LOWER BACK PAIN: EXERCISES AND STRETCHES

      ANATOMY

The lumbar spine is an area of ​​the back located between the dorsal vertebrae and the sacrum. It consists of 5 vertebrae that form a lordosis or anterior curvature in the back. They support the weight of the body and give mobility to the spine in flexion, extension, inclination and slight rotation. Between each vertebra is the articular disc formed by a fibrous ring and a nucleus pulposus, its function is to allow movement and acts as a shock absorber. The lumbar spinal discs are larger than the rest of the spine as they have to bear more load, their nucleus pulposus is slightly posterior, which generates a greater number of hernias in this area.

Lumbar Vertebrae

MUSCULATURE

·         Lumbar erector spinae: They are located in the posterior area of ​​the back and are responsible for extending the spine and staying upright. Their contracture is usually painful.

·         Abs: When they are strengthened, they reduce the load that the lumbar curve receives. They frequently atrophy with age and obesity, causing hyperlordosis (increased curvature of the spine).

·         Iliopsoas: the lumbar spine is inserted in the anterior area; its function is flexor and internal rotator and its contraction increases the lumbar curvature.

·         Gluteus and Pyramidal: Located in the posterior area they extend the lower limbs, perform external rotation and support the pelvis so that it does not fall with the only support of one foot.

·         Hamstrings: They range from the hamstrings of the pelvis to the femur and fibula through the back. Various lumbar problems are related to shortened hamstrings, due to the fact that they perform a positional change of the pelvis, leading to retroversion and affecting the curvature of the back.

Musculature lower back

 

  LOWER BACK PAIN

Low back pain is defined as pain or discomfort in the back of the body, located between the margin of the twelve ribs and the lower gluteal region, which may worsen until it limits habitual activities. It is a very common health problem and represents the main cause of activity limitation, disability, loss of productivity and absenteeism in the world, which generates enormous economic burdens for social security. Ten years ago, it was considered a problem limited to western countries. Since then, however, a large number of studies have shown that low back pain is a major problem in countries with lower and middle development levels.

Low back pain syndrome is one of the most common conditions in clinical practice, up to 84% of adults experience a low back pain episode at a certain period of their life. It can have a major negative impact on quality of life and function, and is often associated with depression and anxiety.

Analysis of the incidence of lower back pain showed that the majority of our sample population suffered from pain in the lower back. Nonspecific lower back pain is frequently encountered in primary care, with 25-50% of cases following a chronic course. Over recent decades, a large body of research has focused on the effectiveness of both pharmacological and non-pharmacological treatments.

The origin of low back pain can be classified as mechanical, neuropathic and secondary due to another disease. Mechanical back pain implies that the source of the pain originates from the spine or its associated structures. Neuropathic pain indicates that the presence of symptoms is due to irritation of the spinal nerve root. There are several ways to distinguish mechanical pain from neuropathic pain in the lower back when taking an anamnesis. Patients often describe neuropathic pain at the tip of the finger by pointing to the nerve path, while mechanical pain can often be transmitted to the buttocks and upper leg, while pain below the knee is more common in the root pain.

In this report I will speak about some exercises for to stretch and strengthen that zone and minimize possible pains. In accurate pain, I recommend you begin stretching and doing simple movements of pelvic, and after start strength your abdominal area.

 

  STRETCHES

1. LUMBAR ERECTOR SPINAE

On your back on a firm surface, extend one leg towards the ground and the other bring the knee to the chest with the help of the arms to stretch the posterior musculature of the back. Stay 30 seconds in this position and change legs.

Lumbar erector spinae stretch

2. GLUTEUS

Same position as in the previous exercise, but the knee that previously went towards the chest now goes towards the opposite shoulder until tension is felt in the buttock. Hold 30 seconds.

Gluteus stretch

3. QUADRATUS LUMBAR

Sitting on heels, hands fully forward and back stretched. Lean to both sides and stay in position for 30 seconds.

