Lower Back Pain Strategies

Lower Back Pain Strategies by Your Musculoskeletal Specialist Paula Nutting
Mobility – the ability of the musculoskeletal structures or segments of the body to move or be moved to allow the presence of range of notion for functional activities. The ability of an individual to initiate, control or sustain active movements of the body to perform simple to complex motor skills.

Hypomobility – caused by adaptive shortening of soft tissues and can occur as the result of many disorders or situations.
Factors –
prolonged immobilization of a body segment
sedentary lifestyle postural mal-alignment and muscle imbalances
impaired muscle performance (weakness) associated with an array of musculoskeletal or neuromuscular disorders
tissue trauma resulting in inflammation and
pain congenital or acquired deformities.

All these impairments can lead to functional limitations and an increase in injury risk. Remedial massage treatment especially stretching can improve impaired muscle performance or prevent injury as they become an integral component of individualized intervention.

Contracture – is defined as the adaptive shortening of the muscle-tendon unit and other soft tissues that cross or surround a joint, which results in significant resistance to passive or active stretch and limitation of ROM.

Types of contractures
Myostatic Contracture – no specific muscle pathology present. Reduced number but not length of sarcomeres. Can be resolved in a relatively short time with stretching exercises.
Pseudomyostatic Contracture – a constant state of contraction giving excessive resistance to passive stretch. Associated with hypertonicity of spastic or rigid nature - a central nervous system lesion such as CVA, spinal cord injury, traumatic brain injury. Muscle spasm or guarding and pain may cause a pseudomyostatic contracture. Inhibition procedures to temporarily relax the spasm or tonicity will allow full, passive elongation of the muscle to occur.
Arthrogenic and Periarticular Contractures – intra-articular pathology including adhesion, synovial proliferation, joint effusion, irregularities in articular cartilage, or osteophyte formation. Connective tissues that cross or attach to a joint or it’s capsule become stiff, this reduces normal arthrokinematic motion.
Fibrotic Contracture and Irreversible Contracture – these can cause adhesions and development of fibrotic contractures. It is possible to stretch fibrotic contractures and eventually increase ROM, it is very difficult to re-establish optimal tissue length.

Stretching is a general term used to describe any therapeutic manoeuvre designed to increase mobility of soft tissue and subsequently improve ROM by elongating structures that have adaptively shortened and have become hypomobile over time.

Physiology of the Stretch Reflex
It is a monosynaptic reflex arc, two types of neurons are involved (sensory and motor). The reflex occurs when a sudden contraction of a muscle occurs. Slight stretching of a muscle stimulates receptors in the muscle – muscle spindles – these spindles monitor changes in muscle length. The stretch reflex operates as a feedback mechanism to control muscle length by causing muscle contraction.

Physiology of the Tendon Reflex
The tendon reflex operates as a feedback mechanism to control muscle tension by causing muscle relaxation. It protects tendons and their associated muscles from excessive tension. Receptors called Golgi tendon organs detect and respond to changes in muscle tension caused by passive stretch or muscular contraction. When tension is applied to the organ nerve impulses are generated along a sensory neuron, this synapses with and inhibits a motor neuron that innervates the muscle associated with the tendon organ. As tension increases, and the inhibitory impulses increase, the inhibition of the motor neurons to the muscle creates excess tension and causes relaxation of the muscle. It is a protective mechanism to reduce muscle damage due to excessive tension.

Indications for Use of Stretching

When ROM is limited because ST have lost their extensibility as the result of adhesions, contractures, and scar tissue formation, causing functional limitations or disabilities.
When restricted motion may lead to structural deformities otherwise preventable
When there is muscle weakness and shortening of opposing tissue
As part of a total fitness program designed to prevent musculoskeletal injuries
Prior to and after vigorous exercise to potentially minimize post-exercise muscle soreness.

Contraindications to Stretching
When a bony block limits joint motion
After a recent fracture before union is complete
Whenever there is evidence of an acute inflammatory or infectious process (heat & swelling) or when soft tissue healing could be disrupted in the tight tissues and surrounding region
Whenever a haematoma or other indication of tissue trauma is observed
When hypermobility already exists
When contractures or shortened soft tissues are providing increased joint stability in lieu of normal structural stability or neuromuscular control
When contractures or shortened soft tissues are the basis for increased functional abilities, particularly in patients with paralysis or severs muscle weakness.

Types of stretching

Passive or assisted – sustained or intermittent external, end-range stretch force applied with overpressure elongates a shortened muscle-tendon unit and periarticular connective tissues by moving a restricted joint just past the available ROM. If patient relaxed it is Passive stretching. If the patient assists in moving the joint through a greater range it is assisted.

