How can we stay
healthy across our life span? The general consensus amongst those in the
kinesiology field is that we need to keep moving. Our profession is involved in
an endless battle attempting to motivate the public to get off the couch for
their own good, their own longevity, their own quality of life and for the
betterment of society as a whole. But there is huge undervalued factor that is
preventing many Americans from taking the appropriate action. Pain is a
powerful de-motivator, and as we get older, it always seems to get worse. If
kinesiology professionals want to be more successful at getting the population
active throughout their entire lives there needs to be more focus on addressing
this incredibly powerful motivational block. I cannot count the number of
people I know in their twenties and thirties alone who struggle with chronic
pain issues, let alone the middle aged and the elderly populations. How can we
expect most 65 year olds to confidently work out when our sedentary population
of twenty something’s cannot even go out for a run or pick up a box without
their back hurting?
A common statistic
that is often thrown around is that 85% of people will experience debilitating
back pain at least once in their life time. In many academic and clinical
circles it has been pretty much accepted as an unavoidable fact of human life.
Humans just get bad backs as they get older. I remember early on in my
undergraduate studies when my anatomy and physiology professor, who was an
adamant evolutionist, would go on about the many compromises that were made in
our evolutionary development which reflect the lack of intelligent design, one
being the structural inadequacies in the design of our back when we progressed
to an upright bipedal posture. Then the following lectures went on to emphasize
how the lumbar spine has more degrees of viable range of motion than the
thoracic spine, and thus should be more flexible than the thoracic spine. This
was the first introduction that my fellow health care students and I had to
spinal mechanics and it was already beginning to ground a monumental
foundational misperception of how our spines work. You cannot build a house
with a compromised foundation and expect it to be structurally sound, just as
you can’t craft an accurate structure of knowledge built upon foundational
misinterpretations. If there is a misunderstanding of how the spine works
mechanically on the fundamental level, this will not allow a full and accurate
understanding of how the spine accumulates trauma that then manifests its self
as pain and chronic mechanical dysfunction. If we don’t understand what is
generating the pain we cannot appropriately correct it.
Instead let us
consider it not being an anatomical design problem but rather a life style
problem. Our spines were mechanically designed to be undertaking different
stresses than what are required of them in the day to day demands of the modern
lifestyle. The human back is an amazing feat of engineering when it is used for
its intended purpose. Humans for the last hundred years have not lived their
lives the way their bodies were mechanically designed to operate. Over the
space of a life time, the way we live in the modern era takes a slow and
progressive toll on our backs.
Despite current
clinical wisdom, it is extremely rare that a back injury is caused by a single
event. Rather, repeated application of subfailure magnitude loads develop over
extended periods of time which serve as a cumulative pathway leading to an
eventual culminating event (McGill 2007). However, in the clinical arena it is
the culminating event that is often presumed to be the cause, and it is because
of this false assumption that treatments then revolve around a singular focus
directed towards that particular event (McGill 2007). This misdirection of treatment fails to
address the real cause of the cumulative trauma (McGill 2007). In these cases there are usually two possible
pathways responsible for the development of trauma, and usually it is a
combination of these two factors. One way that these stresses are produced is from
repeated application of low loads, as in years of stooping over to pick up
light loads with a flexed spine. As tissues fatigue with each progressive load
cycle, the failure tolerances of those tissues slowly degrade until a
culminating back injury occurs. The other possible mode of tissue trauma
accruement is through the implementation of a single subfailure magnitude load
applied over a an extended period of time, as in prolonged bouts of sitting or
remaining in a bent over posture with the lumbar spine in a fixed flexed
position (McGill 2007).
