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TSI Summit 2008: Session #606 The Mechanics of Low Back Pain and Corrective Solutions

Eric Beard Senior Master Instructor National Academy of Sports Medicine eric.beard@nasm.org www.nasm.org

Description
Eighty percent of adults suffer from back pain. This means that everyone has at least one client whose back pain limits their ability to exercise or perform in athletics successfully. Given this statistic, will you have the right strategy to keep your client moving pain-free? This presentation will cover the functional anatomy of the lumbopelvic-hip complex as well as teach you how to become proficient in performing assessments for the low back. You will learn how to utilize the exercises, programs and tools to implement corrective strategies for low back impairments, as well as how to market your abilities in a clinic or health and fitness facility. Topic: Personal Training Level: Intermediate Type: Lecture

Objectives
Explore possible etiologies of back pain Conduct an anatomical review Introduce movement assessments Identify common movement system impairments that lead to and/or accompany back pain Present a systematic process to restore muscular balance and optimal movement system function

What Can Cause Back Pain?


Congenital conditions
Scoliosis Kyphosis

Physical trauma
Car accidents Falls Sports injuries

Cancer Abdominal aneurysm IBS Infection


Meningitis

Stress Degenerative conditions


Arthritis Disc disease

Fibromyalgia Hormonal conditions Repetitive movements And more Also poor posture due to

21st Century Living

Work?

Home?

Play?

Results = Imbalances

Effects of Poor Posture


Sets the body up for Postural Distortion Patterns.
Predictable patterns of muscle imbalance Short/Tight Muscle Lengthened/ Weak Muscle
Feels tight, is lengthened Feels tight, is shortened

MUSCLE IMBALANCE

American Pain Foundation

76.2 20.8 18.7 1.4 million respectively Pain affects more Americans than Diabetes, Coronary Heart Disease and Stroke, and Cancer combined The annual cost of chronic pain in the US is estimated to be $100 billion ($100,000,000,000)

American Pain Foundation


1) Low back pain 27% 2) Severe Headache/ Migraine 15% 3) Neck Pain 15% 4) Facial/TMJ pain 4%

More Good News


Of the 8/10 people in the U.S. who will experience back pain
50% of those people will experience recurring bouts of low back pain To say it another way 4/10 people in the US will have recurring back pain 1 in 4 suffered a day long bout of back pain in the last month 1 in 10 say the pain lasted at least for one full year

US Overworked
According to studies Americans work the longest hours among industrialized countries of the white collar workers log more than 50 hours per week More than 405 million business trips are taken each year in the U.S. 42% of Americans are working more hours now than five years ago

Low Back Statistics


2nd most common reason for a doctors visit 3rd most common reason for surgery 5th most common reason for hospitalization Highest rate of occurrence 45 to 64 years of age

Low Back Statistics


Only 5% of those with back pain have a demonstrated specific cause Less than 1-2% actually have a pinched nerve (*this actually a fabricated diagnosis, it does not really happen) A bulging or herniated disc is common over the age of 45 but is typcially asyomtomatic

Acute vs. Chronic Back Pain


ACUTE Initial onset of pain Spontaneous resolution in 2-4 weeks for 90% of patients. People can have Acute on Chronic exacerbations of pain that act like first onset

CHRONIC
Back pain that does not resolve within 3 months Pain that partially improves, but never completely goes away The baseline pain from which people experience exacerbations

How Do People Deal With Pain?

What does that cost the nation in productivity?

What do we know?
Chronic pain is at an all time high In a cross-sectional study of 100 patients (Cibulka) demonstrated unilateral hip rotation ROM asymmetry in patients with SI joint regional pain Hodges and Richardson 1998 reported that slow speed of contraction of the transverse abdominus during arm and leg movements was well correlated with LBP OSullivan et al 1997 found that synergist substitution of the rectus abdominus for the agonist transverse abdominus during the abdominal drawing-in maneuver suggesting less efficient intersegmental stabilizing mechanisms and greater shear forces at the inter-vertebral joints Hides et al 1994 demonstrated unilateral atrophy of the multifidus in patients with low back pain

Lets Take a Quick Look Inside

Breakfast, Lunch and Dinner

7, 12, 5

When Things Go South

The millions and millions

Movement Assessments

The Kinetic Chain


The Human Movement System is made up of the nervous, muscular and skeletal system.

Nervous System

Muscular System

Skeletal System

Posture is the alignment and function of the human movement system.

Importance of Posture
Proper posture:
Length-tension relationships Force couples and joint motion

Neuromuscular Efficiency
Ability of the nervous system to properly recruit all muscles in all planes of motion.

Movement Assessments
Overhead Squat
A two-legged squat performed with:
the arms held overhead

From a bilateral standing posture assesses:


total body structural alignment, dynamic flexibility, and neuromuscular control

Squatting requires:
optimal motion in the ankles, knees, and hips.

