About 80% of Americans suffer debilitating low back pain at some point in their life. This fact is staggering, yet it doesn’t have to be this common. The key to staying out of this group of low back pain sufferers comes down to one word: Prevention. If I had to choose one common problem amongst all low back pain sufferers, it would be bad low back position during common activities such as brushing your teeth, bending over, picking up a small child, exercising and sitting.
The lumbar spine, which is the lower part of the spine, is meant to have a natural curve to it that displaces the forces of gravity, weight, etc. evenly and minimally. When this natural curve is straightened, or reduced, the forces on the discs, muscles, and ligaments of the low back are significantly increased. For example, sitting without maintaining the natural curve increases the forces on those structures by 30-40%!
There are many conditions that can be covered under the umbrella of low back pain, but in this article, we will cover the following conditions for the sake of this informational handout. The keys of prevention of low back pain are as follows:
Understand your symptoms and risk factors
Body Preparation and Positioning
Proper Activities of Daily Living
Corrective Exercises
Treatment Considerations
Common Low Back Conditions
Lumbar strains and sprains
A lumbar strain is when an injury occurs to the muscles of the low back. A sprain, on the other hand, is an injury to the ligaments or joints; both, however, have similar pain and symptom patterns. When these muscles or ligaments become injured, it can lead to dysfunctional movements, and cause instability in the spine. Patients suffering from this diagnosis often have pain when attempting to walk, sit, exercise and can even occur during sleep.
The main physical causes of this condition are:
Overexertion
Falls
Poor movement mechanics
Poor posture
Heavy lifting
However, with proper education, you can protect yourself from many of these causes. The primary sufferers of this condition, especially chronic cases, often are in poor physical condition with weak stabilizing muscles. A comorbid factor of this condition is often a desk job that involves sitting for most of the day. This type of patient usually has poor sitting posture, which can lead to a weakening of your spinal erectors and destabilize the spine, contributing to the condition. The importance of a strong core and training your spinal muscles cannot be overstated.
In cases where the injury stems from a problem related to overuse, poor posture or improper exercise, there are steps that can be taken to help avoid these injuries from happening. Proper instruction about your postural habits can reduce the detrimental effects of sitting on the spine, as well as education about correct lifting form can reduce these episodes of low back pain and help you build a healthy spine.
Lumbar stenosis
This condition occurs when there is a narrowing of the spinal canal in the lumbar vertebrae (low back). Often this results in compression of the spinal cord, which can lead to pain, numbness, discomfort and radiating symptoms. What the mechanism of this is occurring is usually caused by the degenerative changes of aging. However, there are other causes.
The main physical causes of this condition are:
Degeneration of the lumbar spine
Lumbar disc herniation putting pressure on the spinal cord
Osteoporosis
Dwarfism (achondroplasia)
Tumor
Degeneration of the spinal column is inevitable with aging and may reflect normal changes in an aging spine. It does not necessarily always result in lumbar stenosis but is often the most common cause.
While it is difficult or impossible to combat normal aging of the spine, there are some habits and tips you can use to reduce this condition related to the other causes. Reduce your chances of a lumbar disc herniation by learning proper bending and lifting biomechanics by utilizing your lifting power from your legs and not your back. As far as osteoporosis goes, make sure you are meeting your recommended calcium intake as well as incorporating weight bearing activities into your exercise routine (lifting weights). Post-menopausal women tend to be more susceptible to this condition and should ensure they are doing everything they can to prevent osteoporosis.
Lumbar Disc Disorders
The lumbar spine is made up of five bone segments called vertebrae. In between each vertebra are flexible intervertebral lumbar discs, which act as shock absorbers for the spine. The intervertebral discs are composed of two components, a tough outer ring of fibrous tissue called the annulus fibrosis, and a jelly-like center inside the annulus fibrosis called the nucleus pulposus. The structure is then held together by ligaments on the front and the back of the vertebrae. Additional support is provided by muscles of the trunk.