Once tissue damage
begins to occur, alterations in the spine’s biomechanics begin to occur. An alteration in a spinal joint’s mechanics
will cause the spine to have altered tissue stresses, thereby causing overload
on another previously uninvolved tissue (McGill 2007). Not only will this generate symptoms and pain
patterns that will differ from the original and catalytic traumas, but
according to McGill (2007) “will initiate a cascade of change that can cause
disruptions to the joint and continual pain for years (p. 109)” leading
ultimately to conditions in our old age such as facet arthritis, accelerated
annular degeneration, and nerve root irritation to name just a few. It has been
documented that annular damage almost always occurs long before facet arthritis
manifests its self (Butler 1990). When this series of joint instabilities
follows injury the body responds with the development of arthritic activity in
an attempt to stabilize the joint. What results are pain and a loss of range of
motion (McGill 2007).
It would then seem
intuitive that establishing range of motion (ROM) would be an appropriate
rehabilitation goal for bad backs. However, when it comes to things as complex
as the human body intuition and common sense can often lead us astray. Despite
this, it is a conclusion that many clinicians and academics have reached
through clinical wisdom rather than through thorough scientific analysis. When trying to catch this degenerative process
early on, increasing lumbar ROM will actually exacerbate the problem (McGill
2007). Stiffening of the joints and the
eventual development of arthritis is actually the body’s protective reaction
against pathological increases in lumbar spinal range of motion. Certain
injuries, particularly to the disc, will increase ROM which will in turn
increase translational (non-rotational) bending and shear forces upon the
lumbar spine (McGill 2007). Pathomechanical increases in lumbar ROM occur
during all four grades of disc degeneration. It is not until the 5th
stage of disc degeneration that extra motion is replaced by extreme stiffening
and significant loss of ROM, which are then characterized by collapse and
osteophyte formation (McGill 2007).
Developing lumbar
spinal flexibility for functional health and preventive back care is not much
more than a myth. However, well-intentioned but misguided clinical wisdom is
not the only force driving this prevalent misconception. The unique legislative
landscape of the United States plays a powerful role in reinforcing this
unfortunate circumstance. Lawyers and compensation boards need concrete
objective numbers for the purpose of easily quantifying disability. For this reason they have grasped onto lumbar
spine ROM as an easily measureable determinant (McGill 2007). As a result the
American Medical Association (AMA) created guidelines in 1990 for quantifying
the degree of back disability as based mostly as a loss of ROM. In the legal
realm, therapy is considered complete when full passive anatomical ROM has been
restored (McGill 2007).
However, just because the lumbar spine can
move through a wide ROM, doesn’t mean it should. The spine is architecturally
different than any other joint in the body. It is the one joint that is broken
up into three separate joints (cervical spine, thoracic spine, lumbar spine)
which work as an independent and interdependent system of levers. Then within
them are 24 individual joints that operate together as a dynamic flexible rod,
while having muscular complexes that control these joints that are not only
crossing many joints at once, but are crossing separate joint systems within
those joint systems. We cannot apply the same rules of flexibility to the spine
that we apply to the rest of the body’s joints. Scientific evidence suggests
that after injury most backs actually improve with inter-dynamic stabilizing
approaches and that increasing lumbar spinal mobility in fact exacerbates
problems, fosters joint instability and continues to further stimulate the body
to produce arthritic compensation factors to cope (McGill 2007). The best
method for treating back pathologies is to improve with stabilizing approaches;
motor control learning, enhancement of muscular endurance, posture training, and
training the lumbar spine to retain a
neutral position through all planes of movement while stressing mobility
through the hips and knees (McGill 2007).
McGill (2007),
states that “generally for the injured back spine flexibility should not be
emphasized until the spine has stabilized and has under gone endurance and
strength conditioning - and most will never reach this stage. Despite the
notion of some (i.e. ASCM, AMA) there are few quantitative data to support the
idea that a major emphasis on trunk flexibility will improve back health and
lessen the risk of injury. Further, research has shown that spine flexibility
has little predictive value for future back trouble (p. 184).” In fact many
exercise programs that have included loading of the torso throughout the spines
full ROM have negative results and greater spine mobility has been associated
with low back trouble (McGill 2007). It is important to note that the “Injured
back” in this case can refer to any pathomechanical state of the spine, which
most Americans live with on a day to day basis even though they may be
asymptomatic as far as pain symptoms are concerned. Therefore, these
philosophies do not only apply solely to the painfully symptomatic, but to
virtually every person currently living a modern lifestyle. Tissue trauma
begins to accumulate early, and aberrant motor patterns are developed from a
young age and continue to progress throughout the life span.
