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.

 

 

Is Hip Weakness Contributing to Your Back Pain?

The hips and low back are closely linked by multiple shared muscles.  Contraction of these shared muscles will affect motion at the spine, pelvis, and hips.  Poor movement at one of these areas can create compensatory movement at the others 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 the hip muscles.

Research Shows a Link between Hip Weakness and Back Pain

Weakness or poor endurance of the gluteus maximus has been associated with low back pain in athletes and non-athletes.  Women with longstanding low back pain have smaller gluteus maximus muscles compared to those without low back pain.  Female athletes with low back pain show side to side differences in hip strength which may predispose them to compensatory movements.  Chronic back pain in men is associated with weakness of the gluteus medius muscle, elevated body weight, and tenderness in the low back region.   Weakness of the gluteus medius is often present in those 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 patterns.  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 compensatory movements.

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 the gluteus medius muscle.  Begin by lying on one side with the hips flexed to approximately 45 degrees.  The knees are flexed and the feet kept together.  A resistance band can be placed around the thighs just above the knees.   Start the exercise by rotating the top hip to bring the knees apart.  Hold this position for 2 seconds and then return to the start position slowly.  Be sure to remain lying completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement 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 the bottom hip and knee bent.  The top knee remains straight.  The top hip is maintained in neutral or slight hip extension with the toes pointed forward.  The toes are pointed forward to orient the hip in slight internal rotation.  This increases gluteus medius activity.  Initiate the movement by lifting the top leg about 30 degrees.  Hold this position for a count of 2 seconds and then slowly lower the leg to the start position.  Ankle weights can be added for resistance once 15 proper repetitions can be 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 the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake with this exercise.   Also, as the muscle tires, the leg will drift forward into hip flexion.  It is important to maintain the leg lined up or slightly behind the trunk and upper body.

Quadruped Hip Extension with Knee Flexion

Begin on the hands and knees.  The shoulders are positioned directly over the hands.  The hips are positioned directly over the knees.  The spine is maintained in a neutral position throughout the exercise.  Initiate the movement by flexing one knee to 90 degrees.  Next, lift the heel up towards the ceiling keeping the knee flexed.  Hold this position for 2 seconds then return to the starting position.  Lower the leg back down before repeating another repetition on the same side.  It is important to avoid arching through the low back.  Complete the desired number of repetitions on one side before beginning with the other leg.

Cook Hip Lift

Begin by lying on the back with your hips flexed and feet lined up with the shoulders.   Flex the 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.  A common mistake is to excessively arch the low back.  Be sure to achieve the bridge position by extending through the 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 the other leg.

The positioning of the hips during this exercise facilitates a neutral pelvis and low back position.  This is helpful for people with a history of low back pain.  However, this also increases the challenge to the gluteus muscles compared to a standard bridge.   Raising the 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 the hands on the 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 the heel of the other leg toward floor.  Gently tap the heel and return to the start position.  Throughout the exercise the trunk is maintained in an upright position.  Avoid leaning the trunk to the side or waving the arms.  The knee should not move forward past the toes.  Also, the knee should remain over the toes so it does not cave inwards into valgus.  Perform 8 to 10 slow and controlled repetitions before switching sides to the other leg.

Closing Thoughts

It is important to exercise the 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.   In most cases, exercises should be individually prescribed based on a physical therapist’s examination of movement and strength.   Additional individualized exercises integrating multiple muscles with functional movement patterns are often beneficial to help people achieve their goals.

Low Back Exercises

People with low back pain show poor control and coordination of the spine muscles.   Pain inhibits the function of muscles.  Inhibition often leads to atrophy (loss of muscle size) and abnormal movement.  The lumbar multifidus plays an important role in restoring normal spine movement.   Those with low back pain exhibit atrophied multifidus muscles.  Lost muscle is replaced with deposits of fatty tissue.  Those with longstanding low back pain on only one side of the spine, show loss of multifidus muscle size and fatty infiltration on only the painful side of the back.

low back exercises

Rehabilitation exercises are prescribed to restore the control and coordination of the smaller low back muscles.  Basic exercises are initially used to target the lumbar multifidus and other deep muscles of the back.  It is important that these exercises are performed in a slow and controlled fashion.  Normal breathing patterns should be maintained.  Generally, higher repetitions (10 to 20) are performed in order to promote muscle endurance.  This is consistent with how these muscles function in everyday life.   Below are 5 exercises most people can get started with.