Self-stretching – (aka active stretching, flexibility exercises) independent stretching carried out after instruction and supervision

Neuromuscular Inhibition Techniques – ( aka PNF or facilitated stretching) reflexively relax tension in shortened muscles prior to or during stretching. MET used to stretch muscles and fascia and mobilize joints

Joint mobilization/manipulation – stretching techniques specifically applied to joint structures and used to stretch capsular restrictions or reposition a subluxed or dislocated joint.

Soft Tissue Mobilization and Manipulation – friction massage, myofascial release, acupressure and TP Therapy. Mobilize and manipulate connective tissue that binds down soft tissues

Neural Tissue mobilization – the Neural pathway is mobilized to release adhesions or scar tissue form around meninges, nerve roots, plexus or peripheral nerves.

Elements of stretching

Include alignment and stabilization. Intensity, speed, duration, frequency and mode of stretch; and the integration of neuromuscular inhibition and functional activities into stretching procedures.

Effect of poor Postural Support from Trunk Muscles – with total relaxation of the dynamic stabilizer muscles – the multifidus, rotatores, TA, internal obliques, and QL, the spinal curves become exaggerated and passive structural support is called on to maintain the posture. When there is continued end-range loading supporting tissues become more vulnerable to injury. Continued exaggeration of the curves leads to impaired muscle strength and flexibility. Muscles habitually kept in stretch tend to test weaker because of a shift in the length-tension curve – stretch weakness. Muscles kept in a habitually shortened position tend to lose their elasticity, they are strong only in the shortened position but become weak as they are lengthened – tight weakness.

Lateral shift correction

If the patient has lateral shifting of the spine, it should be corrected prior to flexion extension treatment for lower back pain.

Lateral shift correction when extension relieves discomfort – standing on the side of the thoracic shift with the therapists hands clasped around the contralateral iliac crest and the shoulder against the patients elbow. Simultaneously pull the pelvis towards you while pushing the patient’s thorax away. Continue with the lateral shifting if the curvature is reduced until normal curve is present.

Lateral shift correction when flexion relieves discomfort – self-correction – standing whit the leg opposite the shift on a chair so the hip is in about 90 degrees of flexion. The leg on the side of the lateral shift is kept extended. Have the patient then flex the trunk onto the raised thigh and apply pressure by pulling on the ankle. Recheck the alignment and continue till pain reduction is greatest.

Exercise techniques and stretches to increase flexibility and ROM

Muscle strength or flexibility imbalance in the hip can lead to abnormal lumbopelvic and hip mechanics, which predisposes the patient to or perpetuates low back, sacroiliac or hip pain..
To increase hip extension – prone press ups; Thomas test stretch; modified fencer stretch
To increase hip flexion – bilateral knee to chest; unilateral knee to chest; Quadruped stretch; Chair (airline) stretch
To increase hip abduction – V lying against wall knees extended butt against wall
To increase hip abd & external rotation – sitting with soles of feet together hands on inner surface of the knees.

Lumbar stretching techniques

Increase lumbar flexion

Assisted stretching – cross-sitting. Patient lace the hands behind the neck, adduct the scapulae, and extend the thoracic spine. This locks the thoracic vertebrae. Have the patient then lean the thorax forward onto the pelvis, flexing only at the lumbar spine. Stabilize the pelvis by pulling back on the anterior-superior iliac spines.

Increase lumbar extension

Prone press-up (Self-stretching) – Prone, with hands placed under the shoulders. Patient to extend to elbows and lift the thorax up off the mat keeping the pelvis down. To increase the stretch force, the pelvis can be strapped to the treatment table, this exercise also stretches the hip flexor muscles and soft tissue anterior to the hip.

Increase Lateral Flexibility in the Spine

Used when there is asymmetric flexibility in side bending as well as in the management of scoliosis. They are used to regain flexibility in the frontal plane when muscle or fascial tightness is present with postural dysfunctions, designed to stretch hypomobile structures on the concave side of the lateral curvature. When stretching the trunk, it is necessary to stabilize the spine either above or below the curve.

Prone-Lumbar curve – have the patient stabilize the upper trunk by holding onto the edge of the mat table with the arms. Therapist lifts the hips and legs and laterally bends the trunk away for the concavity.

Heel-sitting – Patient leans forward so the abdomen rests on the anterior thighs. The arms are stretched overhead bilaterally, and the hands are flat on the table. Then have the patient laterally bend the trunk away from the concavity by walking the hands to the convex side of the curve.

