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

FORWARD HEAD POSTURE: EXERCICES AND STRETCHES

Forward head posture and protacted shoulders are two of the most common postural deviations in people of all ages ¹. This posture constitutes the "upper crossed syndrome" being frequently associated with musculoskeletal pain.

Image 1: upper crossed syndrome

“Upper crossed syndrome" is a decompensation level upper back, shoulder and chest. There are contracted muscles (pectoralis major, trapezius and levator scapulae) and inhibited others (deep neck flexors, rhomboids and serratus major), producing an imbalance and reflected in the position of the upper part of the trunk. This results in a curved posture that intrinsically leads to a weakness in the scapula with the consequent destabilization in the shoulder joint.

Stretching of the upper trapezius, the sternocleidomastoid, the levator scapulae and the strengthening of the deep cervical flexor muscles have been shown to be effective in correcting the forward head position ². While the treatment of the protacted shoulders is based more on the strengthening of the scapular stabilizers and the rotator cuff muscles and pectoralis minor stretch ^2,3.

That is why I propose to you, strength training and stretching for the correction of posture based on the study by Roivo et al. (2016) ⁴. This protocol is intended to restore normal muscle balance between opposing muscle groups (agonists and antagonists) and work the elongation capacity of muscle groups that restrict the range of joint movements to those that oppose, this concept being supported by several studies ^2.5.

How long?

The exercises must be performed 2 non-consecutive days a week for at least 16 weeks. For strength training, we start with light loads (1- 1'5 kg) and 3 sets of 12-15 repetitions, with the rest interval between sets of 30 seconds. In the three stretching exercises, there will be 2 series of 30 seconds of duration ⁶. The total intervention program took an average of 15 minutes to complete, and the order of the exercises can be random.

Strength exercises

Side-lying external rotation

Side lying with arm fully adducted to side and internally rotated with elbow flexed to 90°. Patients then externally rotate the shoulder with the hand moving in an arc away from the body.

Prone horizontal abduction with external rotation

In a prone horizontal abduction position, the patient horizontally abducts the arm with the elbow extended and with external humeral rotation. The participant lifts the hand toward the ceiling keeping head/neck neutral and squeezing both shoulder blades together.

Y-to-I exercise

The patient retracts the scapulae with the arms abducted to 90°. As the patient advances, the shoulders are externally rotated with the elbows flexed to 90°, forming a Y. Then the patient moves into a position of full bilateral elevation with the elbow extension forming an I.

Chin tuck

This exercise targets the deep flexor muscles of the upper cervical region, the longus capitis and longus colli muscles. This is a low-load exercise51 that involves performing and holding inner range positions of craniocervical flexion that specifically activate and train the deep cervical flexor, rather than the superficial flexors muscles. This exercise is done in a supine lying position with the head in contact with the floor.

Video link

Stretches

One-sided unilateral self-stretch exercise Pectorals minor

The participant’s forearm is stabilized by a vertical plane before the trunk is rotated in the opposite direction. Therefore, arm on the involved side is externally rotated and abducted to 90°.

Static sternocleidomastoid stretch

Start in optimal posture and place right arm behind body, depressing the shoulder. Draw abs in. Tuck chin and slowly draw left ear to the left shoulder. Continue by rotating the neck upward toward the ceiling until a slight stretch is felt on the right side. We can use the left hand to apply slight pressure and assist in lateral flexion and rotation. Switch sides and repeat.

Static levator scapulae stretch

Start in optimal posture and place right arm behind body, depressing the shoulder. Draw abs in. Tuck chin and slowly draw left ear to the left shoulder. Continue by rotating the neck downward toward the ceiling until a slight stretch is felt on the right side. We can use the left hand to apply slight pressure and assist in lateral flexion and rotation. Switch sides and repeat.

What results were obtained?

After 16 weeks, significant differences were observed at two postural angles in the intervention group from pretest to posttest, with an increase in the cervical angle (44.4 ° ± 3.5 ° vs 46.8 ° ± 3.9 °) and shoulder angle (45.9 °). ± 4.9 ° vs 49.8 ° ± 6.5 °) after the intervention ⁴. Getting a head position less advanced and a lower shoulder protraction.

A: Cervical angle; B: Shoulder angle

In summary

This study indicates that a specific exercise program, performed twice a week and integrated into physical education classes over a period of 16 weeks, may result in improved posture, with increases in cervical and shoulder angles.

