Why Again Should I Avoid Bending and Twisting?

Why Again Should I Avoid Bending and Twisting?

 

 

Unless you live under a rock, everyone has heard not to bend and twist, especially when attempting to lift something off the ground.  But why?  What really happens to our backs that makes this such a "no-no?"  Here is a quick explanation. 

 

Below is a picture of our intervertebral disc...

If you look carefully at the annulus fibrosis, you can see that the fibers run in oblique angles, alternating directions with each layer.  Half of the fibers resist rotation to the right, while the other half resist rotation left.  All of the fibers resist flexion and extension.  But when you combine flexion with rotation to one side or the other side, only half of the annulus fibers provide protection of the nucleus, while the other half does not.  Doing this motion enough times will very likely cause a bulge or herniation of the nucleus pulposus.  

Summer Time is Perfect to Learn Core Engagement

Summer Time is Perfect to Learn Core Engagement

 

 

 

Just this past weekend I was visiting family in Rhode Island.  My 4 year old wanted to go swimming and so I began to blow up the many pool toys my father-in-law had purchased for the kids.  We did not have an air compressor available so I had to do it the old fashioned way.  After blowing up the third toy, I realized that as I pursed my lips tightly around the air nozzle in order to open the safety valve, and began to blow into the tube, my core engaged quickly and firmly.  It was not a "drawing in" or "hollowing," nor was it flexing of my abs.  It felt like my entire core stabilized my spine 360 degrees.  If you are having a difficult time teaching your clients (or youself) what true core recruitment and engagement should feel like, go to the dollar store and pick up an inflatable pool toy.  Try it for yourself.  Upon inflating the toy, keep one hand on your abs/obliques and you will feel it immediately.  Then try to incorporate this recruitment with your lifts.

Common Physical Therapy Questions

Common Physical Therapy Questions

 

As a Physical Therapist, I have heard certain questions frequently over the years.  This past week, I have been treating numerous patients following a Total Hip or Total Knee Replacement Surgery.  Many of these patients have trouble lifting their operative leg into bed when transferring from the sitting to the supine position.  My previous post explains how using the S.O.D. Stretch Strap can assist the patient with maintaining independence while performing this technique.  However, most patients do not have a strap so soon following their return home from the hospital.  They accept the fact that they can't lift their leg and rely on a family member to lift it into bed for them.  Even weeks after surgery, they may rely on someone else's help for this.  When the family asks me if this is normal, I tell them that the weakness is normal.  However, it is not only muscle weakness that is the cause.  The patient must begin to redevelop the motor pattern to lift their leg into bed by practicing it over and over.  Many times, if I perform the leg raise while cueing the patient to assist, after a few times, the patient is amazed at how quickly the movement returns.  It is as if they must re-establish the brain-leg connection in order to perform the task again.  I advise family members to assist only after the patient has made an effort first.  This will help the patient recover quicker and will prevent the family member from injuring themselves in the process of helping.

 

I have also been working with many Worker's Compensation patients who have injured their backs.  Most of them tell me that they bent over to pick something up and felt it "go out" at that moment.  After weeks of successful therapy, including core stabilization activities, body mechanics and lifting education,  I usually get the same question:  "When can I go back to lifting like I used to, without having to think about it?" 

 

And I answer them with: "Never.  You should have never lifted like that to begin with.  That's why I have been teaching you body mechanics and lifting techniques.  It is your goal to establish new posture and body mechanics so that you don't have to think about it the next time you are required to bend to lift something."

 



 



So although most of us have rarely thought about how we are to lift something off the floor, if we are taught the correct way to do it, and practice it repetitively, our new habit will minimize the risk of lower back injury in the future.  Just because we have been lifting a certain way all of our lives, does'nt mean that we have been doing it correctly.  The older we get, the higher the chance that poor lifting techniques will catch up with us. 

 

Training the Obliques

Training the Obliques

 

Here's a training substitution that you can make if you are recovering from a back injury.  Everyone knows that in order to protect your back you must train the core.  So you do sit ups, back extensions, seat torso twists, etc... However, many of the gym exercises that we once thought were beneficial for our core and lower back, may actually cause more spinal problems.  For example, when training obliques, many people will be seen on the Resisted Torso Rotation Machine. 

 

 

Unfortunately, repeated twisting causes deterioration of the annulus portion of the spinal disc.  Adding resistance to the rotational movement of the spine can be even more detrimental.  