In most cases, lumbar disc disease is the result of a normal aging process called disc degeneration which causes structural changes in the normal disc. As we age, the disc begins to lose fluid and become dried out causing the disc to compress. This may lead to the breakdown and degeneration of tough outer ring of the disc (annulus fibrosis) allowing the inner core (nucleus pulposus), to bulge out. This is considered a bulging disc. This puts pressure on the outer ring of the disc, which may cause low back pain. As further degeneration of the disc continues, or with continued stress on the lumbar spine, the inner jelly-like core may rupture out from the outer ring causing a ruptured, or herniated, disk. Once the inner nucleus herniates through the outer ring, pain in the lower back may improve.
However, the fragmented disc material can inflame or put pressure on the spinal nerves leading to an increase in sciatic leg pain, weakness, numbness, or changes in sensation in one or both legs. Most disc herniations occur at the lower lumbar spine at L4-L5 and L5-S1 levels. Occasionally, severe trauma can cause a normal disc to herniate or may cause an already herniated disk to worsen.
Risk Factors of Lumbar Disc Disorders
Age and Gender - the highest incidence in men between the ages of 30 and 50.
Obesity - being overweight puts added stress on lumbar discs.
Sedentary lifestyle - lack of exercise and poor core body strength.
Smoking - Smoking decreases oxygen supply to the discs causing more rapid degeneration.
Improper lifting - using your back muscles instead of your legs to lift heavy objects. Twisting while lifting
Posture - hyperlordotic lumbar curvature, anterior pelvic tilt (lower cross syndrome).
Repetitive activities that strain your spine - jobs that require constant lifting, pulling, bending, or twisting.
Frequent driving - staying seated for long periods and the vibration from the car can put pressure on your discs.
History and Symptoms of Lumbar Disc Disorders
Lumbar disc disorders may include one or a combination of the following symptoms:
Intermittent or constant lower back pain and pain in the buttock,
leg and foot pain, numbness or a tingling sensation in the leg and foot,
Weakness in the leg and foot
Decreased reflexes in the knee or ankle
Changes in bowel or bladder function.
The symptoms will vary depending on if and where the disc has herniated, and what spinal nerve root is affected. Leg pain is usually greater than low back pain with disc herniations and nerve root involvement. However, if there are only annular tears without herniation, the pain will be localized to the low back and buttock. The onset of pain can be sudden or gradual after an injury. Pain may follow heavy lifting, twisting, or straining activities or repetitive stress trauma. However, patients may not recall a prior injury or a precise time the condition began because it is often preceded by frequent episodes of less severe low back pain that usually resolved. Pain is usually characterized by sharp, shooting, or electrical pain that may be aggravated by movement, changing positions, sneezing, coughing, or prolonged sitting and standing. The pain is usually relieved with rest and a recumbent position.
Treatment of Lumbar Disc Disorders
Conservative care should be your first course of treatment to manage lumbar disc disorders, but treatment will depend on the clinical presentation, your age, overall health, and tolerance to therapies. With disc herniations, the first few days of care will focus on centralizing (reducing) leg pain, decreasing inflammation, and preventing further neurological loss by decompressing nerve root impingement and reducing the disc herniation. Osseous mobilization and manipulation and soft tissue therapy may be administered as tolerated. Home care will consist of pain-relief repetitive positional exercises and lumbar stabilization exercises. We will also educate you on ways to protect your lower back, positions to avoid, and how to manage activity. In most cases, bed rest will not be recommended as the sooner you are up and moving, the better the prognosis. Once pain and inflammation have decreased, we will continue working on lumbar stabilization and progress into proprioceptive training. We will evaluate muscle imbalances using posture and movement patterns with the goal of restoring good biomechanics and core body strength. Your home care will emphasize the progression of stabilization protocols and corrective exercises. If you fail to respond to conservative treatment, or in cases of severe neurological loss, a referral for a surgical consultation will be recommended.
Facet syndrome
Over half of facet syndrome cases occur in the neck (cervical spine), and a third occurs in the low back (lumbar spine). Facet joints are the small joints in the back of the spine that are responsible for much of rotational movement and limits side-to-side movement. The pain is often worst when moving from a sitting position to a standing position or moving from a bent-over position back to an upright standing position.
