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It is estimated that 80% of the human race experiences low back pain at least once throughout their lifetime. Fifty percent of the working population admit to experiencing low back pain each year. Each year 15-20% of the people in the United States have complaints of low back pain. Two percent of the U.S. population is either temporarily or chronically disabled by low back pain. Millions of workers suffer on the job injuries annually which costs 100 billion dollars in lost wages, time, and productivity and medical costs.
It is important to understand that there is an outstanding chance that you will recover from your low back pain in the near future. Research studies have shown that 74 % of those that suffer from back pain return to work within 4 weeks and > 90 % in 3 months or less. Some health care providers feel low back pain is like catching a cold – you experience it and in time it goes away.
To sum it up, there is a good chance you will have low back pain, there is a good chance that you will recover but there is also a good chance that you will experience the pain again. Medical research suggests that an active exercise program will reduce disability and may prevent future episodes of pain.
Anatomy of the Low Back
The low back or lumbar spine is an extraordinary engineering marvel. It is composed of bones, discs, joints, tendons, muscles, ligaments and nerves. The spine has 3 main functions. 1.) It connects the pelvis to the trunk and head. 2.) It protects and houses the spinal cord which is made up of billions of nerves that connect the brain to most of the body’s major organs. 3.) The spine provides stability, balance, flexibility, and mobility in order for us to perform our daily activities. It allows you to swing a golf club and at the same time withstands and transfers tremendous forces. For example, let’s assume you weigh 150 pounds, and you bend over about 65 degrees. Your back muscles generate 375 pounds of force to keep you from falling over and if you carry a 50 pound object at the same time, your muscles generate about 700 pounds of force.
Closer inspection reveals five vertebrae (bones) stacked on top of each other with a fluid – filled disc in between each vertebrae. The lumbar spine is like a hollow, C-shaped curve (called the lumbar lordosis) which is arranged to balance tremendous forces. The curve or lumbar lordosis allows the spine to be 15 times stronger than if it were straight. Within the “hollow” of the spine is the spinal cord. The spinal cord is made up of nerves that, very simply put, wire your brain to your muscles and tell them when to contract. These nerves also are responsible for the sensation of touch and pain among other things. They exit out of holes called intervertebral (meaning in between the vertebrae) foramen and are called nerve roots.
The vertebral bodies bear most of the weight and have cartilage end plates which attach to the discs. Spinous processes emerge from the back of a vertebrae and two other bones point to the sides and are called transverse processes. These processes serve as attachments for muscles and ligaments.
Between each vertebral body is a fluid filled disc similar to a jelly donut. The outer fibrous portion is called the annulus fibrosus and the inner jelly is called the nucleus pulposus. Healthy discs provide necessary height to the spine, absorb shock, and distribute forces in all directions.
Ligaments are tough non-elastic (they stretch very little) structures that attach a bone or bones together. There are many ligaments associated with the lumbar spine. The anterior longitudinal ligament holds the front of the vertebral bodies together. The posterior longitudinal ligament holds the back of the vertebral bodies together. The interspinous and intertransverse ligaments pass in between the spinous processes and transverse processes respectively. The ligamentum flavum holds the rear portion of the vertebra together and helps to protect the spinal cord. The thoracolumbar fascia is a large piece of ligamentous tissue that helps hold all of the lumbar vertebra together and works with muscles to stabilize the spine.
There are over 140 muscles that work together to move and stabilize the spine. Many of these muscles are located around the lumbar spine. There are the abdominal muscles, the erector muscles, the hip muscles, and lateral stabilizing muscles. The abdominal muscles consist of the rectus abdominus, the internal and external obliques, and the transverse abdominus. They provide frontal support, help maintain good posture, hold the abdominal organs in the correct location, and act together as your body’s own natural “back belt.” The erector spinae muscles run up and down your back to help you maintain erect posture and they assist in recovering from the forward bent position. Even deeper is a layer of muscles that assist in rotational movements and side bending. The hip muscles, most notably the gluteus maximus, hamstrings, and psoas (pronounced soas) move the pelvis and thighs. The gluteus maximus and hamstrings are your major lifting muscles. In fact, when you bend down to touch your toes, about 67% of the bending comes from your hips which is in turn controled by the gluteus maximus and hamstrings muscles. The psoas muscles help lift your thigh and stabilizes the spine. The lateral stabilizers – the quadratus lumborum and the latissamus dorsi both insert into the spinous and transverse processes via the thoracolumbar fascia. They also stabilize and move the spine. Any one or combination of structures can affect the curve or lumbar lordosis.
Mechanical Low Back Pain
Mechanical low back pain has been reported to arise from trauma (either chronic or sudden) such as a fall, a motor vehicle accident, twisting, prolonged poor postures, mental stress, fatigue, disc extrusion (also known as a slipped disc, rupture, or disc herniation), sometimes painful degenerative disc disease(also called arthritis), aging, congenital defects, poor flexibility, etc. Causes such as infection, hormonal problems, broken bones, systemic disease, and tumors require serious medical intervention but are very rare and are beyond the realm of this discussion.
Acute low back pain is defined as activity intolerance due to lower back or back-related leg symptoms of less than 3 months’ duration. Chronic low back pain, therefore, is defined as pain/problems lasting greater than 3 months. Regardless of the cause or duration of mechanical low back pain, the result is likely to be damaged soft tissue(s) which can stimulate nerves and produce pain.