 

  

Substitute the Seated Torso Twist with the Side Plank to train the Obliques.  It will train the core, and spare the spine.  Hold each repetition for 5-7sec and alternate sides for 8-10 reps each

LEVEL ONE: After each 5-7sec rep, do not drop your hips straight down to the floor.  Instead, push your butt back by hinging at your hips.  This will avoid excessive lateral flexion of the spine and will minimize overall strain on the back

 

LEVEL TWO

 

Check out www.lowbackpainvideos.com for more Lower Back Rehab Exercises

Stabilizing the Lumbar Spine During Common Low Back Exercises

Stabilizing the Lumbar Spine During Common Low Back Exercises

 

During a recent treatment of a patient recovering from lower back strain, she began the Straight Leg Raise exercise for hip strength and spinal stability.  The patient had been previously educated on core recruitment during activities.  However, during the Straight Leg Raise, she complained of difficulty controlling her lower back from moving.  She stated "It feels like my lower back is moving and unstable."  Even after providing manual cues to engage the core, she still had difficulty maintaining spinal stability.  That's when we incorporated shoulder isometrics during the Straight Leg Raise.  Here's what I had her do:

Initial performance without shoulder isometric

Straight Leg Raise with shoulder isometric

 

Having one knee flexed while raising the other leg helps to prevent flattening the lower back into the floor - This maintains more of a neutral spine position.  Prior to lifting the leg, press your hands into the medicine balls.  You will feel your trunk muscles 'engage.'  Follow this with the Straight Leg Raise.  This will help maintain spinal stability, and many times decreases lower back pain.  For a full rehab protocol on lower back pain, check out www.lowbackpainvideos.com 



Clients With Lower Back Pain

Clients With Lower Back Pain

Many times you may begin training a client who states he/she has a history of lower back pain.  An XRay or MRI may not have been performed due to your client's hesitation to see a doctor or having poor insurance.  As a professional, you can hypothesize what the possible diagnosis is by asking a few questions:

1) What is the age of your client?  From the teens to the fifties, disc issues are most common, such as bulging or herniated discs.  After the fifties, arthritis and spinal stenosis is most common.  The symptoms of these diagnoses will present differently

2) Can your client remember a specific incident that brought on the pain?  When was it? This will tell you if it is due to a trauma and if it is chronic or acute

3) What positions or activities increase or relieve the pain?  Many times, someone with a bulging disc or herniated disc feels better standing and walking, while stenosis feels better with sitting and bending.  Use this information to help devise appropriate activities

4) What is a typical day like? Does your client have a desk job or a job that requires repetitive bending, lifting and twisting?    Many times people who repetitively bend, lift and twist will fatigue.  Motor control errors result and injury can occur, specifically disc issues

5) Describe the pain.  Does it radiate down the inside or outside of the leg and knee? Does it pass the knee and reach the foot?  Radiating pain may mean a disc is irritating a nerve root or that a bone spur is placing pressure on the nerve.

The above questions will help guide your treatment/training sessions so that it is customized for your client's specific needs.  For more training information regarding clients with herniated/bulging discs or spinal stenosis, go to: www.lowbackpainvideos.com.  The DVDs here provide step by step exercise protocols for these common back conditions.

Dynamic Flexibility Activities As A Warm Up

Dynamic Flexibility Activities As A Warm Up

 

 

Viscosity is a property of biological tissues, in this case the spine and torso muscles, and it is defined as a resistance to motion.  Viscosisty of these tissues can be reduced to allow subsequent motion of the spine and torso with less stress on the tissues.  To do this, incorporate gentle motion activities (not static stretches) as part of your warm up.  It is suggested that this warm up include spinal stabilization exercises using functional movement patterns, such as diagonal chops and lifts. 

You will also want to keep in mind that the spine does have a "memory."  A prior activity can effect the spine's biomechanics during the next activity.  For example, if you are in the seated posture for a period of time, the spinal ligaments become lax and posterior disc creep may result.  This may lead to injuries such as bulging disc. 

Notice the flexion in the lower back

 Upon positional change, the nucleus of the spinal disc redistributes (no longer creeps).  Therefore, it is a good habit to alter your positions from one exercise to the next.  Follow an exercise that consists of spinal flexion with an exercise where the spine is either in neutral or extended.  This will minimize the chances of disc creep, bulging discs or even herniated discs.     

Follow the seated row exercise above with the plank hip extension exercise, moving from a flexed posture exercise to an neutral/extension exercise

Spine CPM Unit

Spinal CPM

 

Following a Total Knee Replacement, many surgeons will immediately place their patient's leg into a CPM or Continuous Passive Motion Unit in order to 'get the knee moving' so that functional range of motion may be reached as soon as possible.  Some surgeons are advocates of the CPM, while others avoid it.  As it is very common to see a knee or even a shoulder CPM unit, for me years ago it was not so common to see a Spine CPM unit.  However, the clinic I had worked for purchased one for more than $50,000 and used it for many of the patients suffering from lower back pain.  I initially used it but did not notice much of an improvement in my patients' progress.  Many of them actually felt worse.  As I studied more about treating lower back pain, I learned that although many of these patients have limited trunk range of motion, my goal should be to stabilize and strengthen their spine in the neutral position, while maximizing hip and knee mobility, rather than attempting to maximize their spinal flexibility.  Once the patient has progressed through stabilization and into endurance and strength training, then trunk flexibility may be focused on.  However, this is not the main focus and many studies even show that increasing spinal flexibility does not predict whether a patient will or will not have recurring back trouble.  My take home message is that for clients suffering from lower back pain, I must first work on trunk stabilization in the neutral position, and not be so concerned about their spinal flexibility. 