Gluteus stretch

4. ILIOPSOAS

On your knees take a big step forward with one leg, your trunk straight, carry the weight forward until you feel tension in your groin. Hold 30 seconds.

Iliopsoas stretch

5. HAMSTRINGS

On your back or standing, raise the leg to stretch raised to a height with the knee flexed, flex the hip forward but without bending the spine and stretch the knee until you feel tension in the back of the thigh. Hold the position for 30 seconds.

Hamstrings stretch

 

  STRENGTHENING

      6. PELVIS GIRDLE

Face up, you should begin with a good static position so lie on your back with a bent towel under your head. Do movements of your pelvic arching your lower back and then touching it with the floor, trying to be aware of your hip position and try to keep an intermediate position between these two, called the neutral pelvic position. Do it 10 times

Pelvic girdle

 7. TRANSVERSE ABDOMINIS

Face up with both legs flexed, put your hand on you between your belly button and your hip, inhale with your noise and exhale with your mouth trying to hid your belly button and you should feel abdominal area get stronger.

If we feel the palpation area harder, we have successfully activated the deep muscles of the abdomen. The pelvis must be in a neutral position. Perform 3 sets of 12 repetitions.

Transverse abdominis

 From here, we can perform different exercises that increase abdominal tension to help strengthen it:

·         Face up, raise one leg to 90 degrees and then stretch it to 45 degrees.
·         Face up, raise both arms towards the ceiling and bring them back 45 degrees.

Variations to increase abdominal tension

 8. GLUTEUS

Shoulder bridge. Face up, perform retroversion of the pelvis, squeeze the gluteus and raise it to a straight line with the shoulders, pelvis and knees. And go back down. Perform 3 sets of 12 repetitions.

Shoulder bridge

   Of course that exercises have a lot of variations and complications, be careful but don´t be scared in to follow your progression.

EXAMPLES OF VARIATIONS

Shoulder Bridge Variation

Two Legs Raise

Shoulder Bridge Variation 2

Exercises for lower back pain

Physiotherapy exercises for lower back pain

SHOULDER INSTABILITY: EXERCISES

Anatomy

The shoulder or glenohumeral joint is a complex joint and is made up of different bone structures, including the clavicle, sternum, ribs, scapula or shoulder blade, and the humerus.

All these bone structures make up different joints that will give rise, together, to the shoulder joint complex.

- Acromioclavicular joint

- Sternoclavicular joint

- Thoracic scapular joint

- Glenohumeral joint

Shoulder Anatomy

Regarding the musculature, we have different muscles that make up the shoulder joint complex, among which the rotator cuff group, which constitutes the deepest muscle group, should be highlighted.

- Supraspinatus muscle

- Infraspinatus muscle

- Teres minor muscle

- Subscapularis muscle

All these joints that we have mentioned, allow together with the muscles a wide range of movement to the shoulder.

However, this great motor skills also produces repeated friction and overloading, in many cases reproducing the symptoms known as painful shoulder.

The painful shoulder is a fairly common reason for consultation, being the third most frequent cause of musculoskeletal consultation in Primary Care, behind lumbar and cervical pathology.

Shoulder pain is a symptom that concerns a multitude of pathologies, of which the vast majority are due to disorders of the periarticular soft tissues. There are other possible reasons for shoulder pain, such as injury, joint instability, or arthritis.

SHOULDER INSTABILITY

Shoulder instability is excessive movement of the humeral head relative to the glenoid. It is a common abnormality that is often seen in medicine and physical therapy. An appropriate rehabilitation program plays a vital role in the successful outcome after an episode of shoulder instability. The glenohumeral joint allows a great amount of movement, which makes it inherently unstable, being the most frequently dislocated joint in the human body, being more frequent to find dislocations or subluxations of the shoulder.

Due to poor bone congruence and joint capsular laxity, it relies heavily on dynamic stabilizers and the neuromuscular system to provide functional stability. Therefore, the differentiation between normal movement and pathological instability is often difficult to determine. There is a wide range of shoulder instabilities, from subtle subluxations (as seen in head athletes) to major instabilities.

