LOW BACK PAIN: KINESIOLOGICAL CONSIDERATIONS IN PRESCRIPTION OF THERAPEUTIC EXERCISE IN PREVENTION AND REHABILITATION

Size: px

Start display at page:

Download "LOW BACK PAIN: KINESIOLOGICAL CONSIDERATIONS IN PRESCRIPTION OF THERAPEUTIC EXERCISE IN PREVENTION AND REHABILITATION"

Alban Green
5 years ago
Views:

1 LOW BACK PAIN: KINESIOLOGICAL CONSIDERATIONS IN PRESCRIPTION OF THERAPEUTIC EXERCISE IN PREVENTION AND REHABILITATION Dr. V.D. Bindal Associate Professor, LNIPE (Deemed University), Gwalior, M.P, India ABSTRACT The author examines some of the exercises and activities from Kinesiological point of view that are most commonly used for improving low back fitness, or rehabilitating low back pain. Importance of abdominal muscle-strength and their proper exercises, errors in exercises imparted to improve trunk-flexibility, jogging posture, pressure on lumbar discs in different positions, and certain often overlooked therapeutic exercises in low back programme are highlighted. There is a need for the coaches, physical educators, and therapists to consider these aspects while suggesting exercises and activities to the athletes who are susceptible to develop low back pain, or are already suffering from it. Key Words: Therapeutic Exercise, Prevention and Rehabilitation. INTRODUCTION: Low back pain is a very common problem affecting the general population and the athletes alike. The athletes are more prone to low back problems because of repeated movements of bending, twisting, and jumping that stress the lumbosacral spine. Athletes most at risk for developing low back pain are those participating in football, hockey, gymnastics, volleyball, basketball, track and field etc. Low back pain appears to be multifaceted, related to combination of mechanical, neurophysiological, and psychological factors. There are several factors that may contribute to low back pain, including muscular deficiencies (specifically insufficient abdominal strength and trunk flexibility), incorrect posture, and body mechanics. There is ample literature placing due importance on the role of muscle-strength, flexibility, and body mechanics in preventing or remediating low back problems. QUARTERLY ONLINE INDEXED DOUBLE BLIND PEER REVIEWED 19

2 According to Geraci et al. (2005), decreased lumbar extension, increased lumbar flexion, and decreased muscle endurance of the abdominal and back muscles are considered possible risk factors for developing lower back pain. The training errors, and poor spinal mechanics for lifting are also some of the more common precipitating factors in increasing the risk of low back pain among the athletes. With regard to low back functioning, whether it is conditioning exercises imparted for improving low back fitness or for treating low back problems or otherwise, it needs to be seen whether recommended exercises are really conducive to low back functioning, or if they possibly exacerbate back pain and injury in susceptible individuals. A wide variety of different trunk exercises are currently used for training and conditioning purpose, both in athletic programmes (sports and fitness), and in rehabilitation practice (low back pain patients). While prescribing exercises to the youth and adults for prevention as well as rehabilitation of low back pain, certain kinesiological aspects pertaining to the lower back are discussed below so that these exercises can be done safely, as improper exercises sometimes can do harm to the individuals rather than doing them any benefit. ABDOMINAL MUSCULAR STRENGTH: Strong abdominal muscles play a very important role in protecting the lumbar spine, where as weak abdominal musculature has been found to be an important risk indicator for low back pain ( Biering-Sorensen, 1984). According to Farfan (1975), strong abdominal muscles help prevent excessive anterior pelvic tilt, a postural condition often associated with low back pain; furthermore, in forward bending and lifting postures, abdominal muscular tension can reinforce the trunk and reduce the load placed on the musculoskeletal system of the back. STRENGTHENING EXERCISES FOR ABDOMINAL MUSCLES: There are many different exercises that have been used to strengthen the abdominal muscles. However, there are some exercises having drawbacks, and are discussed here. Once upon a time, Straight-Leg-Sit-Up (SLSU) and, Bilateral Straight-Leg-Lift (BSLL) were very popular abdominal muscle strengthening exercises, but have now been almost eliminated from physical QUARTERLY ONLINE INDEXED DOUBLE BLIND PEER REVIEWED 20