Bibliography

1. Grimmer-Somers K. An investigation of poor cervical resting posturer. Aust Physiother. 1997;43(1):7-16.2. Lynch S, Thigpen C, Mihalik JP, Prentice W, Padua D. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. Br J Sports Med. 2010;44(5):376-381.3. McDonnell MK, Sahrmann SA, Van Dillen L. A specific exercise program and modification of postural alignment for treatment of cervicogenic headache: a case report. J Orthop Sports Phys Ther. 2005;35(1):3-15.
4. Ruivo RM, Pezarat-Correia P, Carita AI. Effects of a Resistance and Stretching Training Program on Forward Head and Protracted Shoulder Posture in Adolescents. J Manipulative Physiol Ther. 2017 Jan; 40:1-10.5. Lee M-H, Park S-J, Kim J-S. Effects of neck exercise on highschool students’ neck-shoulder posture. J Phys Ther Sci. 2013;25(5):571-574.
6. Page P. Current concepts in muscle stretching for exercise and rehabilitation. Int J Sports Phys Ther. 2012;7(1):109-119.

forward head posture fix 

flex posture corrector

BEFORE DOING PHYSICAL EXERCISE ... TO STRETCH OR NOT TO STRETCH? ... THAT IS THE QUESTION

The static stretching is held in a stretch of the muscle at rest until a certain position and maintaining the position for 15 - 30 seconds. It is commonly practiced by athletes as part of a routine prior to exercise and as part of a continuous exercise program.

Every weekend I can see that, before a race, a lot of athletes do this type of stretching, which makes me think if I should imitate them or not. With this article I want to scientifically verify if static stretches before physical exercise fulfill the benefits that most people believe they have:

· Improve flexibility,
· Improve physical performance and / or,
· Prevent injuries in the musculotendinous unit.

FLEXIBILITY

There is consistent evidence that static stretching increases flexibility in the short term, although gains in flexibility decrease relatively quickly, so that they are lost in 30 minutes 1-5. But there is also consistent evidence that stretches performed regularly over several weeks produce significant improvements in the range of motion ^6-11.

The mechanism of how this increase in range of motion occurs is subject to debate, which may be changes in neurophysiological factors (for example, changes in the tolerance to stretching) or mechanical factors (for example, viscoelastic changes).

Several studies have shown that static stretching does not change the mechanical properties of the musculotendinous unit ^10,12-18. This would suggest that the increase in range of motion is due to a greater tolerance to stretching, rather than to any mechanical alteration in the tissues.

In summary:
· Static stretching increases flexibility in both the short and long term.
· The mechanism through which static stretching achieves greater flexibility is still debatable. While a greater tolerance to stretching is likely and mechanical changes are very unlikely.

PHYSICAL PERFORMANCE

Effect on explosive strength, power and muscular performance.

Several recent reviews and meta-analyzes ^19-22 have agreed that, static stretching maintained for more than 45 seconds immediately before exercise:

· Influences negatively on maximum strength, power, explosive muscular performance (for example, jumping and running), balance and agility or,

· It has no effect on performance.

In other words, none of the reviews showed a beneficial effect of static stretching on explosive muscle performance.

Effect on endurance performance

The influence of stretching on activities such as running and cycling is less clear. A recent review 23 described how several studies ^24-27 show a negative influence, while others ^23,28-30 show no change in performance. Very few studies 60 report improvements in endurance performance after stretching.

In summary

· Stretching should be avoided for more than 45 seconds immediately prior to participation in activities where strength or power are important, since performance is likely to be reduced without any clear benefit to justify continued use.
· In endurance activities, stretching is difficult to justify immediately before participation, since performance can be reduced without clear benefits that justify continued use.

INJURY PREVENTION

It seems intuitively to make sense that stretching should help prevent injuries or help speed up the return to activity. However, the relationship between the reference flexibility and the future risk of injury is complex, and many studies ^31,32 show that there is no relationship between the two.

In fact, several systematic reviews have evaluated the effect of stretching on the risk of injury ^33-35, concluding that:

- "There is insufficient evidence to support or interrupt routine stretching before or after exercise to avoid injury among competitive or recreational athletes" ³³ and

- "In light of these findings, routine stretching exercises before the start of sports activities are not a proven and effective method to reduce injury rates" ³⁶.

In summary:

· Static stretching does not seem to reduce the risk of injury.

CLINICAL IMPLICATIONS

It is difficult to justify the use of stretching for any of the objectives examined in this article:

· Flexibility: stretching is very effective both in the short and long term. However, flexibility is not as important a factor in performance and injury prevention as was previously thought.

· Short term performance: stretching can decrease performance, especially when performed immediately before explosive activities.

· Injury prevention: there is very little evidence that stretching is effective.

Therefore, the only area in which static stretching seems to offer a specific advantage is in the one with the greatest flexibility. There may be times when the most important goal is to improve flexibility (for example, ballet) by being only in these isolated circumstances in which static stretching may be justifiable.

BIBLIOGRAPHY

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7.            Radford JA, Burns J, Buchbinder R, Landorf KB, Cook C. Does stretching increase ankle dorsiflexion range of motion? A systematic review. Br J Sports Med 2006; 40:870-875.

8.            Bandy WD, Irion JM, Briggler M. The effect of static stretch and dynamic range of motion training on the flexibility of the hamstring muscles. J Orthop Sports Phys Ther 1998; 27:295-300.

9.          Chan SP, Hong Y, Robinson PD. Flexibility and passive resistance of the hamstrings of young adults using two different static stretching protocols. Scand J Med Sci Sports 2001; 11:81-86.