Neural Tension Impairments

If positive nerve tension signs are described by the patient while providing the history and positive signs are detected with testing maneuvers, techniques that are reported to mobilize components of the nervous system may be used to diminish the patient’s symptoms.

Straight Leg Raise with Ankle Dorsiflexion – Once the position that places tension on the involved neurologic tissue is found, maintain the stretch position, and then move one of the joints a few degrees in and out of the stretch position, such as ankle plantar and dorsiflexion, or knee flexion and extension.
Ankle dorsiflexion with eversion places more tension on the tibial tract
Ankle dorsiflexion with inversion places tension on the sural nerve
Ankle plantarflexion with inversion places tension on the common peroneal tract
Adduction of the hip while doing SLR places further tension on the nervous system because the sciatic nerve is lateral to the ischial tuberosity; medial rotation of the hip while doing SLR also increases tension on the sciatic nerve
Passive neck flexion while doing SLR pulls the spinal cord cranially and places the entire nervous system on a stretch.

Slump-sitting Stretch – dorsiflex the ankle just to the point of tissue resistance and symptom reproduction. Increase and release the stretch force by moving one joint in the chain a few degrees, such as knee flexion and extension, or ankle dorsiflexion and plantarflexion.

Prone Knee Bend Stretch – Prone neutral spine, pillow under treatment knee, and hips extended to 0 degrees. Flex knee to the point of resistance and symptom reproduction. Pain in the low back or neurological signs are considered positive for upper lumbar nerve roots and femoral nerve tension. Thigh pain could be rectus femoris tightness. It is important not to hyperextend the spine to avoid confusion with facet or compression pain. Flex and extend the knee a few degrees to apply and release tension.

Duration of stretch

Despite extensive research there continues to be a lack of agreement on how long a single cycle of stretch should be held or how many cycles of stretch should be applied to achieve the most effective, efficient, and sustained stretch-induced gains in ROM.
Duration most often refers to how long a single cycle of stretch is applied
More than one repetition of stretch is referred as a stretch cycle and the cumulative time of all the stretch cycles is considered as aspect of duration.
Long-duration referred to as static, sustained, maintained, prolonged
Short term referred as cyclic, intermittent or ballistic.

Types of stretches

Static – most common term used to describe soft tissue lengthening. The duration 15 sec to several minutes when manual stretch or self-stretching employed.

Research shows static stretching is approx half that created during ballistic stretching.

Static Progressive stretching - Static stretch held until a degree of relaxation is felt by the therapist then lengthened further until a news end-range is felt. This capitalizes on the stress-relaxation properties of soft tissue.

Cyclic Stretching – short duration stretch forces that are repeatedly but gradually applied, released and then re-applied. Multiple stretches in a single treatment session. Held for 5-10 seconds but with no consensus on the optimum number of cycles in the treatment. Based on clinical experience, some therapists hold the opinion that end-range cyclic stretching is as effective and more comfortable for a patient than a static stretch.

Frequency of stretch – number of bouts per day or per week. Dependant upon -underlying cause
Quality and level of healing
The chronicity and severity of contracture
Patients age
Use of corticosteroids
Previous response to stretch

Usually form two to five sessions for tissue healing and to minimize postexercise soreness. Ultimately dependant upon the clinical discretion of the therapist. Whatever frequency is decided upon the patient must utilize the new end-of-range into everyday tasks otherwise the connective tissue will return to the pre-stretched position.

Neuromuscular Inhibition and Muscle Elongation

Inhibition techniques increase muscle length by relaxing and elongating the contractile components of muscle. The sarcomere give will occur more easily when the muscle is relaxed, with less active resistance in the muscle as it is elongated. An advantage to the use of inhibition techniques prior to or during stretching is that muscle elongation is more comfortable for the patient.

Types – Hold-relax or contract relax
- Agonist contraction
- Hold-relax with agonist contraction.

Stretch isolated muscles in their anatomic planes or opposite the line of pull of specific muscle groups rather than in combined diagonal patterns.

HR – prestretch, end-range, isometric contraction 10 sec followed by voluntary relaxation of the tight muscle. Then the limb is passively moved into its new range as the range limiting muscle is elongated.

AC – Deliberate and slow, concentric contraction of the muscle opposite the range limiting muscle. This causes reciprocal inhibition of the antagonist, and increases ROM.

HR with AC – use of a pre-stretch isometric contraction of the range limiting muscle in a lengthened position followed by a concentric contraction of the muscle opposite the range-limiting muscle.
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