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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Muscle Loss in Older Adults: Prevention and Treatment

Loss of muscle with advancing age is referred to as sarcopenia.  This process begins in the fifth decade of life and proceeds at a rate of almost 1% each year.  Declines in muscle strength usually progress faster than muscle size.  Muscle loss with advancing age is associated with many chronic conditions.  These include diabetes, cancer, reduced mobility, disability, and mortality.   It is estimated that 200 million people worldwide will experience sarcopenia that could affect their health over the next 4 decades.

Muscle loss with aging

Muscle loss is quickly becoming a major public health problem with significant clinical, economic, and social consequences.  Prevention and treatment strategies are challenging due to the growing number of older adults above 65.  Exercise and nutritional strategies are considered the primary treatments for age-related muscle loss.  The rest of this article summarizes findings from research on muscle loss in older adults and offers some practical solutions related to exercise.

Diet, Supplements, and Muscle Loss

Muscle is made of proteins.  Amino acids are the building blocks of proteins.  In younger adults (18-30 years old), eating sufficient protein can stimulate some muscle growth by itself.  This can occur with or without exercise in younger adults.  However, muscle growth does not come so easily in older adults.  Therefore, larger amounts of protein in the diet are needed for older adults to preserve or increase muscle.  Younger adults show increased muscle protein rates with the ingestion of 20 grams of protein during a meal.  Older adults require about twice this amount, or 40 grams, to stimulate muscle growth.

Recent research has investigated the role of protein and amino acid supplements for older adults.  The evidence suggests supplementing with protein or amino acids without engaging in an exercise, does little to preserve muscle mass in older adults.  However, increases in muscle size and strength through exercise can be enhanced by certain foods or supplements.    Diets rich in dairy and fish containing polyunsaturated fats make the muscle more sensitive to exercise.  There is also evidence showing protein supplements and creatine monohydrate is beneficial.  Most importantly, research shows that a specific type of exercise, resistance exercise, has powerful positive effects on muscle in older adults.  Resistance exercise is the key to preserving or increasing muscle size and strength as we age.

Resistance Training

Exercise is a highly effective strategy to offset muscle loss.   Exercising with weights has numerous beneficial effects for older adults.  These include increases in muscle mass, strength, power, mood, energy levels, walking speed, balance, and functional performance.  Other forms of exercise, such as aerobic exercise, do not confer these same benefits.  Aerobic exercise, including regular walking, is not enough to prevent muscle loss in older adults.

Contrary to popular belief, adults older than 75 years old can grow significant muscle through resistance exercise.  Heavy weights are not required.  Lighter weights with higher repetitions can result in significant improvements in muscle size and strength regardless of age.  In all cases, the success of any exercise program depends on adherence and staying committed for the long run.  Therefore, it is important to make exercise as enjoyable as possible.  Choose resistance exercises you prefer.  Exercise with friends.  Choose environments (gyms, classes, or in the home) you are most comfortable with.   If you are unsure about how to start, work with a personal trainer or physical therapist.

Developing an Exercise Program to Fight Muscle Loss

Many individuals are unsure about how to structure an exercise program.  Those without resistance training experience or those recovering from an injury have questions about what is safe and appropriate.  How often?  Which exercises?  How many sets?  High or low repetitions? How long should I rest between sets?  These are all excellent questions.  Below I have outlined a list of recommendations for older adults engaging in resistance exercise.  These recommendations are based on research evidence conducted on healthy older adults.

Length of the program

1 year to optimize results but small improvements are often evident after 6-8 weeks.  Ideally, a lifetime committment is best.

Frequency per week

2-3 sessions preferably with one day of recovery between sessions (i.e., Monday, Wednesday, Friday).

Duration of each session

Approximately 1 hour including rest periods between sets and exercises.

Exercises per session

6-8 exercises involving the major muscle groups of the upper and lower body.

Sets per exercise

2-3 sets have been shown to result in greater improvements than single set routines.

Intensity

50-80% of a one-repetition maximum which is the most amount of weight you can perform properly for one repetition.  An easier guide is to use the recommendations for repetitions per set below.

