Chronic Low Back Pain

The management of back pain often includes specific training of muscles surrounding the spine (lumbar multifidus and deep abdominal muscles known as the internal oblique and transversus abdominis) which together provide dynamic stability to the lumbar spine. The deep abdominals tension the lumbar vertebrae through the thoracolumbar fascia and intra-abdominal pressure.

These muscles acting together strengthen the spine, like the guide-wires of a tent. But unlike guide-wires, they also provide and control movement. Their ability to do this is compromised when we have poor posture. Such as when we have a forward-head rounded shoulders “stoop” from too much computer work, and the flexed hip and knee posture from too much sitting.

The main hip flexors are attached to the lower back and are in a shortened (i.e. “tight”) position while you are sitting with your hip flexed and pull on your back. The hamstrings are attached to the bottom of your pelvis and when you are sitting with your knees bent your hamstrings also pull on your back. The result is that our hamstrings become short and tight, and our back becomes rounded. The answer is to stretch your hamstrings and hip flexors.

The two main causes are too much sitting and excess body-fat. Prevention is better than cure – we offer a simple but effective exercise program to avoid lower back problems.

Our abdominal and gluteal muscles also become weak. This is all made worse when we have the dreaded “office belly”. When we stand and walk, our abdominal muscles are almost inactive, while our back, shoulder and muscles have to work overtime. We “shuffle-walk” by bending forwards from the hip, and almost falling forwards.

Exercise program

We offer an exercise program involving the specific training and co-activation of these muscles. Co-activation of these muscles can then be incorporated into functional tasks. This exercise program has been shown to provide a significant reduction in pain and functional disability. We have not included a description or photos here because it is important to learn how to properly do the exercises.

Our exercises promote optimal posture and neuromuscular control of the deep abdominals, diaphragm, and pelvic floor; counteract the rounded shoulders and forward stoop; and improve diaphragm and lumbar spine position, breathing pattern, and trunk stability.

Our Spine

The spine comprises the mobile vertebrae, inter-vertebral discs, the synovial joints between vertebrae (zygapophyseal joints), and ligaments and fascia. It is stabilised and moved by muscles and tendons surrounding and acting on the spinal column and controlled by the nerves and central nervous system.

Our back is an active structure that provides both static and dynamic posture, and movement in three dimensions. Chronic low back pain is often the result of instability or lack of strength in muscles controlling the lumbar spine in flexion, extension, rotation and translational motion. The term translational motion simply means when we move from one place to another.

What can you do?

Our exercises are designed for otherwise healthy adults who have postural lower back pain, or have been medially recommended to exercise because they have spondylolysis or spondylolisthesis of the lumbar spine. As there are many possible causes of back pain, you should receive a proper diagnosis to eliminate other causes.

Specific training of the intrinsic muscles can help improve performance functional tasks or activities of daily life, and decrease back pain.

Exercises

The program includes assessment of standing lumbar curvature, and spine and hip range of movement in flexion and extension. Exercises are used to improve deep abdominal muscle activation without activity of the rectus abdominis or external obliques, and without back movement. These exercises are very specific (no abdominal crunches!) and require only a low level of muscle contraction. The duration progresses until the total time is about 10-15 minutes.

The intrinsic back and abdominal exercise help to support our back.  The goal is to train the spinal extensors and flexors for stability and endurance, not muscular strength.

Improvement in range of movement and flexibility

Once learned, the exercise can be done daily at home. When improvement is achieved, you can incorporate the same muscle control in dynamic movement and light aerobic exercise. The program also has specific stretches, including for hip flexors, hamstrings, abdominals, shoulder, and chest.  Stretches for the abdominals?  Yes, surprisingly important.

Participants can improve posture, range of motion, mobility (flexibility) and significant reduction in lower back pain within three months. The program can help improve static and dynamic stability of your spine during activities of daily life and improve flexibility and posture.

The muscles involved may benefit from improved range of motion and proper muscle motor control between them and the large trunk muscles.  Stretch hip flexors, hamstrings, pecs and traps.  Mobilise the spine.  Activate the inner core.

Core training?

Most people train the large “core” muscles that act on the trunk and spine such as the rectus abdominis and external obliques, and the thoracic part of lumbar iliocostalis. Yet none of these muscles attaches to the spine. Weakness of the smaller “intrinsic” muscles that help maintain posture and active spinal movements is more likely to be involved in low back pain. Particularly when we also have poor posture and spend too long sitting.

Because of this, the rectus abdominis, external obliques, and long back extensors become dominant.  It can take as long as 4-6 weeks to “re-train” to activate the intrinsic muscles. We need to relearn to activate muscles supporting the back and make this a normal part of how we sit, stand, walk, bend, lift and move. Once this activation is achieved, it needs to be done frequently to reinforce so-called “engram” motor programming.

Better muscle control and not strength training

This requires only low levels of activation of the correct muscles, not strength exercises as are usually performed for the “core” muscles. Develop automatic recruitment of the muscles to stabilize the spine during activities or exercise. And a realization that almost any thing we do and exercise involves the back.

Flexion-Extension Warm-up
About six flexion-extension cycles of the “cat-camel” exercise done as a mobility exercise and not a stretch, to reduce any present stresses on the spine.

Quadratus Lumborum Training
The horizontal isometric side bridge. The rolling side bridge is an advanced version with maximal involvement of the quadratus lumborum (QL) and obliques, and cocontraction of the critical spine muscles and transverse abdominis.

The lower fibers of the erector spinae may be weak or inhibited with too much seated computer use and a lower back support in a chair. The QLs and may be overused resulting in muscle fatigue and stretching and strengthening may help. Correcting the forward head and rounded shoulder posture will help even more.

Rectus Abdominis, Obliques, and Transverse Abdominis
No single abdominal exercise is effective for all of the abdominal musculature. Curl-ups or crunches may be done but avoid “sit-up” exercises with bent and straight legs due to the high psoas activation and compressive loads on the low back. Avoid leg raises because they cause a great deal of psoas activation and spine compression.

Back Extensor Training
Avoid front lying upper torso or leg lifts off the floor (“Superman”) because they may place to much load on the spine. A better alternative is the “Bird-Dog” exercise. This engages the longissimus, iliocostalis, and mutifidus muscles of the spine with much less stress on the spine. Most people do this incorrectly – ask your trainer to check that you do it properly. It may take several weeks to get used to it.