It is important to understand that it is next to impossible to determine exactly which tissue(s) are the cause of the low back pain. Someone like yourself may be experiencing pain and quite frankly, the cause is unknown. It could be muscle(s), ligament(s), disc(s), tendon(s), joint(s), and/or other connective tissue. They all can produce similar symptoms which commonly present as pain on one side of the back or across the back. It may radiate into the buttock or into the thigh. Quite often it will be accompanied by painful cramping of the muscles called a muscle spasm. Furthermore, medical research has shown that x-rays are of little help in determining the cause of low back pain except in rare cases such as severe trauma. Magnetic resonance imaging (MRI) is also ineffective at determining the cause of low back pain. For example 2 out of 3 people have positive findings for disc abnormalities on an MRI but are painless. As many as 1 in 3 people have disc bulges and are completely painless. Health care professionals often call low back pain a “pain in search of a pathology.” This means that a patient’s medical tests will be negative or a test will produce a false positive. The cause could be any number of structures.
Treating Low Back Pain
So how do we treat something if we don’t know what exactly is wrong. We do know that mechanical low back pain is caused by damaged soft tissue. The damage stimulates pain nerves called nociceptors. The goal then is to promote healing of the damaged soft tissue which will eliminate the pain, not just treat the pain itself. This is done with a program that is customized to your individual needs.
Here are the steps:
– Protecting the damaged soft tissue to prevent further breakdown. The area of damaged soft tissue is protected with rest and positioning. Activities that cause the pain should be avoided while the low back heals. Pain management techniques should be used and your physical therapist will discuss these with you. Bed rest is usually only necessary for 1-3 days (longer periods of bed rest have not been proven to be beneficial).
– Increasing the circulation and mobility. This will deliver the proper building blocks (proteins, repair cells called fibroblasts, oxygen, proteins, etc.), remove inflammatory and waste products that build up in painful tissue(s), and prevent tissue atrophy. Increasing circulation is accomplished by walking and performing painless range of motion, stretching, and strengthening exercises.
– Correcting the dysfunctions (weakness, poor posture, poor flexibility) that caused the problem in the first place. Progressive strengthening exercises, flexibility exercise, and postural/body mechanics education will help reduce the stress on your low back and promote proper repair.
The Key: Your physical therapist will give you the tools to treat your dysfunctions and create your own customized treatment program. That’s not all. Anyone who has suffered from low back pain must understand that the problem is not corrected when the pain ends. Muscles must be stronger than before the pain started (that takes 12+ weeks), many weeks are needed to improve flexibility, and repeated practice is necessary to incorporate proper posture and body mechanics into your daily activities.
Stationary cycling is usually prescribed for improving the strength and/or range of motion of the hips, knees, ankles as well as cardio-vascular endurance.
The trunk and its associated muscles make up the core. The extremities are the arms, forearms, hands, thighs, legs, ankles/feet. Strong core muscles provide a foundation for the extremities to attach to and work more efficiently. It is hypothesized that a weak core can cause excessive stress on the extremity muscles, tendons, ligaments and joints. Core strengthening is a multi-joint exercise, involving larger muscle groups such as the chest, back, abdominals, back, hip/thigh, and shoulder blade muscles. Core strengthening is often incorporated as part of a low back or neck rehabilitation program. Because recovery or enhancement of core strength provides a stable base for the extremities, it is also commonly part of an arm, forearm, thigh, leg or ankle program.
Cold therapy is used to cause vasoconstriction (the blood vessels constrict or decrease their diameter) to reduce the amount of fluid that leaks out of the capillaries into the tissue spaces (swelling) in response to injury of tissue. Ice or cold is used most frequently in acute injuries, but also an effective pain reliever for even the most chronic pain. Cold therapy may be administered by using a cold pack or an ice massage as seen in the above video.
Possible Treatments
The analysis of walking problems by visually examining the interaction of the low back and the joints of the thighs, legs, and feet during the various stages of walking, including, initial contact, loading response, mid stance, terminal stance, pre swing, mid swing, and terminal swing. Many back, thigh, leg, ankle, and foot problems may be caused by or manifest themselves in subtle gait abnormalities.
Heat is recommended to decrease chronic pain, relax muscles, and for pain relief. It should not be used with an acute or “new” injury.
An isometric exercise is a muscle contraction without joint movement. Isometrics are usually prescribed for gentle nerve and muscle reeducation. They are typically used for strengthening with arthritis patients, post-surgical patients, or as an introductory muscle strengthening exercise. A usual progression is from isometrics to active and resistive exercises that involve joint movement.
The movement of the low back, by the patient, through a range of motion against gravity. AROM is usually prescribed for arthritis, initial recovery of joint motion gentle strengthening without trauma to joints.
Hands-on therapeutic procedures intended to increase soft tissue or low back joint mobility. Mobilization is usually prescribed to increase mobility, decrease joint stiffness, and to relieve pain. There are many types of mobilization techniques including Grimsby, Maitland, Kaltenborn, Isometric Mobilizations, etc.
The movement of the low back, by the patient or therapist, through a range of motion without the use of the muscles that “actively” move the joint(s).
Exercises that gradually increase in resistance (weights) and in repetitions. PRE is usually prescribed for reeducation of muscles and strengthening. Weights, rubber bands, and body weight can be used as resistance.
The longitudinal/axial pull on the lumbar spine, either manual or mechanical, intermittent or continuous. Pelvic traction may be helpful for the relief of low back pain and muscle spasm.
Instruction in the correct biomechanical alignment of the body to reduce undue strain on muscles, joints, ligaments, discs, and other soft tissues. There is an ideal posture but most do not have it. Therapists educate patients about the importance of improving posture and body mechanics with daily activities. Stretching and strengthening exercises may be prescribed to facilitate postural improvement and to prevent further disability and future recurrences of problems.
