Lumbar Spine

Low back pain can begin due to:

Poor posture,

Weak stability muscles,

Heavy Lifting,

Uncontrolled Straining,

Repetetive tasks,

Degenerative Disc Disease,

Osteoporosis.

The severity of pain from a lower back injury does not always correlate to the amount of physical damage. For example, muscle spasm from a simple back strain can cause excruciating back pain, whereas a large herniated disc can be completely painless. Additionally, back pain is a very complicated personal experience. Many disc abnormalities seen on MRI scans are actually painless, and other factors – both physical and psychological – often contribute to a person’s experience of pain.

There is a lot of overlap of nerve supply to most of the structures in the spine (discs, muscles, ligaments, etc), so it is difficult for the brain to distinguish between injury to one structure versus another. For example, a herniated disc can feel identical to a bruised muscle or ligament injury. For this reason, it is very difficult to self-diagnose your pain. It is best to have a qualified physio first take a thorough medical history and physical exam, discuss the symptoms, and if necessary conduct diagnostic tests, in order to try to distinguish the underlying condition causing the pain.

It is best to get a firm clinical diagnosis:
Please keep in mind that the terms for disc problems (such as herniated disc, pinched nerve, bulging disc, slipped disc, ruptured disc, etc.) refer to radiographic findings seen on a CT scan or MRI scan. While radiographic findings are important, they are not as meaningful in determining the source of the pain (the clinical diagnosis) as  specific symptoms and the spine specialist’s findings on physical exam. Usually, the key factor in the clinical diagnosis is to determine if there is a pinched nerve or if the disc space itself is generating the pain. A pinched nerve will generate radicular pain (nerve root pain or sciatica), and disc pain will generate either referred pain or axial pain.

The diagnosis guides the treatment decisions:
It’s important to accurately diagnosis the pain generator, because the type of pain created by the spinal disc dictates the type of treatment, and the treatments for the different diagnoses vary considerably. Two of the more common disc problems include:

  • Herniated disc - If the outer portion of the disc (annular fibers) stretches or ruptures, the inner material of the disc may be allowed to bulge or extrude (herniate) out of the disc. This condition may also be referred to as a pinched nerve, slipped disk, bulging disc, etc. When this happens, the inner material of the disc can come in contact with and irritate the adjacent nerve root, causing pain to run along the path of the nerve – either along the sciatic nerve down the leg (lumbar disc herniation or sciatica) or arm (cervical disc herniation). The inner material of the disc is filled with inflammatory proteins, so even a small disc herniation that allows the inner disc gel to just touch the nerve can cause a great deal of pain;

 

  • Degenerated disc -As we age, the spinal discs dehydrate and become stiffer. While this is a natural aging process, in some individuals, the degenerating disc can become painful and inflame the well-innervated structures next to the disc (e.g. nerve roots). Also, the disc may be damaged as the result of some trauma, and inner or outer portions of the annular fibers may be involved;

 

Treating Low Back Pain:

Minimize bed rest,

Medication,

Correct causative factors such as lifting techniques or repetitive task,

Passive modalities such as taping or back supports,

Flexibility: particularly the joints of the thoracic and lumbar spines, the hip flexors, quads hamstrings and gluts,

Active strengthening.

Active Strengthening – should focus on the muscles that stabilize the pelvis and core.  The Rectus Abdominus (six pack) is not “core”.  Therefore, sit ups are not core stabilisation exercises.  The outer muscles – erector spinae and rectus abdominus move spine whereas  the TA/multifidis (deep layer which inserts into spine) supports the spine. 

The outer layer will take over if the inner muscles are not working – for example with chronic low back pain (inhibition of this muscle).  “Bracing” uses the outer muscles and makes the muscles tighter.  When TA works the outer muscles relax and there is increased flexibility in the spine. This is why chronic stiffness of the back will not be treated properly without core activation.

The plank is not training core muscles if they cannot turn them on –  it is a very high level exercise and aggravates people easily.

The main muscles necessary for good core stability are the -

Transversus Abdominus -

The TA acts as a stabilization muscle for the lower back.  When activated it creates a subtle drawing in of the lower fibres of the abdominal wall, unlike the obvious tensing of the larger fibres of the rectus abdominus and obliques, apparent when coughing.  To properly train the TA, it is important that firstly, the client knows the difference between the two and can activate the TA in isolation from the others.  This is why sometimes Pilates can aggravate people with chronic low back pain.

  • There is an anticipatory action of the TA with activity in the normal population.  This action is inhibited in those with low back pain.

 

  • Must learnt to activate before can train these muscles in a functional environment.  The exercises need to be progressed along the way to be more challenging but not too high level when the person “braces”.

 

  • When the TA works the spine becomes “stable” and controlled leading to improved performance.

 

  • Tight hip flexors and pelvic imbalance will not allow TA to contract properly.

  Increases shear forces will result through the back usually due to an anterior pelvic tilt.

Pelvic Floor-

It is important to realize that both sexes have pelvic floors.  They act as a sling to the abdominal contents and help support the TA in controlling core stability.

The pelvic floor can be activated by drawing up the muscles that would be used to control the flow of urine.  Often it is easy to imagine holding these muscles tight when training core stability.

 

Techniques to strengthen the core muscles -

Exercise Ball,

Biofeedback,

Pilates,

All Fours.

By Melanie Roberts

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