Already by the age
7 most children are beginning to develop aberrant motor patterns in their spines.
The cycle begins as soon as we start
living our days as students sitting down in a class room 8 hours a day. This
flexed position is not corrected by long walks home but continues to be reinforced
by sitting in cars or buses on the way home. Then upon arriving home the child sits down for the rest of the evening watching
TV, playing video games, and best case scenario, doing homework. It has been
documented that higher loads are placed on the discs when sitting in various postures
compared to various standing postures (Nachemson 1966), and that direct
correlations have been associated with prolonged sitting and disc herniation
(Kelsy 1975). Once our nervous system and soft tissues begin to get used to
these postures our neural recruitment patterns and length/tension relationships
between soft tissues becomes compromised which begins to directly affect the
way we move and how stresses and forces are distributed through joint
structures. Essentially we begin to develop aberrant motor patterns. These
stresses will be applied to our joints and tissues not only while we are
sitting but also while we are moving. No one can avoid countless functional
movements a day, so when our form is compromised in these movements we continue
to exacerbate the developing cumulative trauma (McGill 2007). This is precisely
why our focus as clinicians needs to shift towards prevention versus face value
reaction, and why our researchers, educators, and practitioners need to shift
their focus to proactive research and philosophies versus reductionist paradigms.
Let us examine how
the spine functions mechanically. The
spine can be paralleled to a flexible rod that will buckle under compression,
which is obviously what we want to avoid (McGill 2007). The body avoids this by
surrounding the spine with an incredibly dynamic stability and support system
that is nothing short of an engineering marvel. The architecture of the musculature
surrounding the spine is engineered like a system of guy wires (McGill 2007).
If the flexible rod prone to buckling upon compression has guy wires attached
to it like the rigging of a ships mast, the flexible rod will become stiffened
and less likely to buckle (McGill 2007). Imagine a vertical segmented pole
coming out of the ground. Each segment has a rope attached to it and each rope
is being held by a different person in a different location. Each person
applies a specific pulling force on his or her rope, appling just enough force
in relation to the forces applied by the other people to keep their particular
segment from moving. With summation of all the different forces pulling from
all different vectors keeping the rod from buckling under gravity and staying
perfectly upright and erect. Each rope represents a muscle and each segment
represents a vertebrae. Now imagine if that spine wanted to bend forward, but
pivot only at the base, bending forward as a whole and stiffened and stabilized
unit. All those force variations being implemented by the people holding the
ropes would have to change. As the pole
moves through space the changes in force production would not be static but
very dynamic as the loads imposed change in relation to the change in position
in space. That is what your muscles should be doing with your spine as your
body moves through three dimensional space. In order to invoke antibuckling and
stabilizing mechanisms during lifting just the right ratios of cocontraction
between musculature need to be ensured in order to minimize the potential of
spine buckling (McGill 2007).
Now let us examine
which muscles are involved and what their respective roles are in these relationships.
Many base their comprehension of muscle function by simply looking at the
origin/insertion and the lines of action. This is very misleading because then
the assumption must be made that the muscles serve as straight-line cables
(McGill 2007). This is just one component of a broader picture. While it is
true that the physiological cross-sectional area (PCSA) of a muscle governs the
muscle’s force producing potential, it is the line of action and the moment arm
(the perpendicular distance between the line of action of a force and the axis
about which the moment of torque is being measured) that determine the effect
of those forces in the moment of torque production of any particular muscle
(McGill 2007). According to McGill (2007), “It is erroneous to estimate muscle
force based on muscle volume without accounting for fiber architecture or by
taking transverse scans to measure cross-sectional areas”(p. 48). Combining the
straight-line action with the moment arm nets a curving line of action for the
muscle which must be taken into consideration when understanding the force and
mechanical potential of certain muscles.