Proprioception is the body’s ability to sense where it is in space. For example, close your eyes and touch your nose. How were you able to move your finger to your nose without seeing it? Proprioception exercises are used to help retrain your sensory system after the nerves have been damaged during a musculoskeletal injury. Your body uses its sensory system in the joints and muscles to know how they are moving. Balance and coordination both depend on your body’s proprioceptive skills.
Possible Treatments
Exercise designed to lengthen a muscle(s) or soft tissue. Stretching exercises are usually prescribed to improve the flexibility of muscles that have tightened due to disuse or in compensation to pain, spasm or immobilization.
A lumbar laminectomy/discectomy is a common surgery to remove fragments of an extruded herniated disc. The image above is a simplification of the procedure:
– The surgeon makes an incision through the skin just off the centerline of the spine. The bony area of the vertebra, called the lamina is exposed and a small portion of it is removed (called a laminectomy).
– A ligament, called the ligamentum flavum, is reflected back to expose the nerves and the extruded disc material.
– The spinal nerve is retracted (moved back) for better exposure of the extruded disc fragments. The fragments are then removed (this is called a discectomy or removal of the damaged disc fragments).
Physical therapy should be prescribed after surgery. While rehabilitation for each individual can differ, treatment usually consists of flexibility exercise, lumbar stabilization/core strengthening, and aerobic exercise. Studies have shown that patients that undergo physical therapy after lumbar discectomy have better outcomes than those that do not receive physical therapy.
The trunk and its associated muscles make up the core. The extremities are the arms, forearms, hands, thighs, legs, ankles/feet. Strong core muscles provide a foundation for the extremities to attach to and work more efficiently. It is hypothesized that a weak core can cause excessive stress on the extremity muscles, tendons, ligaments and joints. Core strengthening is a multi-joint exercise, involving larger muscle groups such as the chest, back, abdominals, back, hip/thigh, and shoulder blade muscles. Core strengthening is often incorporated as part of a low back or neck rehabilitation program. Because recovery or enhancement of core strength provides a stable base for the extremities, it is also commonly part of an arm, forearm, thigh, leg or ankle program.
Cold therapy is used to cause vasoconstriction (the blood vessels constrict or decrease their diameter) to reduce the amount of fluid that leaks out of the capillaries into the tissue spaces (swelling) in response to injury of tissue. Ice or cold is used most frequently in acute injuries, but also an effective pain reliever for even the most chronic pain. Cold therapy may be administered by using a cold pack or an ice massage as seen in the above video.
Possible Treatments
The analysis of walking problems by visually examining the interaction of the low back and the joints of the thighs, legs, and feet during the various stages of walking, including, initial contact, loading response, mid stance, terminal stance, pre swing, mid swing, and terminal swing. Many back, thigh, leg, ankle, and foot problems may be caused by or manifest themselves in subtle gait abnormalities.
An isometric exercise is a muscle contraction without joint movement. Isometrics are usually prescribed for gentle nerve and muscle reeducation. They are typically used for strengthening with arthritis patients, post-surgical patients, or as an introductory muscle strengthening exercise. A usual progression is from isometrics to active and resistive exercises that involve joint movement.
The movement of the low back, by the patient, through a range of motion against gravity. AROM is usually prescribed for arthritis, initial recovery of joint motion gentle strengthening without trauma to joints.
Hands-on therapeutic procedures intended to increase soft tissue or low back joint mobility. Mobilization is usually prescribed to increase mobility, decrease joint stiffness, and to relieve pain. There are many types of mobilization techniques including Grimsby, Maitland, Kaltenborn, Isometric Mobilizations, etc.
The movement of the low back, by the patient or therapist, through a range of motion without the use of the muscles that “actively” move the joint(s).
Exercises that gradually increase in resistance (weights) and in repetitions. PRE is usually prescribed for reeducation of muscles and strengthening. Weights, rubber bands, and body weight can be used as resistance.
Possible Treatments
Therapeutic massage of body tissue, performed with the hands. Soft tissue mobilization may be used for muscle relaxation, to decrease swelling, to decrease scar tissue adhesions, and for pain relief.
Scoliosis is a curvature of the spine that is greater than 10 degrees. It can affect any part of your spine. Doctors describe a curve as an “C” or “S”. Scoliosis can be classified as mild, moderate, or severe. In most cases, the scoliosis is idiopathic, meaning there is not exact cause. It can affect all age groups and occurs equally between males and females, however girls are 10 times more likely to have their curve worsen over time and need treatment. It occurs more often during growth spurts between the 10 and 15 years old; it can continue into adulthood. The greater the curve, the more likely it can progress over time.
Symptoms include back pain, ribcage may appear asymmetrical, and abnormal posture. In severe cases you can have difficulty with breathing and walking.
Most cases, treatment is not needed as the curve can correct itself as you grow. Your doctor may recommend frequent measuring to monitor your curve. In moderate to severe cases, bracing, physical therapy, and surgery are sometimes required. Your Physical Therapist will determine an individualized treatment plan consisting of exercises, manual therapy, and modalities to help decrease pain, improve muscle flexibility, strengthen your core, back and abdominal muscles, and to normalize your posture in order for you to return to regular activities.
Stationary cycling is usually prescribed for improving the strength and/or range of motion of the hips, knees, ankles as well as cardio-vascular endurance.
The trunk and its associated muscles make up the core. The extremities are the arms, forearms, hands, thighs, legs, ankles/feet. Strong core muscles provide a foundation for the extremities to attach to and work more efficiently. It is hypothesized that a weak core can cause excessive stress on the extremity muscles, tendons, ligaments and joints. Core strengthening is a multi-joint exercise, involving larger muscle groups such as the chest, back, abdominals, back, hip/thigh, and shoulder blade muscles. Core strengthening is often incorporated as part of a low back or neck rehabilitation program. Because recovery or enhancement of core strength provides a stable base for the extremities, it is also commonly part of an arm, forearm, thigh, leg or ankle program.