3 fitness programmes because, i. the Psoas and other hip flexors assume a major role in these exercises and ii. low back problems may be intensified by the increased flexor activity (Mutoh et. al., 1981). During these exercises, the pull of the psoas on the lumbar vertebrae tends to cause hyperextension in the lower back. If the abdominal muscles are of sufficient strength, they can counteract the forceful contraction of the psoas muscle and control this hyper extension. Therefore, for the individuals with insufficient abdominal strength, these exercises may precipitate or aggravate low back problems. However, when one is in a supine position with flexion at the knee and hip joints, the psoas muscle is not in a lengthened state and, therefore its tendency to cause hyperextension of the lower back can be decreased, and because of this reason Flexed Leg-Sit-Up (FLSU) has become a more popular exercise. Robertson et. al. (1986) have found partial trunk curls (in which just the scapulae are raised from the exercise surface) just as effective as full sit ups in terms of use of abdominal musculature. Partial trunk curls, o n one hand maximize abdominal muscle activity, on the other hand, involvement of psoas and other hip flexors is minimized as the range of movement is reduced at least by fifty percent. TRUNK-FLEXIBILITY: Extensibility in the posterior thighs (i.e., the hamstrings muscle group) and lower back are also considered important factors in low back functioning. A tight lower back and/or hamstrings will impair trunk flexion range of motion and may contribute to low back problems. The Standing- Toe-Touch, once a very popular exercise for improving trunk and hamstring flexibility, has been found to be a potentially damaging exercise to the low back. Sitting-Toe- Touch, also called Sitand-Reach is also often recommended for increasing trunk range of motion and, is sometimes used as an indicator of low back functioning. Although, the Sit-and-Reach exercise has fewer drawbacks than the Standing Toe-Touch, there are certain factors that should be considered. Primarily, this exercise is used to improve hamstring extensibility; however, it could overstretch the lower back without lengthening the hamstrings (Cailliet, 1981) and could increase the risk of low back pain. However, unilateral hamstring stretch is recommended rather than stretching both hamstrings simultaneously, to protect the back. QUARTERLY ONLINE INDEXED DOUBLE BLIND PEER REVIEWED 21

4 Using Sit-and-Reach as a test of low back functioning can sometimes give false interpretation. This test measures the flexibility of multiple joints and structures (i.e., low back and hamstrings), and hyperflexibility in one area may mask inflexibility in another area (Sharpe & Liemohn, 1986). This test is also not suitable for obese people as excessive adipose tissue in the abdominal and thigh area may give a false impression of lack of flexibility. POSTURAL CONSIDERATIONS IN JOGGING: Jogging as an activity is one of the most cost efficient ways to burn calories and, is increasingly practised now a days by the health conscious people. However, there are contradictory findings about jogging with respect to its bearing on low back pain. Low back pain is sometimes attributed to the constant pounding from jogging, particularly on non-resilient surfaces. Moreover, jogging has been declared to be an inappropriate activity for individuals susceptible to low back pain (Williams, 1974). Whereas in contradiction to this, White (1986) believes that jogging is more apt to protect one from back pain as it improves strength and endurance of the postural muscles. However, White gives important considerations of how and where one runs. According to Bach et. al. (1985), an upright posture with avoidance of a tendency to lean forward while jogging may help prevent or relieve low back trouble in runners. This recommendation is also supported by the biomechanical research of Cappozzo (1983) who found that, while running, forces on the lumbar spine increased markedly as a function of forward leaning. Since, jogging is one of the most enjoyable, calories burning activity, its altogether complete exclusion as an activity for all individuals susceptible to low back pain is not appropriate. However, with due regard given to certain factors i.e., running surface, foot-wear, acuteness of low back pain and, jogging posture, jogging could be considered as an activity to prevent low back problems for most of the people and, an appropriate activity for some individuals with low back pain. QUARTERLY ONLINE INDEXED DOUBLE BLIND PEER REVIEWED 22