Variations in
neuromuscular compartments within a specific muscle must also be considered.
For example the oblique muscles have many different neuromuscular compartments
that can only be stimulated through varying and specific types of demands. This
can only be achieved through functional and structural movement patterns
(McGill 2007). This is a perfect example of why machines and slow isolationist
techniques typical of body builders do not offer rich proprioceptive
environments that, according to McGill (2007), “provide variable motion,
balance, and force projection challenges involving the full linkage (p. 35).” This is also an excellent example of why the
American College of Sport Medicine’s (ACSM) 5 components of health related
fitness provide a limiting picture of health related fitness. None of the five
components addresses any of the aforementioned critical issues relating to
appropriate body movement health. Preventing pathomechanical movement patterns
while developing the correct fundamental human movement patterns is without
question a critical component to sustainable long term health. Balance and
functional movement should not only be a health component left for the concern of
solely elderly populations but also emphasized for those who are not yet
elderly since these patterns that are exaggerated in old age are crafted in the
younger years through continual reinforcement of aberrant motor patterns. What
is old was once young, and what is young will one day be old. Likewise, force
projection, agility, and power should not only be a requirement for only the
skilled athlete but also a measure of health for the lay person. In order to develope
appropriate physical life skills one must possess a properly functioning motor
system. One is directly dependent upon
the other.
This all leads to
more misperceptions of how the kinetic chain works on a functional level. I
could go into detail about common misunderstandings of how of all trunk
musculature works, but for the sake of simplicity I will only address the major
muscle groups; the erectors, the abdominal wall, the hip flexors and hamstrings
as well the gluteal complex.
Anatomy textbooks
separate the longissimus and iliocostalis groups of the erectors. However, from
a functional stand point it would serve more useful to view the thoracic and
lumbar portions separately since the lumbar and thoracic portions are architecturally
different just as the thoracic and lumbar portions of the vertebrae they
control are architecturally different (Bogduk 1980). Fiber typing studies have
illustrated that the thoracic sections contain up to 75% more slow-twitch
fibers while lumbar sections are generally evenly mixed, suggesting the
postural control responsibilities of the thoracic spine versus the lumbar spine
(Sirca and Kostevc 1985). The thoracic component of these muscles have
relatively short fibers with long tendons that run parallel to the spine
underneath the lumbodorsal fascia, originating in the same spot as the lumbar
erectors, the posterior surface of the sacrum and the medial border of the
iliac crests (McGill 2007). Therefore the thoracic extensors actually have a
significantly greater moment arm about the lumbar spine than do the lumbar
extensors. This gives the thoracic portion of the erector spinae the greatest
production of extensor torque with the least compressive penalties imposed upon
the lumbar vertebrae (McGill 2007). The lumbar erectors on the other hand do
not have a line of action that is parallel with the compressive axis of the
spine. Their line of action is in the posterior and inferior direction which
causes them to generate posterior shear forces during extensor movement along
the superior vertebrae (McGill 2007). What’s more, when the lumbar spine
becomes flexed the lumbar erectors lose their oblique line of action and
reorient to the compressive axis (McGill 2007). This means the muscles
themselves are generating compressive forces upon the lumbar vertebrae while
the vertebrae are in a compromised flexed position preventing the spine’s
ability to resist damaging shear forces. So, when the body is manipulating
loads while moving through three dimensional space it is best to recruit the
thoracic extensors into slight extension to help keep the lumbar vertebrae in
their neutral position while eliminating damaging shear forces and minimizing
damaging compressive forces.