Possible Treatments
Heat is recommended to decrease chronic pain, relax muscles, and for pain relief. It should not be used with an acute or “new” injury.
The movement of the low back, by the patient, through a range of motion against gravity. AROM is usually prescribed for arthritis, initial recovery of joint motion gentle strengthening without trauma to joints.
Hands-on therapeutic procedures intended to increase soft tissue or low back joint mobility. Mobilization is usually prescribed to increase mobility, decrease joint stiffness, and to relieve pain. There are many types of mobilization techniques including Grimsby, Maitland, Kaltenborn, Isometric Mobilizations, etc.
The movement of the low back, by the patient or therapist, through a range of motion without the use of the muscles that “actively” move the joint(s).
Exercises that gradually increase in resistance (weights) and in repetitions. PRE is usually prescribed for reeducation of muscles and strengthening. Weights, rubber bands, and body weight can be used as resistance.
Instruction in the correct biomechanical alignment of the body to reduce undue strain on muscles, joints, ligaments, discs, and other soft tissues. There is an ideal posture but most do not have it. Therapists educate patients about the importance of improving posture and body mechanics with daily activities. Stretching and strengthening exercises may be prescribed to facilitate postural improvement and to prevent further disability and future recurrences of problems.
Possible Treatments
Exercise designed to lengthen a muscle(s) or soft tissue. Stretching exercises are usually prescribed to improve the flexibility of muscles that have tightened due to disuse or in compensation to pain, spasm or immobilization.
Spinal stenosis is the narrowing of the spinal canals. It may involve the central canal, the hollow tube on the backside of the spine through which the spinal cord travels, and/or the transverse foramina, the canals from which the spinal nerves exit.
Narrowing of the spinal canals is usually an age related process (called secondary stenosis). During this process the vertebral discs lose their height (degenerate), the ligaments become stiff, and bone spurs may form. The combination of loss of disc height, hardening of the ligaments, and bone spur formation can cause the stenosis. Other conditions such as spondylolisthesis, trauma, or post-surgical complications, can also cause stenosis.
Because of mechanical compression and blood flow congestion, spinal stenosis can result in severe pain. With lumbar or low back spinal stenosis, symptoms often include low back pain and a diffuse radiation of pain into the buttocks and thighs. Tingling and numbness and leg weakness may be present as well.
Symptoms are often worse with standing, walking, and backward bending/extension of the spine. Sitting, forward bending, and unweighting of the body often provide relief. One of the hallmark signs of lumbar spinal stenosis is a decreased walking tolerance.
Conservative care (rehabilitation), may be helpful. Treatment may consist of stretching, strengthening, joint mobilization/manipulation, aerobic exercise, and activity modification. Walking with an “unweighting system” or aquatic exercise may be helpful.
It is important to work closely with your physician and physical therapist.
Stationary cycling is usually prescribed for improving the strength and/or range of motion of the hips, knees, ankles as well as cardio-vascular endurance.
The trunk and its associated muscles make up the core. The extremities are the arms, forearms, hands, thighs, legs, ankles/feet. Strong core muscles provide a foundation for the extremities to attach to and work more efficiently. It is hypothesized that a weak core can cause excessive stress on the extremity muscles, tendons, ligaments and joints. Core strengthening is a multi-joint exercise, involving larger muscle groups such as the chest, back, abdominals, back, hip/thigh, and shoulder blade muscles. Core strengthening is often incorporated as part of a low back or neck rehabilitation program. Because recovery or enhancement of core strength provides a stable base for the extremities, it is also commonly part of an arm, forearm, thigh, leg or ankle program.
The movement of the low back, by the patient, through a range of motion against gravity. AROM is usually prescribed for arthritis, initial recovery of joint motion gentle strengthening without trauma to joints.
Hands-on therapeutic procedures intended to increase soft tissue or low back joint mobility. Mobilization is usually prescribed to increase mobility, decrease joint stiffness, and to relieve pain. There are many types of mobilization techniques including Grimsby, Maitland, Kaltenborn, Isometric Mobilizations, etc.
The movement of the low back, by the patient or therapist, through a range of motion without the use of the muscles that “actively” move the joint(s).
Exercises that gradually increase in resistance (weights) and in repetitions. PRE is usually prescribed for reeducation of muscles and strengthening. Weights, rubber bands, and body weight can be used as resistance.
The longitudinal/axial pull on the lumbar spine, either manual or mechanical, intermittent or continuous. Pelvic traction may be helpful for the relief of low back pain and muscle spasm.
Aerobic Exercise – The American College of Sports Medicine (ACSM) defines aerobic exercise as “any activity that uses large muscle groups, can be maintained continuously, and is rhythmic in nature.” Aerobic means in the presence of oxygen. In other words, your body is burning its fuel (glucose) in the presence of oxygen. It is performed at less than 85% of your maximum heart rate. An aerobically fit individual can work longer, more vigorously and achieve a quicker recovery at the end of the aerobic session. Jogging, cycling, swimming, aerobics classes, and rowing are examples of aerobic exercise.
Exercise designed to lengthen a muscle(s) or soft tissue. Stretching exercises are usually prescribed to improve the flexibility of muscles that have tightened due to disuse or in compensation to pain, spasm or immobilization.
The analysis of walking problems by visually examining the interaction of the low back and the joints of the thighs, legs, and feet during the various stages of walking, including, initial contact, loading response, mid stance, terminal stance, pre swing, mid swing, and terminal swing. Many back, thigh, leg, ankle, and foot problems may be caused by or manifest themselves in subtle gait abnormalities.