Repetitions per set

7-9 repetitions per set have been shown to be optimal for strength and muscle development.  This means you should only be able to perform 1-3 more repetitions beyond this range before fatigue becomes limiting.  If you can perform more than this amount without requiring a rest break you can increase the weight.

Duration of each repetition

6 seconds or slow controlled movements are recommended.  Muscle power development requires faster tempos of movement.

Rest between sets

1-2 minutes is optimal.  If this seems like a long time, perform some aerobic activity, such as brisk walking between sets.

Choosing Which Resistance Exercises to Perform

Contrary to the opinions of some, there are no good or bad exercises.  The selection of exercises should be based on several considerations.  This is where a personal trainer or physical therapist can help you get started.  As mentioned, the most important consideration is to choose exercises you enjoy performing.  Beyond this idea, I’ll provide some general recommendations and a few examples.

First, incorporate exercises performed in standing positions as opposed to seated or lying down.  For example, the body weight squat is preferred over a seated leg press.  Second, choose free weights over machines whenever possible.  All machines are not bad but using free weights requires greater muscle activation, control, and coordination.  Third, exercises using multiple joints are preferred over single-joint movements.  For example, the cable row is preferred over a biceps curl.   Finally, incorporate at least one exercise for the fundamental movement patterns such as the squat, hip hinge, upper body push (presses), and upper body pull (row).

Closing Thoughts

Aging is accompanied by a decline in physical activity and function.  Loss of muscle contributes to these changes and is also a consequence of them.  This creates a viscous cycle characterized by muscle loss, weakness, declining function, and developmennt of chronic conditions. Other negative consequences ensue such as osteoporosis and increased body fat.  Exercise can slow down these processes and even reverse them.  In fact, resistance exercise is one of the most effective means to combat the effects of aging and many chronic diseases.  Some have referred to resistance exercise as the, “Fountain of Youth.”  Dietary strategies and supplements can enhance the effects of exercise.   However, there is no magic pill.  Success requires goals, a plan, positive habits, and a commitment.  If you are not sure how to get started, call your physical therapist today.

 

 


 

Gluteus Medius Exercise: Getting Started

In a previous article, we discussed the importance of the gluteus medius muscle in controlling lower extremity alignment during the squat.  This muscle also plays a critical role in positioning and stabilizing the pelvis in many other functional activities.  This includes any activity with requires a period of single-leg support such as walking, climbing stairs, and running.  Individuals with knee pain, chronic back pain, hip arthritis, and ankle injuries have all been shown to have weakness in this  important muscle.  Glutues medius exercise can help.

Getting Started with Gluteus Medius Exercise

Basic resistance exercise for the gluteus medius can be initiated in non-weight bearing positions such as lying on the side.  Progressions can include partial weight-bearing positions such as on all fours or plank positions.  As muscular endurance and strength improve, exercises can be progressed to weight-bearing positions in standing.  Standing exercises are initiated in a double-limb stance, or with both legs fixed to the floor and then progressed to single-limb stance.  Each exercise should be performed 2 to 3 times per week to optimize improvements in muscular endurance, strength, and hypertrophy.

It is recommended that each of these basic resistance exercises be initiated with 3 sets of 8 to 15 repetitions.  When 15 repetitions can be performed, the intensity of the exercise can be progressed by adding weight or increasing the resistance band strength.  Muscle strength and hypertrophy can be achieved with any range of repetitions.  However, to optimize strength, higher intensities with lower repetitions are needed.   The main objective of this strengthening program is to progressively overload the gluteus medius so that muscular control, endurance, and strength are developed in a systematic manner.

Clam Shell

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 with this exercise.   The clam shell is a great exercise to start with because it elicits high levels of gluteus medius activity with minimal activity of the tensor fascia latae (TFL).  This is beneficial because the TFL is commonly overactive in individuals with hip and knee pain.

Side-Lying Hip Abduction

Begin by lying on one side with the bottom hip and knee flexed.  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 activation and decreases TFL activation.  Initiate the movement by lifting the top leg about 30 degrees.  Hold this position for a count of two 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 clam shell.  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.