When looking at
functional movement patterns the abdominal wall must be looked at as a unit of
inter-dynamic coactivating musculature opposed to individual muscles with completely
different functions. The abdominal wall
includes the rectus abdominis, and the three layers of the oblique musculature;
external obliques, internal obliques, and the transverse abdominis. The beaded
structure of the rectus abdominis allows for the lateral transmission of forces
through the abdominal fasica layers into oblique musculature which forms a
continuous loop around the abdomen (McGill 2007). The resulting “hoop” stresses
and stiffness assist with spinal stability while moving through space (McGill
2007).
The pelvis, hips,
and related musculature are probably some of the most important and
underappreciated kinetic systems in the body. A healthy back is absolutely
dependent upon proper pelvis and hip function. Unfortunately the modern lifestyle
demands excessive time in the sitting posture which wreaks havoc on our pelvic
and femoral motor control patterns. Functional and structural power is
generated through the hips, with aberrant hip motor patterns power begins to be
recruited by the hamstrings and the lumbar erector complex which exposes the
spine to traumatic shear forces every time we move (McGill 2007). Further, the
pelvis acts as a platform for the spine, so when hip imbalances develop the
tilt axis of the hip with rotate anteriorly or posteriorly, which will
destabilize a level platform for the spine to rest on. In the seated position
our hip flexors are shortened and activated. So when we spend too much time
sitting down our hip flexes begin to remain shortened and activated. The gluteal
complex is a hip extensor, so by definition it is an antagonist muscle group
from the hip flexors, this means that via reciprocal inhibition the gluteal
complex must relax and deactivate as hip flexor activity increases. By sitting
for prolong periods of time we are slowly training our nervous system and soft
tissues to keep the hip flexors short and over active while keeping the gluteal
complex underactive. Depending on who you refer, this very prevalent aberrant
motor pattern is called gluteal amnesia or crossed-pelvis syndrome (McGill 2007).
With proper
mechanics we literally lock the ribcage onto the pelvis depending on the plane
of movement we are traveling through (McGill 2007). This is achieved with just
the right ratios of coactivation between the abdominals bringing the ribcage
down, the thoracic erectors lightly resisting abdominal tension by locking the
lumbar spine into neutral, while the gluteals lock the pelvis into the ribcage.
The small ‘arch’ that forms in the lumbar region is not really an arch, but
rather an illusion of an arch. The lumbar spine is straight (neutral), not
arched, while the gluts stick out a bit posteriorly and the thoracic spine
slightly extends posteriorly leaving a space in the lumbar region that can
appear to be an ‘arch’. If the lumbar region is actively “arching” the lumbar
erectors are overactive and hyperextending the lumbar region creating traumatic
shear forces. This posture is known as excessive lordosis. When the gluteals
are under activated in relation to the hip flexors, specifically the psoas, the
pelvis anteriorly rotates, drifting posteriorly, forcing the lumbar spine into
extension and out of its neutral position. A tight psoas puts another nail in
the compressive coffin. Often perceived to be major a lumbar stabilizer, this
muscle’s physiology is commonly misunderstood.
It is the only hip flexor that crosses the entire lumbar spine before
crossing over the pelvis, however, according to McGill “its activation profile
is not consistent with that of a spine stabilizer, but rather indicates the
role purely as a hip flexor (p. 60).” When activated the psoas generates very
high levels of spine compression, and when pathologically shortened actually
pulls the lumbar vertebrae into lordosis creating traumatic posterior shear
loads while we are standing, sitting, or moving (McGill 2007). In summary what
we end up with is an under activated gluteal complex and abdominal wall coupled
with an over active psoas and lumbar erectors that actively compresses and imposes
traumatic shear forces on the spine.