Dynamic joint stabilizers are the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, major round, and subscapularis), the deltoid, the long head of the biceps, and the scapular musculature. These muscles are capable of generating compressive or coaptating forces in the joint, mainly in ranges of movement where the capsule and ligaments are loose.

In subjects with shoulder instability, muscle strength and neuromuscular control is impaired. They have scapulae that rest in downward rotation and have poor upward rotation, which reduces the area of ​​contact between the humeral head and the glenoid. Symptoms range from mild reports of pain to apprehension, compression, rotator cuff pain, and neuropathic symptoms.

The most commonly recommended initial treatment for shoulder instability is a rehabilitation program. This article tries to create an exercise program to help the shoulder to obtain a correct operation in subjects with instability.

EXERCISES

All included exercises are specific to the shoulder muscles and are designed to improve strength, power and endurance. They should be done with the chest open and the shoulder away from the ears. We will do 3 sets of 12 repetitions, 3 times a week for a minimum of 4 weeks. The initial shoulder position should be relaxed, away from the ear and without being rolled forward.

1. Diagonal: Extension + Adduction

With an elastic band attached above the subject, pull the resistance down and through your body to the opposite side of the leg. During the return movement, you should end with your palm up and your thumb facing up.

Extension + Adduction

2. Diagonal: Flexion + Abduction

Elastic band held at the bottom, start with the arm extended in a 45º position and the palm down. After turning the palm forward, proceed to flex the elbow and raise the arm up and over the affected shoulder. Rotate the palm down and back to bring the arm to the starting position. The opposite movement of the exercise 1.

Flexion + Abduction

3. External rotation

Elastic band attached to one side. Stand with the affected elbow fixed to the side, the elbow at 90º, and the affected arm through the front of the body. Grab the resistance and perform an external arm rotation, keeping the elbow resting on the side. Return to the starting position slowly and controlled.

External Rotation

4. Internal rotation

Elastic band attached to one side. Stand with your elbow fixed at your side at 90º, grasp the resistance and do an internal shoulder rotation. Return to the starting position slowly and controlled.

Internal Rotation

5. External rotation with 90º abduction

Shoulder abducted at 90º. Keeping the shoulder abducted, turn the shoulder back keeping the elbow at 90º. Slowly return to the starting position.

External Rotation with 90 degrees Abduction

6. Abduction

With a dumbbell, your elbow straight and your thumb up, raise your arm to shoulder level at a 30º angle in front of your body. Do not exceed shoulder height. Hold 2 seconds and lower slowly.

Abduction

7. 90º abduction in prone position

Lie on the table, face down, with the involved arm hanging directly to the floor and palm down. Raise your arm to one side, parallel to the ground. Hold 2 seconds and lower slowly.

Abduction in Prone Position

8. Abduction to 100º in prone position

Same as exercise number 7 but with the arm slightly in front of the shoulder (hitchhiker).

100 degrees Abduction in Prone Position

9. Ball

After those exercises, it is interesting continuing the progression with the help of a ball. You can put it in a wall or in the floor and support your weight generating a job of instability and balance for your shoulder.

Exercise with ball

The benefits of this type of exercise in the stability and strengthening of the shoulder have been verified in the current scientific literature, becoming the treatment of first choice for all those shoulder pathologies that are unstable.

CERVICAL PAIN: EXERCISES AND STRETCHES

Cervical pain is one of the most common injuries in people of all ages, being one of the most prevalent conditions in Western society. This problem can be derived from a seating during long periods of time, aggravated by a greater tendency to the use of smartphones, of the computer, use of chairs and tables not suitable for each person and a sedentary lifestyle.

This medical condition can be caused by maintaining an forward head posture (FHP), it is characterized by an excessively advanced position of the head with respect to the neck and an internal rotation of the shoulders.