1-Leg Bridge

Begin by lying on the back with both hips and knees bent.  Perform a bridge with both legs by raising the hips to a neutral trunk, hip, and knee position.  A common mistake is to excessively arch the low back.  Be sure to achieve the bridge position by extending through the hips.  From the bridge position, straighten the knee of one leg while keeping the upper thighs parallel.  Be careful not to allow the pelvis to drop on one side.  Hold this position for 2 seconds then return the leg to the bridge 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.  Resistance can be added by placing a band around the thighs just above the knees.

Prone Plank with Bent Knee Hip Extension

Start facedown supported on the elbows in a plank position with the trunk, hips, and knees in neutral alignment.  Initiate the movement by lifting one leg with the knee bent.   Extend the hip slightly past neutral by bringing the heel toward the ceiling.  Hold this position for 2 seconds.  Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.  A common error with this exercise is to arch or overextend the spine when lifting the leg.  Also, as the abdominal muscles tire, the hips may rise.  Be sure to maintain a neutral trunk, hip, and knee alignment throughout the exercise.

Side Plank with Hip Abduction

Start side-lying supported on one elbow with the shoulders, hips, knees, and ankles in line. Rise to a side plank position with the hips off the floor to achieve neutral alignment of trunk, hips, and knees.  Maintain the side plank position and raise the top leg into abduction approximately 30 degrees.  Hold this position for 2 seconds then slowly lower the top leg. Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.

A common error with this exercise is to allow the pelvis to tip forward or backward.  Also, as the top gluteus medius tires the abducting leg will move into flexion.  As the bottom side tires, the side plank position will be lost.  This exercise has been shown to activate the gluteus medius on both sides at very high levels.  It is also very challenging and may not be an option for everyone.

Closing Thoughts

These 5 exercises do not need to all be performed at once.  Instead, choose 2 to 3 exercises to get started with.  Exercise selection is based on your preferences and the level of challenge each presents.  The clam shell is the least challenging and side plank with hip abduction is the most challenging.  Within 6 to 8 weeks, the exercises may feel less challenging indicating a need for progression.  Progression may include adding resistance or substituting with a new exercise.  Next week we will highlight 5 more exercises which can be performed in standing.

 

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.

 

Five Exercises to Train the Abdominal Muscles

Abdominal muscle weakness and poor control of the trunk (or “core”) can negatively influence athletic performance and activities of daily living.  Poor trunk muscle strength has been associated with injuries in baseball players and several other sports.  Also, exercises to improve trunk muscle strength have been shown to improve soccer and distance running performance.  Trunk muscle weakness has also been linked to falls in seniors and low back pain in adults and children.

Exercises to strengthen the abdominal muscles and improve coordination of the trunk should be integrated into a comprehensive total body strength training program.  Training should never focus on any single muscle or body part.  In general, abdominal exercises should start in supported positions, such as supine lying, and progress to more functional positions, such as standing.  Exercises are predominately training for muscular endurance with short sustained holds (8 to 10 seconds) and a progressive number of repetitions.  As exercises become less challenging, the number of repetitions should be increased or the exercise itself should be progressed to a more challenging position.  The five exercises which follow are ordered from the most basic to the most challenging.

Dead Bugs

Begin in a supine lying position with the arms held straight up and the feet off the floor.  The hips and knees should be bent to 90 degrees.  Gently flatten the low back into the floor and maintain this abdominal contraction throughout the exercise.  Simultaneously raise the right arm overhead and extend the left leg without touching down.  Hold this position for several seconds and maintain low back contact with the floor.  Reverse the movement back to the starting position. Then, perform the opposite diagonal pattern with the left arm and right leg.  You should alternate sides with each repetition.  Maintain low back contact with the floor throughout the exercise.

Stability Ball Roll-Outs

Begin in a tall-kneeling position with both hands on the ball.  Roll the hands along the ball until the elbows or upper arm contacts the ball.  The elbows should remain extended as the hands and hips move together.  Engaging the gluteus and abdominal muscles help maintain proper position during the exercise.  As you lower the body towards the floor, maintain a neutral spine position and avoid arching the low back.  Hold this position for several seconds before reversing the movement back to the starting position.