 

Check out this video on the Spine Six Biomotion Unit and let me know if you have had successful or unsuccessful experiences with it: Spine Six Biomotion.  You may also recognize the picture below, which is similar in concept, but was being sold to households.

Back Belts

Back Belts

 

 

 

 

How many of you have noticed the prevalence of employees in stores such as Walmart, Home Depot and Lowes wearing back belts?  As a therapist, many of my patients recovering from back injury are prescribed these also.  Do they really do what people say they do?  In 1994, the NIOSH (National Institute For Occupational Safety and Health) concluded that they do not prevent injuries or provide protection for workers who do not have a history of injury.  And although these belts may limit side-bending and rotation/twisting range of motion of the spine in standing, they do not limit these motions when the spine is flexed, which is the position of lifting when at work.  Therefore, upon lifting, these belts do not exactly do what people think.  

 



The NIOSH Risk Factors for Low Back Disorder

The NIOSH Risk Factors for Low Back Disorder

 

 

Are you at an elevated risk of lower back disorder? The National Institute for Occupational Safety and Health (NIOSH) released a list of risk factors.  They are as follows:

1. Seated or static work postures

2. Frequent trunk movement particularly rotation

3. Frequent lifting, pushing, pulling activities

4.  Seated whole body vibration (truck driver)

5. Repetitive lumbar full flexion

6. Time frame of performing the activity (how long after arising from bed)

 

Possible Solutions:

1.  Frequently change positions.  Get up and walk around a few minutes.  Stretch by reaching for the ceiling

2.  Avoid rotating the trunk if possible and pivot on your toes in order to turn your entire body in the direction of your activity

3.  Lift, pull, push with proper mechanics

4.  Avoid full lumbar flexion.  Use your legs in order to squat to get to a lower position 

5.  Do not begin these activities until you have been out of bed for at least 30 minutes-1 hour.

 

Your goal is to remove the stressors and enhance the activities that build support/stability

 

 

What is Gluteal Amnesia?

What is Gluteal Amnesia?

 

 

"Gluteal Amnesia" is a term that describes people who do not recruit their gluteal muscles for hip extension and instead rely on their spine extensors and hamstrings.  It is common that they also present with Crossed-Pelvis Syndrome.  During squatting movement patterns, the gluteals will be under-utilized while the erector spinae muscles are over-utilized, compressing the spine.  Exercises to assist the contraction of the gluteal muscles are: Clamshells for Glute Medius and Bent Knee Bridges for Glute Max.

 

CLAMSHELL

BRIDGE

 

Sitting and Lower Back Pain

Sitting and Lower Back Pain

 

 

Many people complain of lower back pain, especially upon sitting.  If they have computer based occupations, this is a major problem for them.  Sitting posture is very important to educate your patients/clients on in order to reduce the stresses on the spinal tissues.  Sitting in a slouch position decreases muscle activity, stresses the annulus portion of the lumbar discs, and may lead to "disc creep" and disc herniation. 

 

SLUMPED

Sitting upright activates the hip flexors and lumbar extensors which in turn create compressive loads on the spine. 

UPRIGHT

 

You can teach your clients/patients how to find a "pelvic neutral" posture, but many feel that by maintaining any one position for an extended period of time will place a stress on the lumbar tissues. 

PELVIC NEUTRAL

 

It is recommended that your position changes frequently in order to shift the stress from one tissue to another, avoiding any type of overload.

 

 

 



Lower Back Herniated Disc

Lower Back Herniated Disc

 

 

 

 

When dealing with a posteriorly herniated lumbar spine disc, one initial treatment that may be beneficial is extending the trunk, either in the standing or prone position (Cobra Stretch).  The idea is that extending backward will force the herniated nucleus material of the intervertebral disc forward within the disc and pressure will be removed from the spinal nerves.  This usually centralizes your symptoms, relieving any neurological pain/symptoms in either leg.  

 

For a full video-based Physical Therapy Rehabilitation Exercise Protocol, go to  https://strengthondemand.com/Low_Back.html

to order your Lower Back Herniated Disc Exercise DVD.

Training A Client Who Complains Of Low Back Pain

When working with a client, proper exercise technique is vital in their progress, injury prevention or rehabilitation.  In my experience, many clients will attempt a functional activity such as a lift from floor to waist (deadlift), and lower back pain will result.  If this occurs, I have two choices.  I can completely stop the activity and move onto something else. Or I can ensure that my client has made an effort to engage his/her core prior to and throughout the activity in order to protect their lower back.  I usually choose the second option.  Check out this video to learn how to assist your client in core recruitment.  90% of the time, after engaging the core, the pain is minimized or completely eliminated.  That is a great lesson for your client to learn, and hopefully they will incorporate this technique whenever they attempt a lift.  The more frequently you educate them on core recruitment, the more likely they will make it a new habit, and the less often they will feel lower back pain upon functional activities. 
Engage Your Core