Having the arms elevated overhead:


stresses the musculature surrounding the shoulder complex increases the demand placed upon the core stabilizing muscles

LPHC: Low Back Arches

Ideal

Compensation

Low Back Arches: Take notice of the area from approximately the mid back through the Sacral Complex. If the area is arched then this area will appear with an excessive lumbar or convex curve.

LPHC: Low Back Arches Overactive Muscles

Hip Flexor Complex

Erector Spinae

Latissimus Dorsi

Iliopsoas (Psoas major + Iliacus)


Origin:
transverse processes and bodies of L1-L4, ilium

Insertion:
lesser trochanter of femur

Concentric Actions:
hip flexion, external rotation, spinal extension (Bilateral), lateral flexion and flexion (Unilateral)

Hip Flexors (Rectus Femoris)


Origin:
anterior inferior iliac spine (ASIS)

Insertion:
tibial tuberosity by way of the patellar tendon

Concentric Actions:
knee extension, hip flexion

Tensor Fascia Latae / Iliotibial Band


Origin:
illiac crest, posterior to the ASIS

Insertion:
lateral aspect of tibia via the ITB

Concentric Actions:
open chain-hip flexion, aBduction, internal rotation closed chain changes to hip aDduction and external rotation of tibia

Erector Spinae (Iliocostalis)


Attachments:
ilium, sacrum (TLF) spinous and transverse processes of lumbar, thoracic, and cervical vertebrae; ribs 1-12 and mastoid process

Concentric Actions:
extension, rotation and lateral flexion of the spine

Latissimus Dorsi
Origin:
Sacrum via the thoracolumbar-fascia, iliac crest; lumbar vertebrae, spine of T6T12, lower three or four ribs, inferior angle of scapula

Insertion:
medial lip of the inter-tubercle groove of the humerus

Concentric Actions:
adduction, extension and internal rotation of the humerus

LPHC: Low Back Arches Underactive Muscles

Abdominal Complex

Gluteus Maximus

Hamstrings

Transverse Abdominus
Origin: thoracolumbar fascia, cartilage of the last six ribs and iliac crest Insertion: linea alba, pubic crest Concentric actions: increases intraabdominal pressure and supports abdominal viscera

Abdominal Complex (Rectus Abdominus)


Attachments points:
various aspects of the pelvis and the ribcage

Concentric Actions:
flexion, rotation, lateral flexion of the spine and posterior rotation of the pelvis

Gluteus Maximus
Origin:
iliac crest, sacrum, coccyx, and the sacrotuberous and sacroiliac ligaments

Insertion:
ITB and gluteal tuberosity of the femur

Concentric Actions:
hip extension, abduction, and external rotation

Hamstring Complex
Origin:
ischial tuberosity and linea aspera of femur

Insertion:
tibia and fibula

Concentric Actions:
knee flexion, hip extension, posterior rotation of pelvis, rotation of the tibia

Return the Body to Normal Alignment

Corrective Exercise Strategy

Integrate

Activate

Lengthen

Inhibit

Plan of Action
Corrective Exercise Continuum

Inhibit
Inhibitory Techniques

Lengthen
Lengthening Techniques

Activate
Activation Techniques

Integrate
Integration Techniques

Self Myofascial Release

Static Stretching Neuromuscular Stretching

Positional Isometrics Isolated Strengthening

Integrated Dynamic Movement

Inhibit: Self Myofascial Release


Pressure (tension) stimulates GTO
Inhibits Muscle Spindle

Allows for optimal tissue lengthening Slow steady roll and static 30-sec. hold can work

Inhibit: Self Myofascial Release


Contraindications for Self Myofascial Release
Malignancy Osteoporosis Osteomyelitis (infection of bone tissue) Phlebitis (infection of superficial veins) Cellulitis (infection of soft tissue) Acute rheumatoid arthritis Blood clot Goiter (enlarged thyroid) Eczema and other skin lesions Open wounds Healing fractures Obstructive edema Advanced diabetes Hematoma or systemic/ localized infection

Inhibit

Lengthen: Static Stretching


Static stretching may produce both mechanical and neural adaptations that result in increased ROM Isometric hold for 3060sec

Lengthen

Activate: Isolated Strengthening


Develops:
Intra-muscular coordination Local muscular endurance Local metabolic efficiency

Not intended for hypertrophy of muscles

Activate

Integrate: Dynamic Movement


Enhances:
functional capacity of the human movement system by increasing multiplanar neuromuscular control

Improves intermuscular coordination

Integrate

Intervertebral vs. Lumbo-pelvic Stabilizers


Intervertebral Stabilizers
Local musculature
Transverse Abdominus Multifidus Pelvic Floor Diaphragm

Lumbopelvic Stabilizers
Global musculature
External Oblique Internal Oblique Quadratus Lumborum

Techniques to Facilitate Deep Core-Intervertebral Stabilizers


Abdominal Drawing-In
Facilitates contraction of the Local Stabilizers Also, facilitates contraction of the diaphragm and pelvic floor musculature Exercise to promote intervertebral stability Under utilized stability training Must come first!