When groups of men
with chronic low back troubles were measured performing squatting types of
tasks, it has been shown that they work to perform this basic motion and motor
pattern of hip extension emphasizing the back extensors and the hamstrings,
they seem to have lost the ability to recruit the gluteal complex to
effectively protect the spine. Therefore traditional strength and endurance
approaches to elevate pain ultimately fail because the aberrant motor pattern
is not being addressed (McGill 2007). When the gluteal complex cannot
contribute its share during hip extension while loading the back, the erector
spinae literally crush spine (McGill 2007). Proper gluteal activation also
contributes to deactivating the lumbar erectors during movement via reciprocal
inhibition. Using the thoracic extensors in conjunction with abdominal wall
bracing, and appropriate gluteal activation minimizes the compressive activity
of the lumbar spine, while neurologically activating the guy wire system of
lumbar stability during imposed loads and movement through space.
We have
established that the modern life style of the average westerner requires our
bodies to sustain stressful repetitive low magnitude loads imposed on us by our
required specialized modern work as well as the sedentary nature characterizing
other types of modern work. Ironically,
when this demographic does actively pursue increasing their physical fitness
and health status they actively choose to train movements that are exacerbators
of the very pathomechanical issues they are suffering from because they have never
addressed their aberrant motor control patterns. Examples aren’t limited to
active exercises either. “Tight hamstrings” are often blamed for back pain, so
naturally people spend a lot of time passively stretching their hamstrings
while neglecting other aspects of active hip mobility. However, entire hip
mobility needs to be emphasized in conjunction with lumbar stability if we want
to foster proper motor patterns. Focusing all our attention on the hamstrings
will just create new imbalances. Further, the majority of evidence suggests
there is no link between tight hamstrings as neither a predictor of back
troubles nor the concept that stretching will increase strength output as well
as providing protective value against back injury risk (Fowels 2000, Avela
2003, Black and Stevens 2001). What’s
more, what is often attributed to “hamstring tightness” is actually neural
tension, often originating from an asymptomatic entrapped sciatic nerve (which
can often get caught up in the obturator foramen when the piriformis or any of the
deep six become dysfunctional, as well as from spinal root compression). According
to McGill (2007) “anatomically, the spinal cord, and all nervous tissues are
linked in series and are tensioned, released, and flossed during coordinated
joint motions (p. 35).” When the hamstrings are stretched the nerve tracts are
stretched in conjunction. However, although tensioning nerves when stretching
can give transient relief, ultimately it will only irritate the nerve more in the
long run (McGill 2007).
Furthermore the way people choose to try and
stretch their hamstrings actually imposes a large amount of shear stress on the
lumbar spine. The usual method is the sit and reach or the standing toe touch.
This is actually taking the concepts of gluteal amnesia to new heights. Bending
over like this with the spine fully flexed completely deactivates the gluteals
while putting incredible tension on the hamstrings and erector spinae, imposing
powerful shear forces on the lumbar spine. I personally have flexion based
intolerances that have developed in my spine and I recall when I was in my intro
to fitness testing class, the professor had us do sit and reaches. I knew it
would irritate my back from experience, I did not foresee missing the next week
of classes being bed ridden with an incapacitating back flare up. There are
much more effective ways to increase hamstring flexibility while sparing the
spine and reinforcing healthy motor habits. Remember when you work on hip
flexibility work on the entire complex, not just one muscle group; the deep six
internal and external rotators, the abductors, the adductors, the flexors, etc.
There needs to be a balance of mobility between all these groups to promote
good spinal mechanics. The hips need to be able to move freely and unrestricted
through all planes of motion, if any of the mentioned musculature becomes
dysfunctional, that ability is compromised.
An example of an
active exercise to avoid that is implemented regularly to increase abdominal
strength is the traditional sit-up. With each sit-up, the lumbar spine is flexed
and large compressive and shears forces are forced upon it. While the spine is
fully flexed and under compression the psoas tightens, greatly magnifying these
compressive and shear forces producing excessive annulus stresses. Research has
definitely shown that sit-ups, knees bent or straight, will cause damage in
most people (McGill 2007). It has been documented that each sit-up performed
imposes a load of 3,300N (730 lbs) of compressive forces on the lumbar spine while
it is in a compromised flexed position (McGill 2007)! 3,300N just happens to be
the National Institute of Occupational Safety and Health’s (NIOSH) action limit
for the lumbar spine (McGill 2007). Amazingly people go to the gym and perform
hundreds of these a week. What’s worse is that the uneducated layman will hire
personal trainers, who they view as professional fitness and health experts,
who then instruct them to attempt to perform hundreds of sit-ups a week.
