In our March and April 2020 blogs, we suggested principles of Optimal Movement that we could be teaching our patients:
- Fascio-Skeletal Weight Bearing
- Appropriate Distribution of Movement
- Proportional Use of Synergists
- Minimization of Unnecessary Effort
Application to Low Back Pain
Let’s now get more specific by talking about the 800 pound gorilla of physical therapy—low back pain. According to that font of all medical wisdom, the internet, low back pain is the third most common reason for a doctor visit in the US. Coming out of PT school in 1983, lumbar stabilization wasn’t even on the radar screen.
- We stretched the back into flexion (William’s), extension (McKenzie’s), side-bending and rotation.
- We then strengthened the back, belly and hip muscles.
We believed that the back hurt because it was stiff and/or weak—it would feel better if it were flexible and strong. A brief perusal of back pain books on Amazon will show that old ideas die hard, and the stretch and strengthen paradigm is still alive and kicking.
Fast forward to the Age of Pilates and we have the more accurate idea that the back can hurt because of hypermobility. However, we tend to still have ‘if only’ concepts of what it takes to stabilize the back. ‘If only’ my multifidi and transverse abdominus were stronger I won’t have back pain. Core stabilization is king! Hmmm.
- Even if I still sit habitually slumped at end-range flexion?
- Even if I still stand sway backed at end-range extension?
- Even if I twist with inadequate hip or thoracic rotation?
- Even if I bend with inadequate hip hinge?
- Even if I serve in tennis with a stiff thoracic kyphosis?
There are larger forces at play in these scenarios which need to be addressed, along with a self-awareness component—what am I doing wrong/how could I move better? Optimal movement principles germane to this topic are Appropriate Distribution of Movement and Proportional Use of Synergists (Division of Labor blog April 2020).
- If my gluts/hams are tight and I’m not using myhip flexors to drive anterior pelvic tilt in sitting and bending, I flex too much in my lumbar spine and create hypermobilities.
- If my hip flexors are tight and I’m not using my hip extensors to drive posterior tilt in standing or walking, I lordose and jam my lower back.
- If my hip rotators are short I twist too much at my lower back when golfing or working on an assembly line.
- If my thoracic spine has fossilized and my thoracic extensors are on permanent holiday, I am required to move and work too much in my lower back.
Check it Out
There is current research that backs this up. For just a few examples, go to PubMed and type in:
- Relationship between the hip and low back pain in athletes who participate in rotation-related sports.
- Hip stiffness patterns in lumbar flexion or extension-based movement syndromes.
- Elimination of intermittent chronic low back pain in a recreational golfer following improvement of hip range of motion impairments.
- The hips influence on low back pain: a distal link to a proximal problem.
- Factors affecting shoulder-pelvic integration during axial trunk rotation is subjects with recurrent low back pain.
We’re not tossing out the baby with the bath water here—core muscle activation has an important role to play, just not the only role. The game here would be to create situations where we simultaneously mobilize hips and thorax while keeping the back stable. And this is much easier said than done.
We Have Room for Improvement
The typical types of exercise we have historically prescribed to improve hip or thoracic mobility are non-specific and global instead of pattern-specific and differentiated. Because of the tendency to move in ‘paths of least resistance’, we need to be clever in how we position our patient to constrain lumbar movement and to funnel movement and effort to under-performing areas.
Furthermore, according to the Transfer Principle, our exercises should be linked to the specific functional contexts in which our patients run into trouble (bending, lifting, pushing, etc.) and should have a sensory training aspect and some kind of decision making algorithm:
- What is the shape of my lower back?
- What do I want the shape of my low back to be—what is my target?
- Where is my movement or effort occurring when I perform a functional activity—how is movement and effort distributed?
- Where should I be moving and working in order to reduce stress on sensitive tissues?
Motor adequacy (muscle length/strength), sensory accuracy (proprioceptive acuity) and intentional clarity (what’s my target) are the three indispensible aspects of human integrated movement—we can and should be including all three.