It is estimated that 80% of the human race experiences low back pain at least once throughout their lifetime. Fifty percent of the working population admit to experiencing low back pain each year. Each year 15-20% of the people in the United States have complaints of low back pain. Two percent of the U.S. population is either temporarily or chronically disabled by low back pain. Millions of workers suffer on the job injuries annually which costs 100 billion dollars in lost wages, time, and productivity and medical costs.
It is important to understand that there is an outstanding chance that you will recover from your low back pain in the near future. Research studies have shown that 74 % of those that suffer from back pain return to work within 4 weeks and > 90 % in 3 months or less. Some health care providers feel low back pain is like catching a cold – you experience it and in time it goes away.
To sum it up, there is a good chance you will have low back pain, there is a good chance that you will recover but there is also a good chance that you will experience the pain again. Medical research suggests that an active exercise program will reduce disability and may prevent future episodes of pain.
Anatomy of the Low Back
The low back or lumbar spine is an extraordinary engineering marvel. It is composed of bones, discs, joints, tendons, muscles, ligaments and nerves. The spine has 3 main functions. 1.) It connects the pelvis to the trunk and head. 2.) It protects and houses the spinal cord which is made up of billions of nerves that connect the brain to most of the body’s major organs. 3.) The spine provides stability, balance, flexibility, and mobility in order for us to perform our daily activities. It allows you to swing a golf club and at the same time withstands and transfers tremendous forces. For example, let’s assume you weigh 150 pounds, and you bend over about 65 degrees. Your back muscles generate 375 pounds of force to keep you from falling over and if you carry a 50 pound object at the same time, your muscles generate about 700 pounds of force.
Closer inspection reveals five vertebrae (bones) stacked on top of each other with a fluid – filled disc in between each vertebrae. The lumbar spine is like a hollow, C-shaped curve (called the lumbar lordosis) which is arranged to balance tremendous forces. The curve or lumbar lordosis allows the spine to be 15 times stronger than if it were straight. Within the “hollow” of the spine is the spinal cord. The spinal cord is made up of nerves that, very simply put, wire your brain to your muscles and tell them when to contract. These nerves also are responsible for the sensation of touch and pain among other things. They exit out of holes called intervertebral (meaning in between the vertebrae) foramen and are called nerve roots.
The vertebral bodies bear most of the weight and have cartilage end plates which attach to the discs. Spinous processes emerge from the back of a vertebrae and two other bones point to the sides and are called transverse processes. These processes serve as attachments for muscles and ligaments.
Between each vertebral body is a fluid filled disc similar to a jelly donut. The outer fibrous portion is called the annulus fibrosus and the inner jelly is called the nucleus pulposus. Healthy discs provide necessary height to the spine, absorb shock, and distribute forces in all directions.
Ligaments are tough non-elastic (they stretch very little) structures that attach a bone or bones together. There are many ligaments associated with the lumbar spine. The anterior longitudinal ligament holds the front of the vertebral bodies together. The posterior longitudinal ligament holds the back of the vertebral bodies together. The interspinous and intertransverse ligaments pass in between the spinous processes and transverse processes respectively. The ligamentum flavum holds the rear portion of the vertebra together and helps to protect the spinal cord. The thoracolumbar fascia is a large piece of ligamentous tissue that helps hold all of the lumbar vertebra together and works with muscles to stabilize the spine.
There are over 140 muscles that work together to move and stabilize the spine. Many of these muscles are located around the lumbar spine. There are the abdominal muscles, the erector muscles, the hip muscles, and lateral stabilizing muscles. The abdominal muscles consist of the rectus abdominus, the internal and external obliques, and the transverse abdominus. They provide frontal support, help maintain good posture, hold the abdominal organs in the correct location, and act together as your body’s own natural “back belt.” The erector spinae muscles run up and down your back to help you maintain erect posture and they assist in recovering from the forward bent position. Even deeper is a layer of muscles that assist in rotational movements and side bending. The hip muscles, most notably the gluteus maximus, hamstrings, and psoas (pronounced soas) move the pelvis and thighs. The gluteus maximus and hamstrings are your major lifting muscles. In fact, when you bend down to touch your toes, about 67% of the bending comes from your hips which is in turn controled by the gluteus maximus and hamstrings muscles. The psoas muscles help lift your thigh and stabilizes the spine. The lateral stabilizers – the quadratus lumborum and the latissamus dorsi both insert into the spinous and transverse processes via the thoracolumbar fascia. They also stabilize and move the spine. Any one or combination of structures can affect the curve or lumbar lordosis.
Mechanical Low Back Pain
Mechanical low back pain has been reported to arise from trauma (either chronic or sudden) such as a fall, a motor vehicle accident, twisting, prolonged poor postures, mental stress, fatigue, disc extrusion (also known as a slipped disc, rupture, or disc herniation), sometimes painful degenerative disc disease(also called arthritis), aging, congenital defects, poor flexibility, etc. Causes such as infection, hormonal problems, broken bones, systemic disease, and tumors require serious medical intervention but are very rare and are beyond the realm of this discussion.
Acute low back pain is defined as activity intolerance due to lower back or back-related leg symptoms of less than 3 months’ duration. Chronic low back pain, therefore, is defined as pain/problems lasting greater than 3 months. Regardless of the cause or duration of mechanical low back pain, the result is likely to be damaged soft tissue(s) which can stimulate nerves and produce pain.