Leg raises, usually
thought to minimize compressive loads on the spine because we are hanging in
space, are not any better. This movement recruits a maximal abdominal
contraction of 100N while the spine is in a flexed position. Both the rectus
and the psoas are contracted harder in this movement than that in the conventional
sit-up and often the spine flexes more as well, especially when people start to
use momentum to swing their legs up as they fatigue (McGill 2007). These
movements not only actively traumatize the spine during their performance, but
they also continuing to train the motor pattern that allows the spine to flex
when the hips are flexed, which is exactly what we want to avoid. The objective
should be to train the spine to remain neutral when the hips are flexed.
When it comes to
extension exercises the coveted “superman”’ is often utilized. In this exercise
the subject lies prone and lifts the arms and legs off the ground by extending
the lumbar spine. Incredibly this imposes 600N (over 1,300 lbs!) of externally
applied compressive and shearing load to a hyperextended lumbar spine (McGill
2007). Furthermore, when the spine is forced into hyper extension the loads are
transferred to the facets and the interspinous ligaments are crushed.
Hyperextensions on the roman chair are not much better, imposing 4000N
compression and shearing torque onto the extended lumbar spine (McGill 2007).
For spinal
extension exercises there are ways to make the exercise simple but still
challenge the musculature while minimizing traumatic compressive forces for
people who need to begin to groove motor patterns. Exercises like the bird dog
and fire hydrant activate the abdominal wall and gluteal complex appropriately
while challenging the lumbar erectors without too much compression. They are
able to accomplish this while superman’s and roman chair “hyper’s” are not
because only one arm or leg is being extended off the ground at a time, opposed
to both legs, or both arms, or all four being extended simultaneously. When
only one limb is raised at a time only one side of the extensor is being
activated at a time (as in natural single leg movements, running or walking for
example) which has been documented to not create traumatic compressive or shear
forces (McGill 2007). Abdominal bracing should be employed during all extensor
movements to help elevate lumbar spinae compressive forces.
Modified curl-ups
where one leg is bent and the other is laid flat on the ground utilize this
same concept to spare the back while training the abdominal motor patterns (McGill
2007). When performing curl ups it is important to not curl up through the
entire range of motion of the abdominals, because this would cause the lumbar
spine too much shearing force on the spine as well as train excessive lumbar
flexion movement patterns. The pivot point for the curl-up should be at the thoracic-lumbar
hinge, without implementing any lumbar flexion. Focus on bracing the abdominals
and only lifting the head off the floor while maintaining a small space for the
neutral lumbar ‘curve’ (McGill 2007). Hold the elevated position while keeping
the abdominal wall braced, take two breaths in this position while maintaining
the abdominal brace for one repetition. This will also help train the
abdominals to be able to maintain stiffness while we breathe.
Cat/camels are
great pre warm-up activity because they reduce spine viscosity which prepares
the spine for stress and load application while helping to locate and work
through the lumbar-thoracic hinge in our motor patterns. This motion should not
be forced into a stretch; the emphasis should be on easy motion, not pushing end
range of motion limitations (McGill 2007).
Based on the
architectural and EMG evidence when it comes to grooving proper oblique
activation there needs to be the right ratio of coactivation from the quadratus
lumborum and transverse abdominis. The optimal technique to achieve this while maximizing
activation and minimizing spinal load appears to be the side bridge (McGill
2007). Abdominal bracing is critical in this exercise as is gluteal activation.
Consciously squeeze the gluts while in the bridge position.
