Back Exercise

ROSA NG

S.R.P. M. H.K. P. A.

It is generally believed that treatment of back problem is never complete without the inclusion of back exercises. It must be emphasised that the aim of these exercises is to help improve the mechanical dysfunction, which is often the cause of back pain. However, there is no "standard set" of back exercises to all low back problems, and they must be varied to keep with the patient's individual needs at different stages of the disease. In this paper, the main objectives of back exercises are discussedwith emphasis on the application, precautions and modifications of some classical, commonly prescribed exercises.

INTRODUCTION
Muscular dysfunction plays an important role in the pathogenesis of low back pain syndromes, and forms an essential part in postural defects . In response to mechanical derangement and pain certain muscle groups, the postural muscles, show a tendency to get hypertonic and tight, and are readily activated in most movement patterns . They are less liable to atrophy and have a pronounced postural function . They include the hamstrings, iliopsoas and trunk extensors . The opposite group, the phasic muscles, on the contrary, tend to react to a given situation by inhibition, atrophy and weakness . They include the abdominals, and the glutei . Faulty posture results when there is an imbalance between these two muscle groups, e .g . the tight hip flexors and lumbar segments of trunk erectors, and the weakened gluteal and abdominal muscles . Ante-version of the pelvis develops with lumbar hyperlordosis and slight flexion in the hip . This causes an uneven distribution of pressure at the disc, joints and ligaments in the lumbar segments and painful changes of all structures may develop . In addition, it will also hasten degenerative changes in this area . After discussion on the part played by muscles in faulty postures, and thus painful syndromes, treatment must essentially be a correction of what has been found to be at fault Careful examination of the problem of each patient is necessary to design an efficient exercise programme for each patient . The main objectives of exercise lies in the strengthening of weakened muscles, thus stabilization of a hypermobile segment, stretching of the tightened soft tissues and thus improving the mobility of a stiff segment, reduction of mechanical derangement, postural training and prevention ` of further recurrence by prophylactic exercise .

abdominals and glutei will result in hyperlordosis and anteversion of the pelvis, thus putting excessive stress on the lumbar segments . From discal pressure studies as well as intraabdominal pressure studies, it is probable that strong abdominal muscles in critical situations diminish the load on the back by rapidly increasing the pressure in the abdominal cavity . In certain situations, e .g . lifting and carrying heavy objects, increase of intra-abdominal or intra-thoracic pressure will relieve some of the load of the lumbar spine . Kennedy suggested the use of dynamic abdominal bracing, a manoeuvre which utilises the intra-abdominal pressure mechanism by controlled action of the oblique abdominal muscle to stabilise and protect the lumbar spine during movement and position of weight bearing . However, exercises need to be selected with care . Those which stress the joint structures in extreme positions are liable to exacerbate the condition, e .g . exercise in supine lying, and slowly raising both straight legs together to "strengthen" the abdominals and psoas muscles is one of the ways in which the symptoms of hypermobile lumbar segments are recurrently aggravated . In initial 30 of movement, the posterior structures are painfully approximated by the powerful muscle action, as the lumbar spine is drawn into excessive lordosis by contraction of iliopsoas on the fixed lumbar spine . (Fig . 1)

(A) INCREASE STABILITY OF THE SPINE BY STRENGTHENING OF WEAKENED MUSCLES

Lumbar segments, after mobilization need stabilization provided by muscles . As discussed previously, weakened Volume 6 1984. 21

Nachaemson's studies demonstrated an increase of intradiscal pressure with both muscular activity and trunk ;flexion. Thus, isometric exercises are less. likely to provoke (future pain and disability since they load the lumbar spine less. Hence they are often used to improve the power of the abdominals especially in the initial stage although later, postural reeducation in the reduction of lumbar lordosis by isotonic exercise can be very helpful. Here are a few examples :(1) Pelvic Tilting Starting position - crook lying on a firm surface. Exercise - the abdominals and the glutei are tightened and the patient "presses" his lower back down flat. Holding his back flat to the surface, the buttocks are elevated. This permits smooth pelvic tilting and gives the patient the kinaesthetic concept of this tilting movement and at the same time stretches the lower back. (Fig. 2)

(Fig. 3) Progression - hands are put by the side of the head and the exercise is repeated with the elbows trying to touch the knees . (Fig. 4).