It is important to understand that it is next to impossible to determine exactly which tissue(s) are the cause of the low back pain. Someone like yourself may be experiencing pain and quite frankly, the cause is unknown. It could be muscle(s), ligament(s), disc(s), tendon(s), joint(s), and/or other connective tissue. They all can produce similar symptoms which commonly present as pain on one side of the back or across the back. It may radiate into the buttock or into the thigh. Quite often it will be accompanied by painful cramping of the muscles called a muscle spasm. Furthermore, medical research has shown that x-rays are of little help in determining the cause of low back pain except in rare cases such as severe trauma. Magnetic resonance imaging (MRI) is also ineffective at determining the cause of low back pain. For example 2 out of 3 people have positive findings for disc abnormalities on an MRI but are painless. As many as 1 in 3 people have disc bulges and are completely painless. Health care professionals often call low back pain a “pain in search of a pathology.” This means that a patient’s medical tests will be negative or a test will produce a false positive. The cause could be any number of structures.
Treating Low Back Pain
So how do we treat something if we don’t know what exactly is wrong. We do know that mechanical low back pain is caused by damaged soft tissue. The damage stimulates pain nerves called nociceptors. The goal then is to promote healing of the damaged soft tissue which will eliminate the pain, not just treat the pain itself. This is done with a program that is customized to your individual needs.
Here are the steps:
– Protecting the damaged soft tissue to prevent further breakdown. The area of damaged soft tissue is protected with rest and positioning. Activities that cause the pain should be avoided while the low back heals. Pain management techniques should be used and your physical therapist will discuss these with you. Bed rest is usually only necessary for 1-3 days (longer periods of bed rest have not been proven to be beneficial).
– Increasing the circulation and mobility. This will deliver the proper building blocks (proteins, repair cells called fibroblasts, oxygen, proteins, etc.), remove inflammatory and waste products that build up in painful tissue(s), and prevent tissue atrophy. Increasing circulation is accomplished by walking and performing painless range of motion, stretching, and strengthening exercises.
– Correcting the dysfunctions (weakness, poor posture, poor flexibility) that caused the problem in the first place. Progressive strengthening exercises, flexibility exercise, and postural/body mechanics education will help reduce the stress on your low back and promote proper repair.
The Key: Your physical therapist will give you the tools to treat your dysfunctions and create your own customized treatment program. That’s not all. Anyone who has suffered from low back pain must understand that the problem is not corrected when the pain ends. Muscles must be stronger than before the pain started (that takes 12+ weeks), many weeks are needed to improve flexibility, and repeated practice is necessary to incorporate proper posture and body mechanics into your daily activities.
Stationary cycling is usually prescribed for improving the strength and/or range of motion of the hips, knees, ankles as well as cardio-vascular endurance.
The trunk and its associated muscles make up the core. The extremities are the arms, forearms, hands, thighs, legs, ankles/feet. Strong core muscles provide a foundation for the extremities to attach to and work more efficiently. It is hypothesized that a weak core can cause excessive stress on the extremity muscles, tendons, ligaments and joints. Core strengthening is a multi-joint exercise, involving larger muscle groups such as the chest, back, abdominals, back, hip/thigh, and shoulder blade muscles. Core strengthening is often incorporated as part of a low back or neck rehabilitation program. Because recovery or enhancement of core strength provides a stable base for the extremities, it is also commonly part of an arm, forearm, thigh, leg or ankle program.
Cold therapy is used to cause vasoconstriction (the blood vessels constrict or decrease their diameter) to reduce the amount of fluid that leaks out of the capillaries into the tissue spaces (swelling) in response to injury of tissue. Ice or cold is used most frequently in acute injuries, but also an effective pain reliever for even the most chronic pain. Cold therapy may be administered by using a cold pack or an ice massage as seen in the above video.
Possible Treatments
The analysis of walking problems by visually examining the interaction of the low back and the joints of the thighs, legs, and feet during the various stages of walking, including, initial contact, loading response, mid stance, terminal stance, pre swing, mid swing, and terminal swing. Many back, thigh, leg, ankle, and foot problems may be caused by or manifest themselves in subtle gait abnormalities.
Heat is recommended to decrease chronic pain, relax muscles, and for pain relief. It should not be used with an acute or “new” injury.
An isometric exercise is a muscle contraction without joint movement. Isometrics are usually prescribed for gentle nerve and muscle reeducation. They are typically used for strengthening with arthritis patients, post-surgical patients, or as an introductory muscle strengthening exercise. A usual progression is from isometrics to active and resistive exercises that involve joint movement.
The movement of the low back, by the patient, through a range of motion against gravity. AROM is usually prescribed for arthritis, initial recovery of joint motion gentle strengthening without trauma to joints.
Hands-on therapeutic procedures intended to increase soft tissue or low back joint mobility. Mobilization is usually prescribed to increase mobility, decrease joint stiffness, and to relieve pain. There are many types of mobilization techniques including Grimsby, Maitland, Kaltenborn, Isometric Mobilizations, etc.
The movement of the low back, by the patient or therapist, through a range of motion without the use of the muscles that “actively” move the joint(s).
Exercises that gradually increase in resistance (weights) and in repetitions. PRE is usually prescribed for reeducation of muscles and strengthening. Weights, rubber bands, and body weight can be used as resistance.
The longitudinal/axial pull on the lumbar spine, either manual or mechanical, intermittent or continuous. Pelvic traction may be helpful for the relief of low back pain and muscle spasm.
Instruction in the correct biomechanical alignment of the body to reduce undue strain on muscles, joints, ligaments, discs, and other soft tissues. There is an ideal posture but most do not have it. Therapists educate patients about the importance of improving posture and body mechanics with daily activities. Stretching and strengthening exercises may be prescribed to facilitate postural improvement and to prevent further disability and future recurrences of problems.