Side Plank with Rotation

Begin in a side-lying position resting on one elbow.  Raise the trunk and knee off the floor until you are fully supported by your elbow and feet.  While maintaining the side plank position, reach up and then under and behind the body with the top hand.  This will induce trunk rotation and challenge the oblique abdominal muscles.  Hold this position for several seconds before reversing the movement back to the starting position.

Half-Kneeling Cable Chop

Assume a half-kneeling position next to a cable column or anchored resistance band.  The kneeling position removes contributions from the lower body and increases the demands on the trunk, pelvis and hip musculature.  From a balanced and upright kneeling position, pull the cable or band diagonally across the body towards the opposite hip.  Maintain a neutral spine and trunk position throughout the exercise.  Avoid rotating the body as your arms pull across the body.  Resisting this movement is what activates the abdominal muscles.  Hold this position for several seconds before reversing the movement back to the starting position.

Lateral Lunge with Press and Reach

This advanced exercise starts from a standing position next to a cable column or anchored resistance band.   Holding the handle or band close to the body; initiate the exercise with a lateral lunge.  Once the lunge position is attained, slowly press the arms straight out in front of the body.  The band or weight will induce a rotational challenge to the trunk muscles.  Resisting this movement is what activates the abdominal muscles.  Next, slowly raise the arms straight overhead while maintaining the lunge position.  Maintain a neutral spine and trunk position throughout the exercise.  Hold this position for several seconds before reversing the movement sequentially back to the starting position.

Closing Thoughts on Abdominal Exercises

Abdominal exercises are one component of a comprehensive exercise program targeting total body muscular strength and physical performance.  Abdominal exercises performed in isolation are rarely successful for improving performance or decreasing pain.  When developing your program, consider these five trunk muscle exercises.   Performing each exercise in a controlled fashion, with a focus on proper technique and muscular endurance will elicit the best results for the long-term.

References

  1. Chaudhari AMW, Mckenzie CS, Pan X, Onate JA. Lumbopelvic control and days missed because of injury in professional baseball pitchers.  Am J Sports Med. 2014;42(11):2734-2740. doi:10.1177/0363546514545861.
  2. Granacher U, Gollhofer A, Hortoba T, Kressig RW, Muehlbauer T. The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: A systematic review. Sports Med. 2013;43:627-641. doi:10.1007/s40279-013-0041-1.
  3. Reed CA, Ford KR, Myer GD, Hewett TE. The Effects of isolated and integrated “core stability” training on athletic performance measures: A systematic review. Sports Med. 2012;42(8):697-706.

Abdominal Oblique Injuries in Rotational Sports

Abdominal oblique injuries, also known as side strains, are common in rotational sports such as baseball, tennis, golf, and track and field.  These injuries are characterized by a sudden, sharp onset of pain near or on the side of the rib cage.  The injury usually occurs during some type of rotational sports movement such as swinging a bat, club or racket; or throwing a ball.

Trunk rotation plays an important role in generating and transferring power during sport.  It is through the trunk or core, that forces are transferred from the lower body to the shoulder and arms. Activities such as throwing and swinging require the core muscles to both stabilize the trunk and create force in order to transfer power to the upper body.

Anatomy of the Abdominal Oblique Muscles

The core includes the thoracolumbar, abdominal, pelvic, and hip musculature.  These muscle groups provide trunk stability to allow integrated limb movements, such as throwing and swinging, to occur. The abdominal core muscles include the rectus abdominis, transversus abdominis, internal oblique and external oblique.  Most abdominal injuries occur in the internal and external oblique muscles.  Less commonly, injuries can occur to the intercostal muscles between the ribs themselves.

The Role of the Oblique Muscles in Sport

The internal and external oblique muscles are responsible for flexion and rotation of the trunk, as well as providing trunk stabilization during complex sports movements.    Poor mobility of the hips or thoracic spine can contribute to excessive stress and compensation through the trunk musculature during swinging or throwing.  Rehabilitation often addresses hip mobility with manual therapy techniques performed by the physical therapist.  An imbalance between right and left side oblique muscles are also common is in sports such as golf and baseball.  This may place excessive forces through the lead side oblique musculature.  Finally, the large forces generated by lower body muscles (quadriceps and hamstrings) may overpower the weaker core musculature leading to injury during explosive sports movements.