(Fig. 4) After 30 or more of hip flexion, the psoas becomes less. effective in contraction and the abdominals become more efficient. From this position, the pelvis will rotate and the lumbar spine flattens. Thus isotonic abdominal exercise should begin with the hips and knees flexed. Note that the intradiscal pressure increases four times in this exercise as compared to supine lying, thus it should not be given to patient with acute disc lesions . Grieve believes that segmental strengthening of a muscle is needed in the treatment of a hypermobile lumbar segment . The principle lies in the stimulation of small, but important local muscle group to work isometrically in maintaining the orientation in space of a single vertebra . Evidence shows that lumbar degenerative joint conditions are accompanied by changes in the relative population of "fast" and "slow" fibres in the segmental musculature, eg. multifidus. He suggested an exercise as described later, and the author has tried the exercise on a patient with success in teaching the exercise, though the effectiveness of the treatment needs more time to be assessed . The Journal of The Hong Kong Physiontherapy Association

(Fig. 2) : Pelvic tilting exercise with lumbar spine pressed down to the floor firmly, and the buttocks elevated slightly . Progression - continue the tilting movement with the legs gradually extended. Any degree of tightness of hip flexors will increase the difficulty of the exercise . (2) "Sit Up" From Supine Position with Hips and Knees Flexed Starting position - Crook lying on a firm surface. Exercise - Head and shoulder are lifted with a gradual curl to touch the knees with the hands . (Fig. 3) 22

Starting position - Patient lies prone, and the therapist, stands at the side and applies his thumbpads to that side of the spinous process (as in application of transverse pressure) of the upper vertebra of the segment concerned . Exercise - Sustained pressure is applied to the bony point, and the patient is instructed not to allow the vertebra to be "displaced" . Initially, a considerable mass of para-vertebral muscle is called to play, but with encouragement and practice, the patient begins to localise the muscular effort . Similarly, localised extension exercise can be given with posterio-anterior pressure applied to the vertebra and the patient is instructed to resist the "displacement" . According to Grieve, with a few sessions of training, posterio-anterior pressure can be selfadministered by the patient and many become highly proficient at the exercise . Going together with the correct method of weight lifting, antigravity muscles of the lower limb may also need strengthening. (Fig . 5) Progression - pull both knees to the chest and bounce rhythmically . (Fig . 6)

(B)

INCREASE MOBILITY OF THE SPINE BY STRETCHING OF TIGHTENED SOFT TISSUE

Postural muscles including the back extensors, hip flexors and the hamstrings tend to be tightened . The musculature around the pelvis must have good extensibility as well as contractibility for good pelvic control . If they are tight, they will prevent pelvic tilt, so it is important that they be stretched before abdominal strengthening or pelvic control exercises can be performed properly . Pelvic stretching should also be accompanied by active movements to maintain the progress achieved . Starting position for exercise should be arranged so that the reciprocal relaxation of their antagonists may assist in the elongation process . The hold-relax and contract-relax methods in PNF can be used in stretching . Hydrotherapy, with the benefit of warmth, support and buoyancy, provides a good means of stretching and general mobilization of stiff joints . (1) Low Back Stretching Exercise Stretch pain elicited on flexing the tight lower back maybe the cause of back pain . The lumbar spinal longitudinal ligaments and muscles must be stretched to regain this elongation range . Starting position - supine lying Exercise - flex one hip and knee to touch the chest with rhythmically passive bouncing at end range . This is repeated for the other leg with emphasis on the lower back being stretched . (Fig . 5)

(Fig . 6)

Any tendency to stretch the back by forward bending in an attempt to touch toes in long sitting position should be avoided . (Fig . 7)

(Fig . 7)

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This exercise can stretch the lower back, but the hamstrings hold the pelvis fixed after a certain degree of rotation . Since they are less elastic and resi lient than the lower part of the back, it may cause a too violent stretch for the low back . (2) Hamstring Stretching Exercise For the reason discussed above, bilateral hamstring stretching in long sitting position should be avoided . "Protective" hamstring stretching is advocated, with the low back protected from excessive stretching during exercise . Starting position - sitting with hip and knee of one leg fully flexed and rotated outward, and the leg being stretched extended on the floor with the knee straight . Exercise - patient tries to reach towards the toes of his extended leg in a bouncing rhythmical manner . The flexed leg prevents stretching of the low back . (Fig . 8) An alternative position for stretching is shown (Fig . 10) with resistance applied at the knee to prevent hip flexion .

(Fig . IQ) McKenzie also advocated stretching of the tightened anterior structures of the spine by passive hyperextension in lying . (Fig . 11) However, this exercise is initially not suitable for patients whose neural arches have been painfully approximated by trauma or stress . From a cautious beginning by repeated extension every hour or so, the exercise is progressed by holding the position longer and by increasing the amount of lumbar extension . However, this must be carefully approached and . care is taken to see that there is no segmental hypermobility or instability which is aggravated by uninhibited and vigorous free movements.

