desk or repeatedly performing bending and twisting can overload sensitive spinal structures.  These structures include the muscles, facet joints, ligaments, discs, and nerves.   Muscle weakness, poor endurance, poor position awareness, and previous history of injury can make one more susceptible to low back injuries.  Most of these injuries are not serious and do not require extensive testing or treatment.

The core muscles function to spare the lumbar spine and surrounding structures from excessive load.  These muscles include the abdominals, low back musculature, diaphragm, and pelvic floor muscles.  No single muscle is more important than the others.  Human movement and low back pain are more complex than one muscle or structure.  Instead, all muscles should ideally function together in coordination.  Pain interferes with coordination and control.  The specific task being performed determines the magnitude and timing of core muscle activity.  Some tasks require a very low load and level of muscle activity such as bending to tie the shoes.  Other tasks require greater muscle activation patterns at high speeds such as swinging a baseball bat.

Exercises to train the core musculature should begin with low loads focusing on control and endurance.  Exercises performed lying on the back targeting the abdominal muscles is a great place to start.  The following exercises can be performed by those with low back pain or those with a history of back pain looking to prevent recurrences.  Once these exercises are no longer challenging, progression is needed.  Future articles will address proper progressions.

Abdominal Bracing

Begin lying on your back with the hips and knees bent.  Find a neutral spine position by gently rocking your pelvis back and forth.  Your neutral position is somewhere between a fully arched and fully flattened position.  In your neutral position, you should be able to hold a small grape under your low back without crushing it.  Maintain a neutral spine and gently contract your abdominal muscles in the front and sides continuing 360 degrees around to the low back.  This muscle contraction should be gentle and no movement should occur.

Once a neutral spine can be maintained with gentle bracing, breathing is added.  Diaphragmatic breathing is performed while maintaining a neutral spine and gentle bracing.  This involves expanding through the belly and rib cage in a 360-degree fashion.  Minimal or no movement occurs in the upper chest and shoulders.  Five deep slow breathes are performed while maintaining a neutral spine and bracing.  No breath holding or movement of the spine should occur.  It is helpful to place one hand on the abdomen and the other hand on the chest to ensure a proper breathing pattern is maintained.   This exercise forms the foundation for all subsequent abdominal exercise progression to follow.

Bent Knee Fall Out

The bent knee fall out is performed after abdominal bracing and diaphragmatic breathing have been mastered.  Begin with a neutral spine, bracing, and diaphragmatic breathing.   Lower one knee to the side towards the floor in a slow and controlled fashion.  No movement in the spine or hips should occur.  It is helpful to place the hands on the hip bones to ensure no movement is taking place.  With each repetition alternate sides.  To increase the challenges add a resistance band around the thighs.  Perform 10 slow repetitions on each side.

90/90 March

This exercise begins with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate lowering the heels to the floor.  Gently touch the heel to the floor without relaxing.   Perform 10 slow repetitions on each side.

Heel Hover

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate extending of the knee so one leg straightens without touching down.  As you lower the legs, it is important that the low back does not arch away from the floor.  Perform 10 slow repetitions on each side.

Double Leg Lift

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Both knees and feet are then simultaneously elevated so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly lower the legs together.  Do not touch down or relax the feet to the floor.  It is important that the low back does not arch away from the floor.  Perform 10 to 20 slow repetitions on each side.  To increase the challenges add a small ball to squeeze between the thighs.

Closing Thoughts on Abdominal Exercise for Low Back Pain

Pain interferes with how our brain transmits signals to our muscles.  This is especially important when your low back pain has persisted for more than several weeks.  These 5 abdominal exercises re-program the lost connections between the brain and core muscles.  Slow coordinated and controlled movements are crucial for success.  Absolutely no holding of the breath should occur.  Breathe holding increases tension throughout the body and interferes with retraining of the muscles and nervous system.   Practice these exercises, master them, and improve your endurance by increasing repetitions.   Once these goals are achieved, you are ready to build strength and resilience with more challenging exercises.

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