The incidence of Abdominal Oblique Injuries in Baseball

A 2010 study in the American Journal of Sports Medicine investigated the incidence and trends of abdominal injuries in professional baseball players.  From 1991 through 2010, abdominal strains accounted for approximately 5% of all injuries in Major League Baseball.   Nearly half of these injuries occurred in pitchers.   These injuries occurred most often during the early part of the season.

In both pitchers and position players, the majority of injuries occurred on the side opposite to their throwing arm.  Pitchers missed, on average 35 days on the disabled list, while position players missed 26 days on average.  Players who receive steroid or PRP injections have been shown to miss more time from injury.   More than 1 out of every 10 sustained a re-injury during their career.  Most of these re-injuries occurred during the same or the following season.   As a result of these injury trends, many MLB teams have increased their focus on preemptive core and trunk strengthening exercises for all players.

Closing Thoughts

The incidence of abdominal oblique injuries is on the rise in rotational sports such as baseball and golf.   These injuries can result in substantial loss of playing time.  Proper training can prevent abdominal oblique injuries from occurring.  In a few weeks, I will post an article describing exercises which can help reduce the risk of sustaining an injury.  These exercises can also be part of a comprehensive rehabilitation program to safely return an injured athlete back to sport.

References

  1. Camp CL, Conte S, Cohen SB, et al. Epidemiology and impact of abdominal oblique injuries in major and minor league baseball. Orthop J Sport Med. 2015;5(3):1-8. doi:10.1177/2325967117694025.
  2. Conte SA, Thompson MM, Marks MA, Dines JS. Abdominal muscle strains in professional baseball. Am J Sports Med. 2010;40(3):650-656. doi:10.1177/0363546511433030.
  3. Nealon AR, Kountouris A, Cook JL. Side strain in sport: A narrative review of pathomechanics, diagnosis, imaging and management for the clinician. J Sci Med Sport. 2017;20:261-266.

Try These 5 Row Variations to Strengthen the Shoulders and Core

Anyone interested in strengthening the core and shoulder musculature should be performing some type of row variation as part of their workouts.  The row is a pulling movement which involves flexing the elbow, extending the shoulder, and pulling the shoulder blade back, also known as retraction.  The row challenges the muscles of the upper back (trapezius, rhomboids, and erector spinae) as well as muscles of the core and low back.  Also, when performed in various standing positions, this exercise can train the entire kinetic chain from the lower body, through the trunk, to the upper body.

It is common for the row to be performed seated with the use of exercise machines.  This is fine for those first learning the movement pattern.  However, seated machine rows do little to challenge the core or lower body musculature.  There are much better options for athletes, those with a history of injury, and those looking to take their workouts to the next level.

If absolute strength is the goal, heavy barbell or dumbbell bent over rows are the best options.  However, these row variations require coaching and practice to perfect proper technique.  Performing heavy rows with improper technique makes one susceptible to low back or shoulder injury.  Again, there are better options, especially for those with a history of injury and looks to train in a more specific fashion.  Try the following five row variations and see which ones work best for you.

Standing 1-Arm High Cable Row

Set up a cable system with the cable positioned slightly above the level of the head.  Stand in a lunge position with the left foot in front of the right.  The majority of body weight should be on the front leg with the knee bent approximately 45 degrees.  Start with a palm down grip with the right arm extended out in front.  To begin the movement, pull the cable, bending at the elbow, straight back towards the trunk while maintaining a neutral spine.  Be sure to emphasize scapular retraction which refers to pulling the shoulder blade back and slightly down.  Also, avoid shrugging the shoulders or arching the low back.

This exercise challenges the core by activating the trunk musculature to resist rotation as the arm and scapula produce the row movement.  This makes the 1-arm high cable row a good option for those who are looking to train anti-rotational trunk muscle endurance.  This high-cable position and lunge stance set-up have also been shown to result in favorable muscle activation patterns of the lower and upper trapezius.  This is important for overhead athletes or those with a history of shoulder problems.

