New informative articles in the Expert’s Say area compliments of www.badback.com.au
1.Lumbar intervertebral disc prolapse (‘slipped disc’)
The outer ligamentous ring of the intervertebral discs can form cracks due to ‘wear and tear’. If the inner semi-fluid core of the disc penetrates through these cracks it may put pressure on adjacent structures including nerve roots. This condition may cause a referral of pain and sensory disturbance down the back of the leg as far down as the foot, commonly called ‘sciatica’ (see Acute nerve root compression). Low back pain may or may not accompany leg pain. This injury is commonly sustained during repeated exertion when bending to lift or push, it may also be caused on the sporting field following a blow to the body.
2.Facet joint syndrome
This is common in people over forty years old. It is caused by wear and tear in the joints of the lumbar spine over time and is a specific type of osteoarthritis. Symptoms include pain, stiffness and limited range of movement of the lumbar spine. Pain may worsen with rest and can be eased with light exercise and stretching. Pain is commonly felt when straightening the low back or lifting the leg when lying down.
3.Vertebral Arch stress fracture (spondylolysis)
This condition can be present at birth or as a result of frequent overloading of the lumbar spine, commonly when arching backward and rotating. This repeated stress can cause small fractures in the vertebrae. This overloading can occur in many sports and is especially prevalent in cricket (bowling) and gymnastics.
4.Acute nerve root compression
Acute nerve root compression is common following lumbar disc prolapse. The prolapsed disc compresses the nerve root causing acute low back pain with sharp pain shooting into the legs intermittently with pins and needles, numbness and muscle weakness. Pain is aggravated by bending, lifting, sitting, coughing and sneezing and is usually eased by lying down on the non-painful side of the body. Pain may also worsen towards the end of the day.
5.Lumbar muscle strain
Muscle strains in the low spine are common during heavy lifting or during exertion when moving the low back in sports such as football, cricket or golf and frequently occur as a result of inadequate lumbar muscle stretching during warm-up. Symptoms include sharp instantaneous localized low back pain aggravated by coughing, sneezing and movement. Symptoms will tend to ease when lying down.
6.Spinal Canal Stenosis
Narrowing, due to a number of causes, can compromise the vertebral column and the spinal cord within. These causes include facet joint degeneration and lumbar disc prolapse ‘slipped disc’. Resultant spinal cord compression may cause vague, poorly localized pain in the low back, groin and legs aggravated by standing and walking. Pain may be eased quickly with rest especially in the sitting position. Canal stenosis is common in people over the age of sixty. It is also common in middle-aged people with a long history of heavy lifting.
Stenosis of the lumbar spinal canal is apotentially disabling cause of osteoarthritic pain of the lower back and legs. This treatable condition is often a major cause of inactivity, loss of productivity and, potentially, loss of independence in many persons, particularly the elderly.
Because of the slow progression of the disease, the diagnosis may be significantly delayed. Given the potentially devastating effects of this condition, rapid diagnosis and treatment are essential if patients are to be returned to their previous levels of activity.
Lumbar instability is caused by lumbar joint and ligament laxity resulting in too much movement at the injured joint level. This may be caused by repeated injury to this and other levels of the lumbar spine over time, with subsequent poor mobility and muscle function in the lumbar spine. Symptoms include poor mobility and tightness in the low back, a feeling of weakness in the low spine and localized pain aggravated by exertion.
Early Injury Management
For approximately the first 72 hours following an injury, the RICE regime should be followed to ensure control of inflammation and pain relief.
R – Rest
I – Ice
C - Compression
E – Elevation
Rest from aggravating activity.
Ice should be applied in the first 72 hours or when inflammation persists. Ice should be applied for 15 to 20 minutes at a time. Ice should not be applied directly to the skin, but through a wet towel or cloth.
Compression can be achieved with an elastic bandage.
Elevation is used to help swelling to return to the heart through the blood stream.
The injured area should be elevated above the level of the heart.
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.
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.
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.
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.
There are proven benefits that arise from stretching the soft tissues—the muscles, ligaments and tendons—around the spine. The spinal column and its surrounding muscles, ligaments and tendons are all designed to move, and limitations in this motion can accentuate pain. Patients with chronic pain may find it takes weeks or months of stretching to mobilize the spine and soft tissues, but will find that meaningful and sustained relief of low back pain follows the increase in motion.
The hamstring muscles tend to play a key role in low back pain, tight hamstring muscles can cause stress on the low back due to accentuation of posterior pelvic tilting. Posterior pelvic tilting will flatten the low back’s natural curve (lordosis) and therefore increase stress on the structure in the low back, including the intervertebral discs. Therefore, it follows that stretching the hamstring muscles typically helps decrease the intensity of low back pain and the frequency of recurrence of injury.
Hamstring stretching is shown below and should be completed on a regular basis, especially prior to exercise. The pressure on the muscle should be applied evenly and bouncing should be avoided, since a bouncing motion will trigger a spasm response in the muscle being stretched.
- Stretches to be held for three sets of 20 to 30 seconds.
- A light warm-up such as walking or exercise bike 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.
Hamstring Stretch 1
Hamstring Stretch 2
Knee to Chest (hip flexor stretch)
The hip flexor muscle attaches on the anterior (front) aspect of the lumbar vertebral bodies and discs. Regular stretching of these muscles will aid in minimising strain on the lumbar spine during exercise. As shown here, the stretch should be completed with the pelvis ‘perched’ on the end of the plinth to enable the hip to extend, stretching th hip flexor muscle. Effectiveness of the stretch will be maximised if the leg to be stertched is pushed doen by a helper. The opposite leg should be held firmly against the chest while the hip flexor is being stretched.
Lumbar Extension stretch
When completing the lumbar extension stretch, the gluteal muscle should be kept loose and relaxed at all times. Tension should not be felt at one point in the spine. Instead, as shown below, you sould only extend back to the position where a stretch is felt across the whole of the low spine. Over time, as you progress you should be able to arch futher back. This stretch should be held for a loner period than normal muscle stretches, approximately 45 seconds to one minute at a time.
Lumbar Extension Stretch – advanced
Lumbar Rotation Stretch
During the lumbar rotation stretch the shoulder should be kept flat on the ground and the leg pulled over to the opposite side.
The fit ball provides support across the whole low back while it is being stretched into extension.