Who wants to put back pain behind them? (Pardon the pun..)
Current statistics show that over 80% of you will get some form of lower back pain throughout life. In any given day, I would say over 80% of my caseload comprises lower back pain, plus or minus additional pathologies. These can be acute presentations, ongoing chronic lower back pain, or an acute-on-chronic (flare up) presentations.
We’ve all heard by now, that in order to treat and prevent lower back pain, whether it be from taking up that new hobby of waterskiing or from that laminectomy surgery two years ago, one needs to strengthen their “core”.
I always ask about what patients are doing to address and prevent their pain, to which most people respond with –
“I’m doing my sit-ups”.
Newsflash! Sit-ups are NOT CORE!
Although we would all like to sport a nice six pack, performing the incorrect abdominal exercises can lead to not only worsening of your back pain but an array of other unpleasant pathologies. Read on…
Unpleasant Side Effects
When performing sit-ups to get fit and healthy, people often leave behind their pelvic floors, the collection of muscles, ligaments, connective tissue and sphincters that combine to support and close the bladder, vagina, uterus and bowel. One in three Australian women experience urinary stress incontinence, according to the Continence Foundation of Australia.
The pelvic floor muscles attach to the pubic bone in front and run underneath the body like a muscular trampoline, inserting into the coccyx at the back. Excessive sit-ups can cause serious damage to this structure. Sit-ups increase pressure inside the abdomen, which in turn pushes down on the pelvic floor. If the pelvic floor isn’t strong and co-ordinated enough to lift and hold to counter this internal pressure during sit-ups, then pelvic organ prolapse is promoted. Also, when the pelvic floor doesn’t work effectively, the upper abdominals substitute to brace the trunk, which increases the downwards pressure on the pelvic floor and this bracing can worsen the original back pain!
Before you panic, pelvic floor muscle training with a qualified physiotherapist is effective in treating stress incontinence, with cure rates up to 85%.
Other Unpleasant Side Effects
According to Stuart McGill, a professor of spine bio-mechanics at the University of Waterloo, sit ups produce the exact same force in the spine that can create disc bulge and disc herniation, two of the most common low back injuries. A sit-up also recruits the hip flexors, the muscles that run from the anterior hip to the lumbar vertebrae in the lower back. When hip flexors are too strong or too tight, they tug on the lumbar spine which can worsen the pathology.
If sit-ups are out, how do I strengthen my back?
As mentioned above, the key lies in exercises to strength the core, which comprises the transverse abdominis, multifidus and the pelvic floor.
Transversus abdominis is the deepest of the abdominal muscles and wraps around the abdomen between the lower ribs and top of the pelvis and acts as a corset to support the pelvis and trunk. When transversus abdominis contracts the waist narrows slightly and the lower abdomen flattens. The function of the transversus abdominis is to stabilise the low back and pelvis prior to movement of the limbs. Lower back pain, abdominal injury or surgery and/or excessive lengthening due to pregnancy can cause a delay or absence in the anticipatory contraction of transversus abdominis. If this muscle contraction delay/absence is not corrected, this dysfunction will remain even after your pain has subsided. This is why recurrent back pain is more than common and patients present with on and off lower back pain for “as long as they can remember”. Each time you have “an episode” of lower back pain, pain inhibition causes further muscle weakening/incorrect timing of the transverse abdominis, hence why your back pain may get to a stage where it does not improve after two days of heat packs like it has for the last five years…
When your physiotherapist begins to teach these exercises, be patient! The first step is to learn to isolate the muscle, to train it to contract. Research has clearly shown that the better you are at isolating this muscle the faster it will integrate into functional tasks and sport specific training. The second step is to strengthen or teach it to co-contract with the other muscles of the core, the deep multifidus and the pelvic floor as you breathe, then the muscles can be taught in sport specific and functional tasks (sitting, standing, squatting, lifting etc).
Multifidus is a deep muscle located along the back of the spine very close to the midline. The deep fibers are short and support single vertebral segments. This muscle functions together with transversus abdominis the pelvic floor muscles to stabilise the low back and pelvis prior to movement of the limbs.
A study by Freeman MD1, Woodham MA and Woodham AW suggested that the lumbar multifidus muscles are important stabilisers of the lumbar spine, and dysfunction in these muscles is strongly associated with lower back pain. The dysfunction is a result of pain inhibition from the spine, and it tends to continue even after the pain has resolved, likely contributing to the high recurrence rate of lower back pain. Persisting lumbar multifidus muscle dysfunction is identified by atrophic replacement of multifidus muscle with fat, a condition that is best seen on magnetic resonance imaging. Muscle training directed at teaching patients to activate their multifidus is an important feature of any clinical approach to the lower back pain patient with demonstrated multifidus dysfunction or atrophy.
Another study by Hides JA1, Richardson CA and Jull GA also suggested that multifidus muscle recovery is not spontaneous on remission of painful symptoms and the lack of localised, muscle support may be one reason for the high recurrence rate of low back pain following the initial episode.
The anatomy of the pelvic floor has been discussed above and must work in cooperation with the multifidus, and transversus abdominis for your lumbar spine, sacroiliac joints, bladder and uterus to be stabilised properly.
Where to go from here…
The physiotherapists at South Perth Physiotherapy will educate you on how to strengthen the correct muscles in order to treat and prevent your lower back pain. Real time ultrasound imaging (RTUI) is utilised to paint a specific picture of the function of these muscles. Studies have also shown that RTUI adds to compliance of exercises as a means of optimal feedback. A study by Van K1, Hides JA and Richardson CA signified that real-time ultrasound imaging can be used to provide visual biofeedback and improve performance and retention in the ability to activate the multifidus muscle.
Remember that trying to function with a poor “core” is like trying to fire a cannon from a canoe. Come and have a chat to the physiotherapists at South Perth Physiotherapy to discuss how to use those muscles with the greatest efficiency!
Lauren is the Principal Physiotherapist at South Perth Physiotherapy and has a keen interest in exercise rehabilitation for acute and chronic lower back pain. The correct rehabilitation that is! All bodies are different and need to be assessed and treated in different ways. Lauren is experienced in Pilates education and teaches individualised programs at the clinic. Her extensive background in exercise prescription is also utilised to develop a specific program for every patient.
PM R. 2010 Feb;2(2):142-6; The role of the lumbar multifidus in chronic low back pain: a review. Freeman MD1, Woodham MA, Woodham AW.
Spine (Phila Pa 1976). 1996 Dec 1;21(23):2763-9. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Hides JA1, Richardson CA, Jull GA.
J Orthop Sports Phys Ther. 2006 Dec;36(12):920-5. The use of real-time ultrasound imaging for biofeedback of lumbar multifidus muscle contraction in healthy subjects. Van K1, Hides JA, Richardson CA.