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

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

SUBACROMIAL OR ROTATOR CUFF IMPINGEMENT: EXERCISES

What is subacromial impingement syndrome?

 There is a little space between acromion and humerus where ligaments, tendons and bursas are working together. When we raise our arms more than 90 degrees that space does smaller and we could feel pain in that zone if we have any shoulder pathology. In my professional experience, this pathology is one of the most frequency in the shoulder.
 Subacromial impingement syndrome could be for different causes. Several structures, such as the subacromial bursa, the tendons of the rotator cuff, the acromion, the coraco-acromial ligament, and the tendon of the long head biceps muscle, are involved in the pathogenesis of subacromial impingement syndrome.
  

Treatment with exercises

 I want to resume a review about the treatment of this pathology through home exercises with clinically significant effects on pain reduction and improving function in patients with persistent subacromial impingement syndrome. ¹. It consist in a specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers.
 

Acromioplasty with exercise vs exercise alone

 “But my doctor said I could need an acromioplasty”. Ok, you can try to do the next exercises while you are waiting for a surgery. Because: 

-      This exercise strategy reduces the need for arthroscopic subacromial decompression within the three months timeframe used in the study ¹,

-      in the first six months, a 47% of patients without operative treatment improve their pain and mobility ² and

-      in the 2.5 years, a 78% of patients without operative treatment improve their pain and mobility ³.
  

Range of Motion and Stretching Exercises 

This type of exercises should be performed daily. Each stretch should be held for 30 seconds and repeated 5 times, with a 10-second rest between each stretch. 


1.       Pendulum: stand up, support an arm in a table and the other one in the air. Do 20 small clockwise circles and 20 anticlockwise, make forward and backwards motions and side to side movements.

Pendulum Exercises

  2.       Posture exercises: Put hands on the hips, lean back and hold.

Posture Exercises

  3.       Shoulder shrugs: Pull the shoulders up and back, and hold. Pinch the back of the shoulder blades together using good posture.

Shoulder Shrugs

  4.       Active assisted range of motion: with a cane or stick raise your arms forwards, external rotation and abduction.

Active assisted range of motion

  5.       Active range of motion: in front of a mirror, raise you arms at the same time and try not elevate your shoulders.

Active range of motion

  6.       Anterior shoulder stretch: Place hands at shoulder level on each side of a door or in a corner of a room. Lean forward into the door or corner and hold.

Anterior Shoulder Stretch

  7.       Posterior shoulder stretch: put your arm over the opposite shoulder and feel the stretch in the back of your shoulder.
  

Posterior Shoulder Stretch

  

Strengthening Exercises

Strengthening should be performed 3 times weekly. 

Each exercise was performed at 3 sets of 10 repetitions with a 60-second rest between each set the first week, followed by 3 sets of 15 the second week, followed by 3 sets of 20 the third week; then increasing TheraBand resistance.



8.       External Rotation: lying on one side with your elbow at 90 degrees, raise your hand with or without weight.

External Rotation

  9.       Scaption: Hold the arm forward, thumb up or down, raise the arm. May add resistance. This exercise should be done only if there is no pain.

Scaption

  10.   Chair press: While seated, press up on the chair, lifting the body off the chair. Try to keep the spine straight.

Chair Press

  11.   Cat-Camel: put your hand just down your shoulders and your knees down hip. Keep a neutral hip position, then arch your spine from neck to bottom.

Cat - Camel

  12.   Press-up: Lie on back, elbow locked straight, weights in hands. Move your arm up toward the ceiling as far as possible.

Press Up

  13.   Rows: Seated or standing, bend your elbows and pull the elastic cord back. Try to pinch your shoulder blades behind you.

Rows

  14.   Upright row: Do one arm at a time. While standing, lean over a table and bend at the waist. Pull the hand weight back, pulling shoulder blade back.

Upright Row

  15.   Low Trapezius: stand up, open your chest and with the elbow extended reach the elastic band behind you.

Low Trapezius

        

Bibliography

  1. Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg 2009;18:138-60. 

2. Rahme H, Solem-Bertoft E, Westerberg CE, Lundberg E, Sorensen S, Hilding S. The subacromial impingement syndrome. A study of results of treatment with special emphasis on predictive factors and paingenerating mechanisms. Scand J Rehab Med 1998;30:253-62. 

3. Brox JI, Gjengedal E, Uppheim G, et al. Arthroscopic surgery versus supervised exercises in patient with rotator cuff disease (stage II impingement syndrome): A prospective, randomised, controlled studyin 125 patients with a 2 ½ year follow-up. J Shoulder Elbow Surg 1997;8:102-11.

Shoulder impingement Rotator cuff tear Impingement syndrome Shoulder impingement syndrome Rotator cuff impingement syndrome Subacromial impingement syndrome Rotator impingement Subacromial impingement Impingement