Cable Lawnmower Pull

This exercise begins with the trunk flexed and rotated to the opposite side of the exercising arm.  The hand of the exercising arm starts at the level of the opposite knee. To begin the movement, the trunk is rotated toward the exercising arm while extending the hip and trunk to a vertical position.  The exercise ends with the arm at waist level with the shoulder blade retracted as if placing the elbow in the back pocket.  Pause for 1 or 2 seconds then slowly reverse the movement returning to the starting position.

The lawnmower pull is a multi-joint functional exercise performed in a diagonal pattern replicating many movements in sport.  The exercise incorporates the transfer of force from the lower body through the trunk to the upper body.  It has been shown to activate the trapezius and serratus anterior muscles at low to moderate levels.  These muscles are important for maintaining shoulder health in overhead athletes (i.e., baseball players) and those with a history of shoulder pain.  The exercise can be performed with a cable system, resistance band, or dumbbell.

1-Arm Band Rotational Row

Set up a resistance band anchored at approximately waist to belly button level.  Position the front leg with the foot facing towards the anchored band.  The rear leg will begin facing the same direction but must be free to pivot once the exercise commences.  The right arm begins extended and the majority of body weight begins on the left leg.  The movement occurs with the simultaneous coordination of an upper-body row, trunk rotation, and weight shift to the rear leg.  Pause in the end position for  1 to 2 seconds before reversing the movement in a slow and controlled fashion.

This row variation is ideal for rotational athletes such as baseball players.  It incorporates the coordinated activity of the lower body, trunk, and upper body.  Controlling the eccentric, or negative, part of the exercise is important.  This exercise also teaches weight transfer and weight acceptable from the rear to lead leg and vice versa.  Be sure to perform the exercise from both sides to avoid reinforcing any side to side asymmetries which are common in athletes.

Suspension Trainer Row

Anchor a suspension trainer, such as a TRX, in an overhead position.  Grasp both handles with the arms extended.  Position the feet in front of the body spread slightly wider than shoulder-width apart.  Your body should be maintained in a neutral position with your head, trunk,  and legs forming a straight line.  Perform the row movement and pause at the top position for 1 to 2 seconds before returning to the start position in a slow and controlled fashion.  Maintain the trunk in a rigid position throughout the exercise. To increase the challenge of this exercise position your feet further away from your upper body to assume a more inverted position.

The inverted position assumed in the suspension trainer row elicits high activation of the abdominals,  latissimus dorsi, upper back muscles, and hip extensor muscles (glutes and hamstrings). This exercise produces lower levels of lumbar spine muscle activity due to lower spine loads incurred from the suspended position.  These factors make the suspension trainer or inverted row a good option for patients with a history of low back pain.

Dumbbell Renegade Row

Hold two dumbbells and assume a push-up position with the feet spread slightly wider than shoulder-width apart.  Align the head, trunk, and lower body in a straight line and maintain this position throughout the exercise.  Initiate a row with one arm while maintaining stability through the trunk and lower body.   Control the descent of the load back to the floor.  Be sure to alternate sides with each repetition.  Light loads are recommended when first learning this exercise.

The push-up position utilized in the renegade row increases challenges to the abdominal musculature.   Furthermore, 1-arm row variations have been shown to elicit great oblique abdominal muscle activity compared to rows performed with both arms simultaneously.   This is a more advanced row variation so it may be best to start with cable or suspension rows before embarking on the renegade row.

Closing Thoughts

There are many variations to the row exercise and I have described only five.  For beginners, it is best to start with cable row variations and suspension trainer rows.  The lawnmower pull and rotational row are more complex movements which require total body coordination.  Thus, these exercises are more challenging to master.  To really challenge the core and shoulder stability, the renegade row is a higher level option.  The most important points are that you choose the most appropriate variation for your level of training and that your technique is as close to perfect as possible.