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12.          Halbertsma JP, Goeken LN. Stretching exercises: effect on passive extensibility and stiffness in short hamstrings of healthy subjects. Arch Phys Med Rehabil 1994; 75:976-981.

13.          Klinge K, Magnusson SP, Simonsen EB, Aagaard P, Klausen K, Kjaer M. The effect of strength and flexibility training on skeletal muscle electromyographic activity, stiffness, and viscoelastic stress relaxation response. Am J Sports Med 1997; 25:710-716.

14.          Magnusson SP, Simonsen EB, Aagaard P, Boesen J, Johannsen F, Kjaer M. Determinants of musculoskeletal flexibility: viscoelastic properties, cross‐sectional area, EMG and stretch tolerance. Scand J Med Sci Sports 1997; 7:195-202.

15.          Gajdosik RL, Allred JD, Gabbert HL, Sonsteng BA. A stretching program increases the dynamic passive length and passive resistive properties of the calf muscle-tendon unit of unconditioned younger women. Eur J Appl Physiol 2007; 99:449-454.

16.          Weppler CH, Magnusson SP. Increasing muscle extensibility: a matter of increasing length or modifying sensation? Phys Ther 2010; 90:438-449.

17.          Konrad A, Gad M, Tilp M. Effect of PNF stretching training on the properties of human muscle and tendon structures. Scand J Med Sci Sports 2014.

18.          Ben M, Harvey L. Regular stretch does not increase muscle extensibility: a randomized controlled trial. Scand J Med Sci Sports 2010; 20:136-144.

19.          Behm D, Bambury A, Farrel C, Power K. Effect of acute static stretching on force, balance, reaction time, and movement time. Med Sci Sports Exerc 2004; 36:1397-1402.

20.          Kay AD, Blazevich AJ. Effect of acute static stretch on maximal muscle performance: a systematic review. Med Sci Sports Exerc 2012; 44:154-164.

21.          Simic L, Sarabon N, Markovic G. Does pre‐exercise static stretching inhibit maximal muscular performance? A meta‐analytical review. Scand J Med Sci Sports 2013; 23:131-148.

22.          Winchester JB, Nelson AG, Landin D, Young MA, Schexnayder IC. Static stretching impairs sprint performance in collegiate track and field athletes. J Strength Cond Res 2008; 22:13-18.

23.          Peck E, Chomko G, Gaz DV, Farrell AM. The effects of stretching on performance. Curr Sports Med Rep 2014; 13:179-185.

24.          Wilson JM, Hornbuckle LM, Kim JS, Ugrinowitsch C, Lee S-R, Zourdos MC, et al. Effects of static stretching on energy cost and running endurance performance. J Strength Cond Res 2010; 24:2274-2279.

25.          Lowery RP, Joy JM, Brown LE, Oliveira de Souza E, Wistocki DR, Davis GS, et al. Effects of static stretching on 1-mile uphill run performance. J Strength Cond Res 2014; 28:161-167.

26.          Wolfe AE, Brown LE, Coburn JW, Kersey RD, Bottaro M. Time course of the effects of static stretching on cycling economy. J Strength Cond Res 2011; 25:2980-2984.

27.          Esposito F, Cè E, Limonta E. Cycling efficiency and time to exhaustion are reduced after acute passive stretching administration. Scand J Med Sci Sports 2012; 22:737-745.

28.          Mojock CD, Kim JS, Eccles DW, Panton LB. The effects of static stretching on running economy and endurance performance in female distance runners during treadmill running. J Strength Cond Res 2011; 25:2170-2176.

29.          Hayes PR, Walker A. Pre-exercise stretching does not impact upon running economy. J Strength Cond Res 2007; 21:1227-1232.

30.          Allison SJ, Bailey DM, Folland JP. Prolonged static stretching does not influence running economy despite changes in neuromuscular function. J Sports Sci 2008; 26:1489-1495.

31.          Bennell K, Tully E, Harvey N. Does the toe-touch test predict hamstring injury in Australian Rules footballers? Aust J Physiother 1999; 45:103-109.

32.          Wang HK, Chen CH, Shiang TY, Jan MH, Lin KH. Risk-factor analysis of high school basketball–player ankle injuries: a prospective controlled cohort study evaluating postural sway, ankle strength, and flexibility. Arch Phys Med Rehabil 2006; 87:821-825.

33.          Thacker SB, Gilchrist J, Stroup DF, Kimsey CJ. The impact of stretching on sports injury risk: a systematic review of the literature. Med Sci Sports Exerc 2004; 36:371-378.

34.          Herbert RD, Gabriel M. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. BMJ 2002; 325:468.

35.          Shrier I. Does stretching improve performance? A systematic and critical review of the literature. Clin J Sport Med 2004; 14:267-273.

36.          Schiff MA, Caine DJ, O'Halloran R. Injury prevention in sports. Am J Lifestyle Med 2010; 4:42-64.

stretch

stretch before or after exercise