Lumbar Multifidus Activation

Begin on all fours with one knee placed on a small pillow, towel roll, or foam pad.  The shoulders are positioned over the hands and hips over the knees.  The spine is maintained in a neutral position.  Slowly lift the knee which is not supported on the foam pad.  The thigh and hip should move straight up.  This induces a small amount of rotation which is controlled by the multifidus.  Hold the up position for 2 to 3 seconds then slowly lower the knee back to the floor.  The 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 the hips flexed and the feet lined up with the 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 the body back down in a slow and controlled manner.  Perform 10 to 20 repetitions for multiple sets.

Be sure to achieve the bridge position by extending through the 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 mobility exercises.  You can also try bringing your fleet slightly closer together and the knees slightly wider apart.  This will allow you to achieve greater hip extension range of motion.

Bridge + March

Perform a standard bridge and hold the top position.  With the hips elevated from the floor, lift one foot 2 to 3 inches from the floor.  Hold the foot off the floor for 2 to 3 seconds before lowering.  Without lowering the hips down to the floor, lift the other foot in the same fashion.  Lower the 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

Begin on the hands and knees with the back flat.   The shoulders are directly over the hands and hips directly over the knees.  Slowly raise the left arm and right leg until horizontal with the trunk.  Maintain a straight line with the trunk, upper extremity, and lower extremity.  It is important to avoid trunk rotation and not allow the back to sag or arch.  Hold this position for 2 to 3 seconds.  Then repeat with the right arm & left leg, alternating sides with each repetition.  To increase the challenges of the exercise extend the hold time to 10 seconds. Perform 10 to 12 repetitions on each side for multiple sets.

Modified Side Plank

Lie on the side, with the knees comfortably bent.  Prop up on the elbow bearing weight through the forearm.   Next, lift the pelvis up from the surface so the only contact remaining on the surface is through the forearm and lower leg.  Do not go beyond the neutral position (the body is in a straight line) and 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.  To increase the challenges of the exercise extend the hold time to 10 seconds.  Perform 10 to 12 repetitions on each side.

Closing Thoughts

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 the core.  Once basic low back and abdominal exercises can be performed correctly, progression is needed.  Exercises which integrate the smaller and larger muscles of the trunk with the extremities (advanced core exercises) are used to restore full function.   These exercises are developed on an individual basis with consideration for the goals, preferences, and activity levels of the individual.  A physical therapist can determine the best approach for you.

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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Self-Management of Pain: Your Physical Therapist as a Guide

Too many medical approaches in today’s society are dependent on others (therapists, doctors, etc) and include passive treatments (medications, injections, etc.).  It can be empowering to take control of your own health and seek active forms of treatment for conditions such as low back pain, arthritis, or even every day sprains and strains.  Self-management allows you to develop a sense of control over your problem and offer you tools to use for a lifetime.  However, many are unsure where to start.

Therapeutic Alliance and Self-Management of Pain

In order to optimize self-management for any painful condition, a meaningful working relationship, or therapeutic alliance, in which the patient and provider work together, should be established.  This begins by developing a patient-preferred approach to treatment.  If you prefer to exercise aerobically then you should not be forced to perform lumbar stabilization exercises for your back pain.  If you enjoy strength training in the gym you should not be prescribed aerobic exercise for your knee pain.  Exercise you enjoy is medicine for the body and mind.  Both forms of exercise have been shown to be beneficial for managing back pain.  Let’s choose together what you prefer.

Developing a positive therapeutic alliance with your physical therapist also allows for the careful monitoring of progress over time.  There are going to ups and downs along the way.  Your physical therapist can help pick you up during challenging times.  Your physical therapist can also progress your plan appropriately when things are going well.  A physical therapist can work as a coach offering constructive feedback and encouragement.   They can help you make periodic adjustments to your self-management program.  With this approach, you are in control of your own health and your therapist acts only as a guide.

The interaction between you and your health care provider has been shown to be one of the strongest predictors of patient satisfaction with physical therapy care, and a key contributor to a successful outcome.  Research shows the amount and quality of the interaction between a patient and their physical therapist has a profound impact for those with persistent back pain.  Taking advantage of these positive interactions will magnify the effects of any exercise program or lifestyle modification. Having the same therapist, will potentially enhance the therapeutic alliance, guide you towards your preferred self-management strategies, and help you achieve the best possible long-term outcome.

What Self-Management Looks Like

Your physical therapist will first seek to understand your beliefs about pain and your condition.  Many people hold negative beliefs which are unhelpful to recovery or they are simply untrue.  For example, many people continue to believe that a herniated disc will never heal.  Your physical therapist will redirect you towards what you can control and strategies to improve self-efficacy.