References

  1. De Mey K, Danneels L, Cagnie B, Lotte VDB, Johan F, Cools AM. Kinetic chain influences on upper and lower trapezius muscle activation during eight variations of a scapular retraction exercise in overhead athletes. J Sci Med Sport. May 2012:6-11. doi:10.1016/j.jsams.2012.04.008.
  2. Fenwick CM, Brown SH, McGill SM. Comparison of different rowing exercises: Trunk muscle activation and lumbar spine motion, load, and stiffness. J Strength Cond Res. 2009;23(5):1408-1417.
  3. Harris S, Ruffi E, Brewer W, Ortiz A. Muscle activation patterns during suspension training exercises. Int J Sport Phyiscal Ther. 2017;12(1):42-52.
  4. Saeterbakken A, Andersen V, Brudeseth A, Lund H, Fimland MS. The effect of performing bi- and unilateral row exercises on core muscle activation. Int J Sports Med. 2015;36:900-905.
  5. Wattanaprakornkul D, Halaki M, Cathers I, Ginn KA. Direction-specific recruitment of rotator cuff muscles during bench press and row. J Electromyogr Kinesiol. 2011;21:1041-1049. doi:10.1016/j.jelekin.2011.09.002.
  6. Youdas J, Keith J, Nonn D, Squires A, Hollman J. Activation of spinal stabilizers and shoulder complex muscles during an inverted row using a portable pull-up device and body weight resistance. J Strength Cond Res. 2016;30(7):1933-1941.

Low Back Pain: How Helpful is an MRI?

It’s not often that I am in agreement with health insurance companies but they seem to be getting one thing right as of late. We have noticed an increase in patient’s referred to our clinics for low back pain that have not undergone advanced diagnostic imaging techniques, such as MRI. It appears that large insurance companies are denying authorization for these MRI’s until the patient has undergone a course of physical therapy (more on the topic). Physical therapists are certainly on board with these decisions but some of our patients are often confused or annoyed by their insurance company dictating their care. So, should patients with an acute onset of low back pain undergo routine MRI or undergo a course of physical therapy first? Why not be safe and undergo the MRI first? How can a physical therapist offer treatment without knowing what the problem or diagnosis is?

Physical Therapy or MRI First?

A recent study published in the journal Health Services Research investigated this question. Researchers found that those patients seeking primary care services for low back pain and were referred for an early MRI underwent higher health care utilization at increased costs compared to those receiving early physical therapy. The additional cost of receiving the MRI first was nearly $5000 more than receiving early physical therapy. Earlier research studies show that consulting a physical therapist early results in decreased odds of undergoing diagnostic imaging (here) and decreased odds of undergoing future surgery for low back pain (here). Delaying physical therapy has also been associated with increased prescription opioid (narcotic pain medication) use and most of us are aware of how big of an epidemic this is becoming (more here).

Why Not Play it Safe and Undergo the MRI First?

A 2003 study in the Journal of the American Medical Association compared the use of early MRI vs. early x-ray for patients with a new episode of low back pain. One year later, pain levels and disability were no better in those undergoing the MRI. Of note, the group receiving the early MRI was more likely to undergo back surgery. This is not surprising given the high likelihood of pathological findings in asymptomatic subjects (no low back pain) who undergo advanced diagnostic imaging. A 2015 systematic review reported the prevalence of disc degeneration in asymptomatic individuals ranged from 37% of 20-year olds to 96% of 80-year olds. Similar rates were reported for asymptomatic disc bulges. If so many people without low back pain have these findings on MRI we cannot confidently conclude that these findings are the true cause of symptoms. Making erroneous assumptions based on MRI findings often leads to over treatment. The more testing and treatment a patient undergoes the more likely factors such as fear and anxiety come into play and these are the factors that have been associated with persistent or chronic low back pain.

Physical Therapy Treatment without Imaging

MRI or further medical work up is always indicated in situations where serious pathology is suspected or when response to initial treatment is poor. However, low back pain emanating from serious pathology has been estimated to occur in less than 2 percent of cases. Doctor’s of physical therapy are trained in screening for these signs and when there are any suspicions of non-musculoskeletal problems prompt referral is indicated. In most cases these problems are ruled out based on a detailed interview and medical history. Physical therapists then base their examination and treatment on the individual patient’s signs and symptoms; not based on a diagnosis or MRI scan. Physical therapists are concerned with how movement affects symptoms and how symptoms affect movement.

In most cases of low back pain delaying the MRI is the best approach.