The main physical causes of this condition are:
Excessive weight
Overuse (sports or labor)
Whiplash/motor vehicle accident
Pre-existing arthritis
Sitting for long periods of time
However, with the proper education, you can protect yourself from many of these causes. The primary sufferers of this condition, especially chronic cases, often are in poor physical condition with weak stabilizing paraspinal muscles. A comorbid factor of this condition is often a desk job that involves sitting for most of the day. This type of patient usually has poor sitting posture, which can lead to a weakening of your spinal erectors and destabilize the spine, contributing to the condition. The importance of a strong core and training your spinal muscles cannot be overstated.
In cases where the injury stems from a problem related to overuse, poor posture or improper exercise, there are steps that can be taken to help avoid these injuries from happening. Proper instruction about your postural habits can reduce the detrimental effects of sitting on the spine, as well as education about correct lifting form can reduce these episodes of low back pain and help you build a healthy spine.
Lower Crossed Syndrome
The abdominal muscles are inactive and not supporting the spine, while the spinal erectors are pulling the lumbar spine forward, resulting in something called hyperlordosis. This means that the spine in the lower back has an exaggerated curve, which can result in accelerated degeneration of the joints of the spine.
At the same time, the hip flexors are facilitated and are chronically tight while the gluteus muscles are inhibited and have reduced activation. This leaves the back muscles to do most of the work to extend the spine instead of the gluteus muscles keeping the pelvis level.
Body Preparation and Positioning
Sternum Up- Keeping the sternum up automatically sets the body into the good posture and maintains:
Neutral Spine: Maintaining good spinal alignment decreases the stress placed on the spine and discs.
Hip Hinging: Bending at the hips, and not the low back, decreases the stress placed on the low back and increases strength & power.
1. Power Zone- The zone that will optimize lifting strength and injury reduction.
Bend your elbows at a 90-degree angle, and you are in the “Primary Power Zone.”
The area up to the shoulders and down to the hips is acceptable.
The more you can work in the “power zone” the less fatigue on your bod
2. Abdominal Bracing- When all of your core muscles work together, a "Super Stiffness" occurs, and all three layers of the abdominal wall are activated to protect and stabilize the spine and discs.
Without bending forward, contract the abdominal muscles (like you are about the get punched in your gut - feel them tighten with one hand) and the buttock muscles (as if you are holding in a bowel movement). You will feel the lower back muscles contract (with the other hand) when you contract your abs and buttocks. Activities of Daily Living
Optimal Activities of Daily Living Considerations
The below images and descriptions were resourced from The Journal of Bodywork and Movement Therapies (2004) 8, 85–87 written by Craig Liebenson, DC
These are a sampling of some daily activities that you may encounter. We encourage you to practice and apply the body preparation and positioning described above. The Sternum Up, Power Zone and Abdominal Bracing should be utilized to protect and spare the spine.
Hip Hinge
· Keep the spine upright by hinging from the hips as you bend your knees
· Maintain all three points of contact as you move to an upright position
Going from Sit-to-Stand
· Start in a seated position at the edge of your chair with your feet under your thighs before sitting up
· To initiate movement begin upward movement by using your hips and knees
· To avoid strain to your back, keep your torso upright when rising from the chair.
Picking up a bag of the ground
· When picking up a bag from the ground, bend from the hips and knees.
· Make sure to keep the back flat and keep lower back’s natural curve by keeping it curved forward while bending.
· When lifting, initiate the movement by keeping the back flat while extending with the hips, and tightening the glutes.
Brushing your teeth
· Keep your chest upright while brushing the teeth.
· When you bend forward to rinse your brush or mouth bend from the hips, not from the waist.
· Keep your chest lifted while you bend forward.
Changing a diaper
· Before changing your baby ensure that you have a changing station that is the appropriate height.
· If it is too low (below your waist), you will be forced to bend forward from the waist.
· The correct height is approximately waist high and allows you to maneuver your baby without having to bend much.
Picking objects from ground
· When lowering to pick up the object, bend from the knees and keep your chest lifted.
· When lifting keep your spine upright by hinging from the hips and knees.
· If the object is not directly in front of you, it is important to keep your chest lifted in front of you while keeping your lower back’s natural curve.
· Avoid lifting immediately after sitting for a prolonged period.
Corrective Exercise Strategy
This will build a set of corrective exercises and stretches you can implement to your daily routine. We realize there are different types of corrective exercises for these conditions. We have provided you with just a sampling of beginner level correctives. More advanced solutions should be performed by a doctor or physical therapist so any red flags are taken into consideration.