(Fig . 8)

(3)

Hip Flexor Stretching Exercise Shortened hip flexors on a fixed femur will tend to pull on the anterior portion of the lumbar spine and results in an increase in lumbar lordosis . Stretching of the hip flexors often causes hyper-extension of the lumbar spine . The correct stretching of this muscle group presupposes that the patient has mastered pelvic tilting and is therefore capable of maintaining a flat back during exercise . Starting position - patient lies supine with his leg to be stretched held down against the floor . Exercise - the opposite leg is then flexed rhythmically to the chest as in the knee-chest exercise . Patient is reminded to hold the back flat against the floor during stretching, preventing it to be pulled by the hip flexors into hyperlordosis . (Fig . 9)

(Fig . 11)
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(C) REDUCTION OF MECHANICAL DERANGEMENT

Lumbar disc is most commonly damaged under flexion stresses, when the nucleus is forced posteriorly . The nucleus fluid is forced through the weakened annulus and extrusion of nuclear material results. McKenzie believes that during extension, there is an anterior shift of the nucleus which is merely the reversal of the development of pain in progressive disc lesions. This is manifested by the centralisation phenomenon. He advocated a scheme of repeated extension exercises in lying, aiming to reduce the derangement, producing centralisation of symptoms . In this exercise, care is taken to see that there is no radiation or peripherisation of symptoms, during which the exercise should be stopped immediately . (D)

(E) PROPHYLACTIC EXERCISE AND ADVICE

Low back pain appears generally more common in those with weak- trunk musculature, tight hamstrings, hip flexors and lumbosacral soft tissues, and a tendency to lordosis because of lax abd urinals. Thus repetition of treatment exercises after pain has subsided helps to prevent further attacks. McKenzie demonstrated the application of a few basic principles of prophylaxis in low back pain, which includes the admonitions not to lose the lumbar lordosis together with a passive extension exercise regime . This tends to reduce the frequency of recurrence in a group of patients with "flexion derangement" . Similarly, a flexion exercise regime, designed to mobilise chronically tightened dorsal lumbosacral soft tissues is the treatment of choice to some. Thus, the choice of prophylactic measures and treatment should be dictated entirely by the occupation and needs of the patient as deduced from the clinical presentation, and not by the dictates of this or that approach to the problem of low back pain . Ergonomics and education about back care is important as prophylaxis against further attacks. Advice on posture at rest and during work and activities, e.g. prolonged sitting, reaching or stooping, driving and lifting should be given. A comprehensive analysis of occupational and domesticduty stresses imposed upon an individual is a formidable undertaking . References Calliet R. :
Low Back Pain Syndrome. Common

POSTURAL RETRAINING

Pelvic tilting exercise learned previously is repeated in the upright position . This exercise maybe done against the wall with feet 30-45 cm away from the floor, flexing at hips and knees to 90 . (Fig . 12) This will aid in flattening of the back and pelvic tilting in supine position can be done with patient upright against the wall . This is again repeated with the feet extending gradually until the patient can perform pelvic tilting in upright position . When this stance can be performed unsupported, proper posture has been reached . He is then taught to "carry over" this posture and integrate it to his everday activities . With a flat back, the lumbar spine is less lordotic . There is less shearing stress on the lumbar spine, and the posterior articulations are separated and are less subjected to weight bearing.

Davis, Philadelphia . (1966) Livingstone (1981)

Grieve G.P .:

Vertebral Joint Problems.

Janda V., Schmid H.J .A.: Muscle as a pathogenic factor in back pain.
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Jowett R.L ., Fidler M.W ., : Histochemical changes in the multifidus in mechanical derangement of the spine. Orth . Cl. N. Am . 6:145 (1975) Kendall P.H ., Jenkins J .M .: Exercises for backache : A double - blinded controlled trial. Physio. 54 :154 (1968) Kennedy B.: A muscle bracing technique utilising intra-abdominal pressure to stabilise the lumbar spine. Aust. J. Physio 11 : (1) 102-106 (1965) Kennedy B.: An Australian programme for management of back problems . Physio. 66 : (4) : 108-110 (1980) Macnab I.:
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N .Z. Med. J .

McKenzie R.A . : Prophylaxis in recurrent low back pain . 89 :22 (1972)

McKenzie R.A .: The Lumbar Spine : Mechanical Diagnosis and Therapy. Spinal Publication. (1981) Nachaemson A.L ., Lindh M. : Measurement of abdominal and back muscle strength with and without low back pain . Scand J. Rehal. Med. 1 :60 (1969) Nachaemson A .L . : A Critical Look at conservative treatment for LBP . In : Jayson M. (ed.) The Lumbar Spine and Back pain . 2nd ed . Sector (1980)

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