The next important
step is to groove and build correct squat patterns. If we recall, those with
aberrant squatting patterns are not physically capable of sparing their backs
during squatting movements because they use the hamstrings and erector spinae
to drive extension movement (McGill 2007). Retraining the gluteal complex
cannot be performed with traditional clinical practices that utilize a machine.
Performing the traditional clinical squat emphasizing hip, knee, ankle alignment
requires little hip abduction (McGill 2007). Minimizing hip abduction during
the squat minimizes gluteus medius activation, when gluteus medius activation
in minimized onset of gluteus maximus activation is delayed until lower squat
angles are reached (McGill 2007). This pattern is exactly what we are trying to
avoid training. The ‘Potty squat’ is the best way to begin developing one’s
squatting motor patterns. The potty squat has the hips follow a trajectory
along a line about 45 degrees from vertical (McGill 2007). The emphasis should
be on maintaining a neutral lumbar spine by lifting the chest (mild thoracic
extension), bracing the abdominals and squeezing the gluteals to drive the hips
into extension (McGill 2007). Practicing gluteal activation during a warm up
prior to performing potty squats by performing supine glut bridges for the
gluteus maximus and mini band walks for the abductor group can be great aids in
trying to familiarize problematic clients with their gluteal activation (McGill
2007).
Single leg
exercises like the lunge and the single leg squat are excellent exercises to
begin grooving motor patterns because in one legged movements the gluteus
medius is recruited immediately to assist the frontal plane hip drive while
activating only one side of the erectors at a time, while triggering a faster
integration of the gluteus maximus during the descent of the motion (McGill
2007).
There are also
numerous habits that one should remove or add to their day to day routines to
help manage and aid in the correction of symptomatic pain. For example, imagine
a kinesiology student who waited to the last second to write a paper for his
aging class. As a result he had to sit for 12 hours straight while furiously piecing
it together so that by the time he was finished he developed a non-specific
back ache. There are certain things he might want to do before he goes to bed
to help reverse some of the stresses he imposed on his spine. For example he
could stand up for at least an hour before retiring, and while he is standing
apply what he knows about spinal mechanics and physiology. Like devoting time
to relieving pressure on the lumbar spine by actively bracing his abdominal
wall and squeezing his gluteals on and off in an attempt to get those muscle
groups reawakened after they had been put to sleep from the prolonged hours of
sitting. Using knowledge to become body aware can be one of the most powerful
tools one can utilize to effectively manage their body systems for long lasting
health sustainability and independence throughout the entire life span.
The challenge for
the scientist and clinician alike is to become fluent with the functional
significance of anatomy, so as to guide decisions to craft the most appropriate
prevention programs for the asymptomatic and the best treatments for the
symptomatic. Unfortunately until more clinicians take a more proactive role in
this aspect we will need to become more proactive in educating ourselves on how
to become more body aware. The more we learn how to spare our spine and groove
healthy movement patterns that have been lost through the demands of the modern
life-style the better able we will be at being able to remain active throughout
our life span and into old age, greatly increasing extended quality of life for
everyone.
References
Bogduk, N. (1980) A Reappraisal of
the Anatomy of the Human Lumbar Erector Spinae. Journal of
Anatomy, 131 (3): 525
Butler, D., Trafimov, J.H.,
Anderson, G.B.J., McNiel, T.W., and Hackman, M.S. (1990) Disc Degenerates Before
Facets. Spine, 15: 111-113
Kelsey J.L. (1975) An
Epidemiological Study of the Relationship Between Occupations and Acute
Herniated Lumbar Intervertebral Discs. International Journal of epidemiology,
4: 197-205
McGill, S.M. (2007) Low Back Disorders: Evidence Based
Prevention and Rehabilitation. Champaign, Il: Human Kinetics
Nachemson, A. (1966) The Load on
the Lumbar Discs in Different Positions of the Body. Clinical Orthopedics and Related Research, 45:107
Sirca, A. and Kostevc, V. (1985)
The Fiber Type Composition of Thoracic and Lumbar paravertebral muscles in man. Journal of Anatomy, 141:131