Proprioception is the body’s ability to sense where it is in space. For example, close your eyes and touch your nose. How were you able to move your finger to your nose without seeing it? Proprioception exercises are used to help retrain your sensory system after the nerves have been damaged during a musculoskeletal injury. Your body uses its sensory system in the joints and muscles to know how they are moving. Balance and coordination both depend on your body’s proprioceptive skills.
Possible Treatments
Exercise designed to lengthen a muscle(s) or soft tissue. Stretching exercises are usually prescribed to improve the flexibility of muscles that have tightened due to disuse or in compensation to pain, spasm or immobilization.
A lumbar laminectomy/discectomy is a common surgery to remove fragments of an extruded herniated disc. The image above is a simplification of the procedure:
– The surgeon makes an incision through the skin just off the centerline of the spine. The bony area of the vertebra, called the lamina is exposed and a small portion of it is removed (called a laminectomy).
– A ligament, called the ligamentum flavum, is reflected back to expose the nerves and the extruded disc material.
– The spinal nerve is retracted (moved back) for better exposure of the extruded disc fragments. The fragments are then removed (this is called a discectomy or removal of the damaged disc fragments).
Physical therapy should be prescribed after surgery. While rehabilitation for each individual can differ, treatment usually consists of flexibility exercise, lumbar stabilization/core strengthening, and aerobic exercise. Studies have shown that patients that undergo physical therapy after lumbar discectomy have better outcomes than those that do not receive physical therapy.
The trunk and its associated muscles make up the core. The extremities are the arms, forearms, hands, thighs, legs, ankles/feet. Strong core muscles provide a foundation for the extremities to attach to and work more efficiently. It is hypothesized that a weak core can cause excessive stress on the extremity muscles, tendons, ligaments and joints. Core strengthening is a multi-joint exercise, involving larger muscle groups such as the chest, back, abdominals, back, hip/thigh, and shoulder blade muscles. Core strengthening is often incorporated as part of a low back or neck rehabilitation program. Because recovery or enhancement of core strength provides a stable base for the extremities, it is also commonly part of an arm, forearm, thigh, leg or ankle program.
Cold therapy is used to cause vasoconstriction (the blood vessels constrict or decrease their diameter) to reduce the amount of fluid that leaks out of the capillaries into the tissue spaces (swelling) in response to injury of tissue. Ice or cold is used most frequently in acute injuries, but also an effective pain reliever for even the most chronic pain. Cold therapy may be administered by using a cold pack or an ice massage as seen in the above video.
Possible Treatments
The analysis of walking problems by visually examining the interaction of the low back and the joints of the thighs, legs, and feet during the various stages of walking, including, initial contact, loading response, mid stance, terminal stance, pre swing, mid swing, and terminal swing. Many back, thigh, leg, ankle, and foot problems may be caused by or manifest themselves in subtle gait abnormalities.
An isometric exercise is a muscle contraction without joint movement. Isometrics are usually prescribed for gentle nerve and muscle reeducation. They are typically used for strengthening with arthritis patients, post-surgical patients, or as an introductory muscle strengthening exercise. A usual progression is from isometrics to active and resistive exercises that involve joint movement.
The movement of the low back, by the patient, through a range of motion against gravity. AROM is usually prescribed for arthritis, initial recovery of joint motion gentle strengthening without trauma to joints.
Hands-on therapeutic procedures intended to increase soft tissue or low back joint mobility. Mobilization is usually prescribed to increase mobility, decrease joint stiffness, and to relieve pain. There are many types of mobilization techniques including Grimsby, Maitland, Kaltenborn, Isometric Mobilizations, etc.
The movement of the low back, by the patient or therapist, through a range of motion without the use of the muscles that “actively” move the joint(s).
Exercises that gradually increase in resistance (weights) and in repetitions. PRE is usually prescribed for reeducation of muscles and strengthening. Weights, rubber bands, and body weight can be used as resistance.
Possible Treatments
Therapeutic massage of body tissue, performed with the hands. Soft tissue mobilization may be used for muscle relaxation, to decrease swelling, to decrease scar tissue adhesions, and for pain relief.
Scoliosis is a curvature of the spine that is greater than 10 degrees. It can affect any part of your spine. Doctors describe a curve as an “C” or “S”. Scoliosis can be classified as mild, moderate, or severe. In most cases, the scoliosis is idiopathic, meaning there is not exact cause. It can affect all age groups and occurs equally between males and females, however girls are 10 times more likely to have their curve worsen over time and need treatment. It occurs more often during growth spurts between the 10 and 15 years old; it can continue into adulthood. The greater the curve, the more likely it can progress over time.
Symptoms include back pain, ribcage may appear asymmetrical, and abnormal posture. In severe cases you can have difficulty with breathing and walking.
Most cases, treatment is not needed as the curve can correct itself as you grow. Your doctor may recommend frequent measuring to monitor your curve. In moderate to severe cases, bracing, physical therapy, and surgery are sometimes required. Your Physical Therapist will determine an individualized treatment plan consisting of exercises, manual therapy, and modalities to help decrease pain, improve muscle flexibility, strengthen your core, back and abdominal muscles, and to normalize your posture in order for you to return to regular activities.
Stationary cycling is usually prescribed for improving the strength and/or range of motion of the hips, knees, ankles as well as cardio-vascular endurance.
The trunk and its associated muscles make up the core. The extremities are the arms, forearms, hands, thighs, legs, ankles/feet. Strong core muscles provide a foundation for the extremities to attach to and work more efficiently. It is hypothesized that a weak core can cause excessive stress on the extremity muscles, tendons, ligaments and joints. Core strengthening is a multi-joint exercise, involving larger muscle groups such as the chest, back, abdominals, back, hip/thigh, and shoulder blade muscles. Core strengthening is often incorporated as part of a low back or neck rehabilitation program. Because recovery or enhancement of core strength provides a stable base for the extremities, it is also commonly part of an arm, forearm, thigh, leg or ankle program.