5 PRESSURE ON LUMBAR DISCS: In activities and exercises, the pressure on lumbar discs is an important factor to consider while selecting them. Pressure on disc varies tremendously with alterations in posture. For example, the pressure on third lumbar (L3) disc is minimum in supine lying, which increases progressively as one moves to standing to sitting to forward bending postures (Nachemson, 1987). Many seemingly mild exercises and activities, such as arm exercises in the supine position, and unsupported sitting, create greater pressures on the discs than occurring while standing. Therefore, this aspect should be kept in the mind while designing or selecting exercises for an individual who is susceptible to suffer from low back pain. THERAPEUTIC EXERCISE: There are many types of therapeutic exercise interventions available for preventing a nd treating low back pain, and some may oppose another s treatment philosophy. It is believed that flexion exercises to low back region widen intervertebral foramina and decrease pressure within the affected disc, whereas the extension exercises cause approximation of facet joints. Therefore, these type of exercises may be included or excluded in one s programme in accordance with any existing pathology, or his susceptibility for particular symptom that may be improved or aggravated with the exercises selected. It is very common to include spinal stabilization exercises in both injury prevention and rehabilitation programmes of low back pain. Most of the programmes emphasize strengthening the erector spine, rectus abdominis, and the external oblique muscles for achieving pain free function of the spine. Some of the muscles that provide primary stabilization to the lumbar spine i.e., transverse abdominis and internal obliques are often overlooked in traditional injury prevention and rehabilitation programmes, and therefore appropriate exercises for these muscles should be included to enhance the success rate in remediating low back problems (Peterson, 2003). Most of the stretching and strengthening exercises should be performed in the mid range by those having low back pain, particularly in the acute and subacute phases (Geraci, 2005). QUARTERLY ONLINE INDEXED DOUBLE BLIND PEER REVIEWED 23

6 The function of gluteus maximus muscle is of great importance in both rehabilitation and prevention of lumbar spine pathology, as it plays a significant role in transferring forces from the lower extremity up toward the spine during sport. Its insufficiency may result in abnormal stresses being placed on lower back region and can manifest itself in further injury or incomplete rehabilitation. Therefore, it needs to be taken care of during rehabilitation or conditioning programme. CONCLUSION: A detailed and proper assessment of each individual athlete is very essential before prescribing him exercises for conditioning, or preventing and rehabilitating low back problem. It must be noted that no single muscle or muscle-group alone is responsible for stability of the lower spine and therefore, multiple exercises and activities to improve trunk muscles and flexibility as appropriate to that sport should be selected, with due regard paid to the kinesiological factors as applicable. References Bach, D.K., Green, D.S., Jensen, G.M., & Savinar, E. (1985), A Comparison of muscular tightness in runners and non-runners and the relation of muscular tightness to low back pain in runners. Journal of Orthopaedic and Sports Physical Therapy, 6, Biering Sorensen, F. (1984), Physical Measurements as Risk indicators for low-back trouble over a one year period. Spine, 9, Cailliet, R., Low back pain syndrome, Philadelphia, F.A. Davis Co. (1981). Cappozzo, A. (1983), Force actions in the human trunk during running. Journal of Sports Medicine, 23, Farfan, H.F. (1975), Muscular mechanism of the Lumbar Spine and the Position of Power and efficiency. Orthopaedic Clinics of North America, 6(1), Geraci, M.C. (2005), Low back pain in Adolescent Athletes: Diagnosis, Rehabilitation, and Prevention. Athletic Therapy Today, 10(5), Konrad, P. et. al. (2001), Neuromuscular evaluation of Trunk Training exercises. Journal of Athletic Training, 36 (2), Mutoh, Y. et. al. (1981), The relation between Sit up exercises and the occurrence of low back pain. International series on Biomechanics, VIII A, Nachemson, A., Lumbar intradiscal pressure. The Lumbar Spine and Back Pain. Churchill Livingstone, London (1987). QUARTERLY ONLINE INDEXED DOUBLE BLIND PEER REVIEWED 24

7 Peterson, C.L. (2003), Strengthening the Core from the Inside out. Athletic Therapy Today, 8 (4), Robertson, L.D. et.al. (1986), Abdominal Fitness Testing-A New Approach. Proceedings of the VIII Commonwealth and International Conference on Sports, Physical Edcuation, Dance, Recreation and Health, London : Sharpe, G.L., Liemohn, W.P., and Snodgrass, L.B. (1988), Exercise Prescription and the Low back-kinesiological Factors. Journal of Physical Education, Recreation & Dance, Nov., Smith, L.K. et. al. Brunnstrom s Clinical Kinesiology, (5 th ed.). F.A. Davis Company, Philadelphia, (1996). White, A.W. (1986), Back to Health Running can help strengthen the Support system for Your Spine and banish Low back Pain. Runners World, 21(5), Williams, P.C., Low Back and Neck Pain, Springfield, IL: Charles C. Thomas (1974). QUARTERLY ONLINE INDEXED DOUBLE BLIND PEER REVIEWED 25

ACE s Essentials of Exercise Science for Fitness Professionals TRUNK

ACE s Essentials of Exercise Science for Fitness Professionals TRUNK Posture and Balance Posture refers to the biomechanical alignment of the individual body parts and the orientation of the body to the