FHP is associated with low cervical flexion (C4-C7) and high cervical hyperextension (C1-C3), generating musculoskeletal changes at the cervical level. The deep neck muscles are considered very important in the stability, support and adjustment of the neck posture. Generally, there is a weakness of the deep flexor neck muscles in addition to a lack of strength of the external retractors and rotators of the shoulder. To solve this weakness, the body must generate compensations producing a shortening of the high fibers of the trapezium, sternocleidomastoid, scapula elevator, pectoralis major and minor and extensor musculature of the head.

Bad cervical posture can lead to a limitation of mobility and cause excessive tension of muscles and soft tissues. People with neck pain tend to move their head forward with respect to the neck without realizing it. In addition, previous studies have associated FHP and shoulders in internal rotation with cervical and headaches.

To correct this posture, it has been observed that proper activation of the deep flexor muscles of the neck during craniocervical flexion helps maintain an upright posture of the head. Therefore, the strengthening of weakened muscles and stretching of the trapezius, sternocleidomastoid and scapula lift can have positive effects on FHP and cervical pain.

Given the aforementioned consequences of the FHP, it seems correct to create and disseminate an exercise program to correct these dysfunctions.

Video on YouTube with explanation about the exercises and stretching that we explain below:

https://www.youtube.com/watch?v=Lxjzfj0Ma04

Strength exercises

Perform 3 sets of 10 repetitions in each exercise, the shoulders and neck should be at the beginning in a relaxed position. That is, open chest, shoulders away from the ears and slight cervical flexion

1. Cervical flexion

Face up with the head resting on the floor, perform a cervical flexion reducing the distance between the chin and the sternum. We activate and train the deep neck muscles. (Image 1)

Image 1: Deep neck flexors exercise

2. External rotation

In lateral recumbency with the elbow resting on the side, perform an external shoulder rotation movement making a movement towards the side of the hand that moves away from the body. Use a hand-held weight to get more training in the rotator muscles of the shoulder. (Image 2)

Image 2: External shoulder rotators exercise

3. T shape

When standing with legs bent, trunk tilted forward, back straight and arms stretched to the ground, abduct both arms with elbows extended to a position of 90º with respect to the body forming a T. Use weights on both arms to improve strength in the external abductor and rotator musculature of the shoulder, in addition to scapula approximators and stabilizers (Image 3 and 4)

Image 3: Abduction shoulder exercise with extended elbows (front view)

Image 4: Abduction shoulder exercise with extended elbows (sagittal view)

4. W shape

Standing with your legs bent, trunk tilted forward, back straight, shoulders adducted on your chest, elbows bent 100 ° and palms up, abduct your shoulders to back height forming a W. Use weights on both arms to increase training in the external abductor, flexor and rotator muscles of the shoulder, as well as scapula approximators and stabilizers. (Image 5 and 6)

Image 5: Abducted shoulder elbow flexion exercise (front view)

Image 6: Abduction shoulder exercise flexed elbows (sagittal view)

Stretching

Perform each stretch 30 seconds.

1. Pectoral

With the forearm resting on a wall and the shoulder at 90 °, make a rotation with the body in the opposite direction to the arm so that we achieve a separation between the origin and insertion of the pectoral muscle. (Image 7)

Image 7: Pectoral stretching (anterior and posterior view)

2. Upper trapezius

Perform a cervical flexion (look down), contralateral tilt (bring the ear to the shoulder) and homolateral rotation, with the contralateral hand increase the position of the neck to help increase tension in the trapezius. (Image 8)

Image 8: Trapeze Stretch

3. Neck Extenders

Perform a pure cervical flexion (look down), with both hands passively increase the position of the neck until tension is felt in the posterior area of ​​the neck. (Image 9)

Image 9: Stretching the neck extenders

KNEE OSTEOARTHRITIS: EXERCISES

WHAT IS IT?

Osteoarthritis, or wear of the knee joint, is a painful, non-inflammatory, irreversible degenerative disease of the knee joint caused by wear of the articular cartilage.