Often a large amount of active participation over a long time is needed to change unhelpful beliefs and poor lifestyle habits.  Your physical therapist will guide you towards forms of physical activity you prefer and which are appropriate.  It is also important that you fully understand the time it takes for the body to heal itself.  The body’s natural healing mechanisms can be enhanced with the appropriate dose of physical activity.  Start too slow and your recovery will be delayed.  Start too fast and “flare-ups” will kill your motivation. Your physical therapist will help you find the best starting point and teach you how to progress.

Exacerbations of pain are going to occur.  You are going to have “flare-ups” of your back pain, neck pain, or shoulder pain.  This needs to be accepted and expected.  You want to develop resilience for these set ups.  There are always strategies available to help you through these challenging times.  Thinking the worst is never helpful in these situations.  Remaining optimistic is the first step.  Next, identify what is under your control to get you back on track.  This is where your physical therapist can help you focus your efforts.

Closing Thoughts                         

People with persistent painful conditions don’t always need more medical treatment.  They need a coach or guide to show them how to manage on their own with active forms of treatment.  Physical therapists can fill this role.  Developing a positive working relationship, or therapeutic alliance, with your physical therapist will get you set on the right track.  The rest is up to you.

Persistent Low Back Pain: The Physical Therapist’s Role

Low back pain is the most common cause of disability and lost work time in industrialized countries.   Persistent low back pain is characterized by periods of high and low pain intensity which can persist for years.  Periodic “flare- ups” are common and often result in the seeking of medical treatment.  Medications and surgery are often ineffective and may be harmful in some situations.  Physical therapy is a non-invasive treatment approach which is often considered in those with persistent low back pain.  However, improvements are often short-term for those with longstanding pain.  Similar to surgery and medications, the long-term success of physical therapy treatments for chronic back pain is questionable.

Traditional approaches utilizing physical therapy involve a short, but intense course of treatment such as 12 visits over a 4 to 8 week period.  However, this type of treatment approach is likely insufficient to positively influence a person’s beliefs and behaviors about their pain.  Changing these beliefs and behaviors are crucial if an individual with persistent pain is to self-manage through physical activity and lifestyle changes.

Persistent Low Back Pain is Complex

When pain persists beyond expected time frames, changes occur within our nervous system.  These changes include abnormal pain processing pathways and poor execution of movement patterns.  Because the nervous system is so complex, individual “pain experiences” vary greatly among those with persistent low back pain.  Diagnostic tests and scans, including MRI, are of little help because the primary problem is in the nervous system, not the low back.

The low back muscles of those with persistent pain undergo substantial changes over time.  This is believed to be caused by changes in the central nervous system.  These changes include atrophy (loss of muscle) and deposits of fatty tissue in the place of the lost muscle.  In particular the lumbar multifidus muscle has been shown to be selectively atrophied in many, but not all, individuals with persistent back pain.  Not only does the structure of muscle change with long-standing pain, but so does the nervous system’s ability to activate certain muscles.  Some muscles may become underactive while others become overactive.  These patterns differ among individuals with back pain making symptoms highly variable.   A common strategy is when many muscles of the low back contract simultaneously resulting in an unhelpful stiffening or bracing of the trunk.

Persistent Low Back Pain & Exercise

Altered pain processing pathways in the nervous system and changes in the back muscles leads to difficulty learning low back exercises.  A long term stimulus is likely needed to overcome atrophy of spinal muscles and to regain proper muscle function.  Performing low back exercise several times per week for 1 to 2 months is not adequate dosage.  Therefore, those with persistent pain may require repeated practice for several months in order to master the most basic of exercises.

In order to restore normal movement patterns exercise prescription must be matched to the individual’s beliefs and functional problems.  Ongoing types of cognitive interventions, such as education about the science of pain are beneficial to facilitate participation in exercise and physical activity.  An emphasis on education and a gradual progression of physical activity then becomes the long-term treatment.

The Role of the Physical Therapist in Helping Those with Persistent Low Back Pain

A recent episode of low back pain often responds well to manual therapy treatments such as mobilization, manipulation, or massage.  Sometimes, ice or hot packs can be helpful in these situations. However, passive interventions are of little help for those with persistent pain.  Instead, treatments that effectively involve the patient in long-term performance of physical activity are likely to be most valuable. These approaches seek to empower the patient by emphasizing their own preferred types of physical activities which can be progressed and modified as needed over time by the physical therapist.

