Injury Information 

Lumbar Spine:
Hip pain may commonly be referred from irritation of structures the upper lumbar spine. Pain will tend to be poorly localized and may or may not be accompanied by back pain.

Sacro-iliac joint:
Pain from inflammation of the sacro-iliac joint may refer pain to the back of the thigh, the hip joint or the groin. Pain may or may not be present in the sacro-iliac spine. (Refer to gluteal pain).

Injury Treatment 

Exercises

Strengthening programs should only be commenced when:

The injury is not painful to touch.
The injury is not painful in the morning.
The injury is not painful to stretch.
The injury is not painful with light to moderate exercise.

Exercises should be 3 sets of 8-12 repetitions.

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Stretches

Stretches

• Stretches to be held for three sets of 20 to 30 seconds
• A light warm-up such as walking, exercise bike, or range of movement exercises (moving the joint through a gentle, comfortable range) for five to ten minutes, should be undergone before stretching
• Stretches should be held just at the first point of tension.
• Stretching should be slow and gentle and no excessive tension or discomfort should be felt during stretching.
• Stretches can be done to help treat an injury but should also be done before and after exercise.

 

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Programs

Lumbar Stabilisation Programs

 

The basis for stabilisation training is that the various structures of the spine degenerate (wear and tear) as a result the forces associated with normal daily activities. This degeneration is usually not a painful process. Sometimes it will result in temporary, relatively minor pain - the "back strain" - and usually resolves in a few days. Sometimes the consequences are more significant - "my back went out" - but usually, in several weeks the pain is gone. Eventually this essentially pain free wear and tear may result in such a level of degeneration that the elements of the spine are unable to tolerate the forces associated with daily activities and pain may becomes chronic. At this point neither positioning routines, like flexion or extension, nor modalities like heat, massage and manipulation have any lasting effect on improving the patient's functional ability.

To decrease cumulative microtrauma and avoid this progression of disability the patients must learn their neutral spine position and develop the ability to maintain this position in daily activities. The neutral spine position is the alignment of the spine where it tolerates mechanical forces best. This position can be different for different people; often it is related to the specific problem in the spine. Someone with spondylolisthesis (a problem in the posterior part of the spinal column) may have a slightly flexed neutral position (flexion bias). Someone with a severe disc herniation may have an extension bias neutral. Many people have a mid-range neutral position. This is the position which the patient must maintain when there are significant forces acting on the spine. Significant forces on the spine occur during:

• Prolonged positioning (for example, sitting or standing for a long time, etc.)
• Major movements (for example, getting in and out of the car, getting in and out of bed, etc.)
• Movements requiring force (for example, pushing, pulling, reaching, etc.)

This exercise takes active participation on the part of the patient, specialised knowledge and experience on the part of the physiotherapist with ongoing supervision. To find out more about Lumbar Stabilsation programs contact your local physiotherapist in our locality guide.

Exercise

Training begins with instruction in the patient's neutral position and in the use of the abdominal muscles to maintain this position (abdominal bracing). The abdominal muscles both in the front and sides towards the back are extremely well suited to maintaining the spine's position and to absorbing forces which would otherwise be transmitted to the spinal structures at risk such as ligaments and lumbar discs. Even abdominal bracing alone can eliminate the pain associated with various, simple activities. The patient then begins to learn a stabilization exercise program including:

• beginning with bracing in the four point kneel position.
• exercises in which the abdominals work to hold the neutral position while movements of the arms and legs increase and decrease forces which would tend to take the spine out of neutral. This helps develop coordination and endurance of the abdominals.
• flexibility exercises with particular emphasis on the hips and legs. This helps develop the mobility needed as the patients learns to make more effective use of the legs as the power source for movements.
• aerobic activities This helps build up cardiopulmonary ability and therefore generalized endurance. Aerobic exercises are also known to increase the body's production of natural, pain relieving chemicals (endorphins).

Each exercise program must be developed specifically for the individual patient and close supervision from a physiotherapist is needed to assure perfect technique both at the beginning of training and when progressing exercises to more difficult variations. Each patient should have a written home program of exercises from their physiotherapist and daily exercise is critical to the development of stronger and more automatic control of the spine.

Functional Training

Another important component of the stabilization program is functional training - instruction in the practical application of neutral spine positioning techniques. Exercise here must be practical and adapted to an individuals everyday lifestyle.

Lifting: Efficient lifting requires power and the body's most effective power source is the legs. Traditional lifting instruction includes maintaining the spine in a vertical position and keeping the feet under the trunk: "Use the legs, not the back. Keep objects close to you. Keep objects in front of you. Move your feet, not your trunk". However, unless the spine is in its optimum position to transmit this force and the abdominals are braced to protect the spine, the spine will not tolerate this kind of action well. By using the abdominals to maintain the neutral position a wide variety of powerful movements are possible making spine safe body mechanics practical, fluid and powerful.

Functional training begins with examining how various activities and positions tend to effect the spine. For example, reaching up with the arms tends to extend the spine, sitting or squatting tends to flex it. The front abdominals can be used to counter forces which tend to extend us, and hinging at the hip can help us avoid flexing out of neutral while bending forward. Hip hinging refers to bending forward from the hips (and usually knees) rather than from the low back. This takes special instruction and practice since it requires the use of muscles in sequences which are not intuitive, for example, bracing the abdominals and using the buttock muscles to straighten the trunk. Instruction in various ways of pivoting to avoid twisting the spine allows one to move for objects from side to side without having to shuffle the feet. Bracing, hip hinging and pivoting are combined to teach various ways to get from standing to supine on the floor, come from sitting to standing, pushing, pulling, lifting, reaching,etc. all while maintaining the neutral position and while moving fluidly. As the patient improves in the ability to maintain neutral position specialised techniques for individual job or recreational activities are taught. Patients are also taught various strategies for static positioning like sitting and lying. For most of these activities there are several ways to perform the task while maintaining neutral. Having options from which to choose is important if the techniques are to be practical and adaptable to various situations. The ultimate goal is for the patient to have a complete understanding of how to control the various forces which act upon their spine so that they can solve movement problems independently.

 

Functional spine stabilisation is not physically difficult for most people. It does take "reprogramming" of movement habits and, for most patients, the hardest part is at the start when it is hard to remember the techniques, especially in the absence of pain. However, in the end most patients find that functional stabilisation techniques make daily activities easier, less painful and, because they are based on principals of athletic movement, more powerful. This kind of training is not just indicated in cases of difficult, chronic spine problems where avoidance of surgery is the goal. By incorporating aggressive, conservative care when low back pain first begins many of the "back sprains" and periods where the "back goes out" which often lead to chronic back problems can be eliminated.

 

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