Possible Treatments
Heat is recommended to decrease chronic pain, relax muscles, and for pain relief. It should not be used with an acute or “new” injury.
The movement of the low back, by the patient, through a range of motion against gravity. AROM is usually prescribed for arthritis, initial recovery of joint motion gentle strengthening without trauma to joints.
Hands-on therapeutic procedures intended to increase soft tissue or low back joint mobility. Mobilization is usually prescribed to increase mobility, decrease joint stiffness, and to relieve pain. There are many types of mobilization techniques including Grimsby, Maitland, Kaltenborn, Isometric Mobilizations, etc.
The movement of the low back, by the patient or therapist, through a range of motion without the use of the muscles that “actively” move the joint(s).
Exercises that gradually increase in resistance (weights) and in repetitions. PRE is usually prescribed for reeducation of muscles and strengthening. Weights, rubber bands, and body weight can be used as resistance.
Instruction in the correct biomechanical alignment of the body to reduce undue strain on muscles, joints, ligaments, discs, and other soft tissues. There is an ideal posture but most do not have it. Therapists educate patients about the importance of improving posture and body mechanics with daily activities. Stretching and strengthening exercises may be prescribed to facilitate postural improvement and to prevent further disability and future recurrences of problems.
Possible Treatments
Exercise designed to lengthen a muscle(s) or soft tissue. Stretching exercises are usually prescribed to improve the flexibility of muscles that have tightened due to disuse or in compensation to pain, spasm or immobilization.
Spinal stenosis is the narrowing of the spinal canals. It may involve the central canal, the hollow tube on the backside of the spine through which the spinal cord travels, and/or the transverse foramina, the canals from which the spinal nerves exit.
Narrowing of the spinal canals is usually an age related process (called secondary stenosis). During this process the vertebral discs lose their height (degenerate), the ligaments become stiff, and bone spurs may form. The combination of loss of disc height, hardening of the ligaments, and bone spur formation can cause the stenosis. Other conditions such as spondylolisthesis, trauma, or post-surgical complications, can also cause stenosis.
Because of mechanical compression and blood flow congestion, spinal stenosis can result in severe pain. With lumbar or low back spinal stenosis, symptoms often include low back pain and a diffuse radiation of pain into the buttocks and thighs. Tingling and numbness and leg weakness may be present as well.
Symptoms are often worse with standing, walking, and backward bending/extension of the spine. Sitting, forward bending, and unweighting of the body often provide relief. One of the hallmark signs of lumbar spinal stenosis is a decreased walking tolerance.
Conservative care (rehabilitation), may be helpful. Treatment may consist of stretching, strengthening, joint mobilization/manipulation, aerobic exercise, and activity modification. Walking with an “unweighting system” or aquatic exercise may be helpful.
It is important to work closely with your physician and physical therapist.
Stationary cycling is usually prescribed for improving the strength and/or range of motion of the hips, knees, ankles as well as cardio-vascular endurance.
The trunk and its associated muscles make up the core. The extremities are the arms, forearms, hands, thighs, legs, ankles/feet. Strong core muscles provide a foundation for the extremities to attach to and work more efficiently. It is hypothesized that a weak core can cause excessive stress on the extremity muscles, tendons, ligaments and joints. Core strengthening is a multi-joint exercise, involving larger muscle groups such as the chest, back, abdominals, back, hip/thigh, and shoulder blade muscles. Core strengthening is often incorporated as part of a low back or neck rehabilitation program. Because recovery or enhancement of core strength provides a stable base for the extremities, it is also commonly part of an arm, forearm, thigh, leg or ankle program.
The movement of the low back, by the patient, through a range of motion against gravity. AROM is usually prescribed for arthritis, initial recovery of joint motion gentle strengthening without trauma to joints.
Hands-on therapeutic procedures intended to increase soft tissue or low back joint mobility. Mobilization is usually prescribed to increase mobility, decrease joint stiffness, and to relieve pain. There are many types of mobilization techniques including Grimsby, Maitland, Kaltenborn, Isometric Mobilizations, etc.
The movement of the low back, by the patient or therapist, through a range of motion without the use of the muscles that “actively” move the joint(s).
Exercises that gradually increase in resistance (weights) and in repetitions. PRE is usually prescribed for reeducation of muscles and strengthening. Weights, rubber bands, and body weight can be used as resistance.
The longitudinal/axial pull on the lumbar spine, either manual or mechanical, intermittent or continuous. Pelvic traction may be helpful for the relief of low back pain and muscle spasm.
Aerobic Exercise – The American College of Sports Medicine (ACSM) defines aerobic exercise as “any activity that uses large muscle groups, can be maintained continuously, and is rhythmic in nature.” Aerobic means in the presence of oxygen. In other words, your body is burning its fuel (glucose) in the presence of oxygen. It is performed at less than 85% of your maximum heart rate. An aerobically fit individual can work longer, more vigorously and achieve a quicker recovery at the end of the aerobic session. Jogging, cycling, swimming, aerobics classes, and rowing are examples of aerobic exercise.
Exercise designed to lengthen a muscle(s) or soft tissue. Stretching exercises are usually prescribed to improve the flexibility of muscles that have tightened due to disuse or in compensation to pain, spasm or immobilization.
The analysis of walking problems by visually examining the interaction of the low back and the joints of the thighs, legs, and feet during the various stages of walking, including, initial contact, loading response, mid stance, terminal stance, pre swing, mid swing, and terminal swing. Many back, thigh, leg, ankle, and foot problems may be caused by or manifest themselves in subtle gait abnormalities.