Osteoarthritis of the lower limb is a common condition that affects the elderly, approximately 20% of people over 60 years of age worldwide experience knee pain. It represents 80% - 90% of hip and knee replacements in the United States and the United Kingdom.

KNEE ANATOMY

The knee is formed by the union of 2 important bones, the femur in its distal portion, and the tibia in the proximal portion. It also has a small bone, called the patella, which articulates with the anterior and inferior portion of the femur. It can mainly perform flexion and extension movements. It is surrounded by an articular capsule and several ligaments that give it stability. In its vicinity, powerful muscles are inserted that make limb movement possible.

It is composed of the joint action of the femur, tibia, patella and two fibrocartilaginous discs that are the meniscus. Femur and tibia make up the main body of the joint, while the patella acts as a pulley and serves as an insertion to the quadriceps muscle tendon and the patelar tendon whose function is to transmit the force generated when the quadriceps is contracted.

PROTHESIS

A knee prosthesis is a mechanical element composed of various metal and plastic components that replace the knee joint consisting of tibia, femur and kneecap.

Should I wear a prosthesis? No, we must understand that osteoarthritis is a degeneration of the joint due to its use. Over the years, all people have osteoarthritis to a greater or lesser extent. Osteoarthritis is NOT an indication of putting on a prosthesis, the indication of putting on the prosthesis is given by pain and / or the functional limitation produced by this osteoarthritis.

CAUSES

The main causes of osteoarthritis of the knee are:

Trauma during sports and recreational activities, hard physical work overload, congenital joint deformity, metabolic disorders, overweight.

TREATMENT

The guideline for the treatment of osteoarthritis is exercise as a non-pharmacological therapy. Exercise improves the symptoms and general well-being of people with this pathology, while they are relatively safe as compared to pharmacological treatments. The improvement of pain and functional results after treatment with osteoarthritis exercises are demonstrated by numerous studies.

Great benefits, regarding pain and function, were observed in people with osteoarthritis of the knee who exercised. The effectiveness of the exercise was generally greater at 2 months after starting the exercise, according to the results of the studies.

For the treatment of osteoarthritis pain we also use radiofrequency, deep heat that helps relieve nerve endings and relax symptoms.

MAIN FACTORS

- The age of who suffers from this deficiency affects, trials with younger participants demonstrated a more appreciable functional improvement than older patients after exercise treatment. In the older population, other age-related conditions (eg, reduced functions in the cardiovascular and musculoskeletal systems) may also explain the observed effect.

- Osteoarthritis severity: in general, the results support the inverse association between benefits of exercise and the severity of osteoarthritis of the knee (that is, it is believed that the exercise produces a greater improvement with a milder knee osteoarthritis than more severe). Patients on the waiting list for surgery, who have knee osteoarthritis in the most advanced stage of the clinical spectrum, showed a smaller exercise response compared to those who were not on a waiting list.

EXERCISE PROGRAM

We will perform the exercises 3 sets of 10 repetitions each, 3 times / week.

Exercise 1:

Lying on your back with your leg straight and a towel under your knee, perform quadriceps contractions by crushing the towel with a hollow of your knee. Bring the toe towards us to feel more muscle contraction.

Exercise 2:

Lying on your back with your leg straight, raise it straight until you reach about 45 degrees from the ground, bringing the tip of the foot up and down again, relaxing the tip of the foot.

Exercise 3:

Lying on your side with your hips and knees bent, separate your knees from each other but not your feet Being able to increase the resistance by placing an elastic band between the knees. We want to focus on strengthening the buttocks.

Exercise 4:

Sitting on a high surface, make knee extensions bringing the tip of the foot towards us at the end of the movement and withstand that tension for 5 seconds.

Exercise 5:

Standing with one leg elevated and the support leg slightly bent, balance for 20-30 seconds and rest for a few seconds. If it seems easy you can increase the difficulty by making circles with the leg that is in the air, closing your eyes, using unstable surfaces ...