Can Opener’s
· Lay on your right side and have your arms straight out.
· Take your left leg and bend it by flexing your hip.
· Rotate your torso and try to reach the ground on the other side of your body.
· Make sure to maintain your left knee contacted to the ground.
· Repeat on the other side.
· Perform 2-3 sets of 8-12 reps based on the quality of movement.
Cross-Crawl- (Bird Dog Alternating Arm & Leg)
· Begin on your hands and knees in a quadruped position.
· While abdominally bracing, slowly extend your right leg and left arm into a fully straightened “bird dog” position.
· Hold this contraction for two seconds before returning to touch your right hand to your left knee and repeating for ten repetitions before switching sides.
· Keep your abdominals engaged the entire time and did not arch your back or twist your hips at any point
Glute Bridge
· Lay on your back on an exercise mat or the floor in a bent-knee position with your feet flat on the floor.
· Place your feet hip-width apart with the toes facing away from you.
· Gently contract your abdominal muscles to flatten your low back into the floor. Attempt to maintain this gentle muscle contraction throughout the exercise.
· Gently exhale. Keep the abdominals engaged and pressing through your heels, lift your hips up off the floor until your body is in a straight line between your knees and shoulders.
· Avoid pushing your hips too high, which can cause hyperextension (arching) in your low back.
· Lowering Phase: Inhale and slowly lower yourself back to your starting position.
Single Leg Glute Bridge
· Lay on your back on an exercise mat or the floor in a bent-knee position with your feet flat on the floor.
· Raise one leg off of the ground, pulling the knee to your chest. This will be your starting position.
· Execute the movement by driving through the heel, extending your hip upward and raising your glutes off of the ground.
· Extend as far as possible without arching your back, pause and then return to the starting position.
· Repeat for 10-15 repetitions.
Front Plank
· Lay face down with your elbows bent directly under your shoulders and your knees bent.
· Engage your abdominals and raise your body off the ground onto your elbows and knees.
· Maintain a straight spine, chin tucked, and abdominal brace. Do not allow hips to drop or spine to arch!
· Hold this position for 30 seconds or to fatigue.
· Once you can perform with ease, change from a knee position to a toe position.
Side Plank
· Begin lying on your side, resting your weight on your forearm and feet with your elbow directly under your shoulder.
· Have your legs stacked one on top of the other and lift your hips forward and up to the ceiling until your body is straight keeping your shoulders, hips, and ankles in a line.
· Engage your abdominals while holding this position for 30-60 seconds or to fatigue.
· Repeat on the opposite side.
Standing Back Extensions
· Stand up, with your feet about hip-width apart, and place your hands on top of your pelvis (the back of your hips).
· Keep your knees straight as you gently bend until you can feel a mild to moderate stretch in your lower back. (not sure you should feel a stretch as the back muscles are shortening. This is intended to “undo” the lumbar flexion due to sitting).
· Return to the starting position and repeat ten times, trying to extend slightly farther back each time.
· If you experience low back pain or discomfort when extending back, only extend back until you “touch discomfort.”
· Stop this exercise immediately if you notice increased radiating pain into your leg.
Triplanar Hip Flexor Stretch
· Begin standing in a “lunge” position with one leg back until a stretch is felt in your hip.
· Lunge forward to increase the stretch in your hip. Hold this position for two or three seconds and return to neutral.
· Slowly lunge forward ten times, each time increasing the stretch.
· Perform ten additional repetitions of increased stretch by rotating your body away from your back leg.
· Perform a final set of 10 repetitions of increased stretch by raising your arm on the same side and rotating your body away while performing lunges.
Single Leg Deadlift
· Begin by holding a dumbbell or kettlebell in one arm by your side.
· Transfer your body weight to the leg opposite the arm holding the weight with your knee bent only slightly.
· Slowly flex forward from the hips on your stance leg while moving your chest and the dumbbell toward the floor.
· Keep your back and kicking leg straight while keeping your glutes and core tight.
· Once a stretch along your glutes and hamstrings is felt, pause at the bottom, and then nearly return to the top.
· Repeat for 10-15 repetitions before switching to the opposite leg.
Information curated from the Chiropractic Success Academy