Techniques to Facilitate Dynamic Lumbo-Pelvic Stabilizers


Abdominal Bracing
Facilitates contraction of the Global Stabilizers Exercise to promote lumbopelvic stability Over-utilized strength training Important, but should be done second to drawing-in maneuver

Spine Stability = Intervertebral Stability + Lumbopelvic Stability

Hodges Model
Focuses on intervertebral stability

McGill Model
Focuses on lumbopelvic stability

Core Stabilization Exercises

Keep pelvis and spine neutral, abdominals gently engaged, hold static or lift and lower slowly 10-20 reps, rest, repeat

Core Stabilization Exercises

Keep pelvis and spine neutral, abdominals gently engaged, hold static or lift and lower slowly 10-20 reps, rest, repeat

Core Strength Exercises

8-12 reps with control, flex, extend and rotate the spine and hips as needed

Core Strength/Power Exercises

8-12 reps as fast as you can safely control

Comprehensive Treatment and Prevention


See a licensed medical professional if you have active pain, chronic pain, referred symptoms etc. Chiropractic Physical Therapy Acupuncture Therapeutic Massage Therapeutic Modalities
Ice, heat, cold laser, TENs, ultrasound and more

Regular (specific) physical activity!!!

Summary
Anatomical review of LPHC Rationale for CEx Detailed Movement Assessments
Help identify movement compensation Will increase your value as a fitness professional

NASM CEx process

Thank You!

Eric Beard Senior Master Instructor National Academy of Sports Medicine eric.beard@nasm.org www.nasm.org

References
[1] Porterfield JA, DeRosa C. Mechanical low back pain. 2nd edition. Philadelphia, PA: W.B. Saunders; 1998. [2]Richardson C, Jull G, Hodges P, Hides J. Therapeutic exercise for spinal segmental stabilization in low back pain. London: Churchill Livingstone; 1999. [3]Gracovetsky S, Farfan H. The optimum spine. Spine 1986; 11:543-73. [4]Gracovetsky S, Farfan H, Heuller C. The abdominal mechanism. Spine 1985; 10:317-24. [5]]Panjabi MM: The stabilizing system of the spine. Part I: Function, dysfunction, adaptation, and enhancement. J Spinal Disord 1992; 5:383-9. [6]Hodges PW, Richardson CA. Feedforward contraction of transverse abdominis is not influenced by the direction of arm movement. Exp Brain Res 1997; 114:62-70. [7]Hodges PW, Richardson CA. Relationship between limb movement speed and associated contraction of the trunk muscles. Ergonomics 1907; 40:1220-30. [8]Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Ortho Scand 1989; 230(Suppl):20-4. [9]Crisco J, Panjabi MM: The intersegmental and multisegmental muscles of the lumbar spine. Spine 1991; 16:793-99. [10] Clark MA. Integrated training for the new millennium. Thousand Oaks, CA: National Academy of Sports Medicine; 2001.

References
[11] Clark MA. Integrated core stabilzation training. Thousand Oaks, CA: National Academy of Sports Medicine; 2001. [12] Hodges PW, Richardson CA. Neuromotor dysfunction of the trunk musculature in low back pain patients. In: Proceedings of the international congress of the world confederation of physical therapists. Washington, DC; 1995. [13] Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. Spine 1996;21(22):2640-50. [14] Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther 1997;77:132-4. [15] Hodges PW, Richardson CA, Jull G. Evaluation of the relationship between laboratory and clinical tests of transverse abdominus function. Physiother Res Int 1996;1:30-40. [16] OSullivan PE, Twomey L, Allison G, Sinclair J, Miller K, Knox J. Altered patterns of abdominal muscle activation in patients with chronic low back pain. Aus J Physiother 1997;43(2):91-8. [17] Richardson CA, Jull G. Muscle controlpain control. what exercises would you prescribe? Man Med;1:2-10, 195. [18] Ashmen KJ, Swanik CB, Lephart SM. Strength and flexibility characteristics of athletes with chronic low back pain. J Sports Rehab 1996;5:275-86. [19] Beim G, Giraldo JL, Pincivero DM, Borror MJ, Fu FH. Abdominal strengthening exercises: a comparative EMG study. J Sports Rehab 1997;6:11-20. [20] Nachemson A. The load on the lumbar discs in different positions of the body. Clin Orthoped 1966;122. [21] Norris CM. Abdominal muscle training in sports. Br J Sports Med 1993;7(1):19-27.

References
22. Neumann DA. Kinesiology of the musculoskeletal system: Foundations for physical rehabilitation. St. Louis: Mosby; 2002. 23. Janda V. Muscles and cervicogenic pain syndromes. In: Grant R., editor.Physical therapy of the cervical and thoracic spine. New York: Churchill Livingstone; 1988. p. 153-66. 24. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby, Inc.; 2002. 25. Clark M., Corn R., Lucett, S., Corrective Exercise Strategy for Lumbo-Pelvic-Hip Complex (LPHC) Impairment, First Edition, NASM; 2005 26. NASM Research Institute at UNC, A Review of Core Literature and Concepts; 2008-06-12