There is no one-size fits all approach to prescribing exercise for those with persistent low back pain.  Core stabilization exercise receives a great deal of attention but this form of treatment is only helpful in some.  The same goes for stretching, resistance exercise, and aerobic exercise.  All these forms of exercise can be helpful in some but not all.  Therefore, the physical therapist and the patient should collaborate to develop an exercise plan which the patient finds enjoyable or preferable.  This is the only way the program will be adhered to for the long-term.

Final Thoughts on Physical Therapy for Persistent Low Back Pain

The traditional approach of attending physical therapy sessions 2 to 3 times a week for 4 to 8 weeks is not optimal.  Instead, the physical therapist and patient should seek to develop a long-term working relationship over time.  Initially, physical therapy sessions may occur multiple times a week but only for a few weeks.  Sessions should then be spaced out over time.  The physical therapist can assist the patient in progressing or modifying their exercise program at each session.

The physical therapists primary role is as a coach or guide who empowers the individual to self-manage for the long-term.   The ultimate goal is for the individual to manage and be prepared for fluctuations in their back pain.  Those with persistent back pain are ideally suited to directly access the services of a physical therapist without a physician referral.  In these instances, sessions are best when spaced out every few months or as needed.

Medications for Low Back Pain: Helpful or Harmful?

It has been estimated that half of Americans will experience low back pain each year.  Approximately 80% will experience low back pain at some point in their lifetime.  Now the good news: It is estimated that about 90% of those who experience back pain will recover well within a few weeks or months.  The other 10% may go on to experience chronic disabling back pain that remains resistant to treatment.   Identifying factors which may lead to chronic pain is a complex matter.   Some believe that controlling the initial intensity of pain is the key.  However, the research does not strongly support this idea.  In fact, efforts to control pain with medication may actually be more harmful than helpful.

Opioids, Low Back Pain, and Depression

Recent practice guidelines published in the European Spine Journal recommend against the use of imaging (MRI or CT scans), injection, anti-inflammatory medications (ibuprofen, etc), and opioids. These same guidelines suggest using patient education, exercise, and manual therapy should be the first treatments used for those with low back pain or sciatica.  Contrary to popular belief, research does not support the use of opioids for short-term pain relief in those with back pain or sciatica.

In the United States, there is a strong association between depression, low back pain, and being prescribed opioid medication.  Individuals with low back pain and a history of depression are more likely to be prescribed opioid medication.  Not only are individuals with depression more likely to be prescribed opioids, but the dosage these individuals are prescribed is twice as high per year compared to those who have no history of depression.  It is then reasonable to theorize that individuals with a history of depression are more likely to develop a dependency or addiction to these powerful medications.   Given the proven benefits of exercise for depression and low back pain, exercise should be used as a first line treatment for these individuals before considering prescription medication.

Muscle Relaxants and Low Back Pain

Muscle relaxants may offer a safer pharmacological option to manage back pain compared to opioids.  Research does suggest a potential short-term benefit to using muscle relaxants when pain is severe.  However, evidence is lacking to support the use of these medications for patients with low back pain lasting greater than 3 months.  Adverse reactions to these medications are usually minimal and similar to those experienced with placebo.

Anti-Inflammatory Medications

The best available evidence suggests a very small and non-significant benefit to using non-steroidal inflammatory medications for back pain and sciatica.  The benefits to using these medications for a new episode of back pain is questionable and the side effects can be severe.  The most serious side effects include ulcers, cardiovascular events (heart attack or stroke), and kidney failure.  If these medications are used, short-term doses should be used in order to minimize risk.

Closing Thoughts

I am not a medical physician.  I cannot prescribe medication and I cannot counsel anyone who is currently taking prescription medication.  However, I do hope that anyone taking prescription medication for low back pain understands the risks, especially with using opioids.  Please carefully discuss these risks with your physician.  Living an active medication-free life, with little or no pain, is possible and always a reasonable goal.

References

  1. Smith JA, Fuino RL, Pesis-Katz I, et al. Differences in opioid prescribing in low back pain patients with and without depression: A cross- sectional study of a national sample from the United States. Pain Reports. 2017;2:1-7.
  2. Ransmussen-Barr E, Held U, Grooten W, et al. Non-steroidal anti-inflammatory drugs for sciatica (Review ). Cochrane Database Syst Rev. 2016;(10):1-53. doi:10.1002/14651858.CD012382.www.cochranelibrary.com.
  3. Shaheed CA, Maher CG, Williams KA, Mclachlan AJ. Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur J Pain. 2017;21:228-237. doi:10.1002/ejp.907.
  4. Stochkendahl MJ, Kjaer P, Hartvigsen J. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27:60-75. doi:10.1007/s00586-017-5099-2.