Help for Low-Back Pain

Are your clients complaining of low back pain, or do they describe themselves as having a “bad back?” If so, their complaints are not uncommon. The Mayo Clinic recently reported that 4 out of 5 adults experience at least one bout of back The American Association of Neurological Surgeons reports that more than 65 million Americans suffer from low-back pain every year and that back pain is the second most common reason for visits to doctors’ offices. Furthermore, 50% of all patients who suffer from an episode of low-back pain will have another occurrence within 1 year (American Association of Neurological Surgeons 2000).

Considering these statistics, the likelihood of your encountering clients with low back pain is quite high. This article will take you through three lumbar-spine diagnoses, the common causes, suggested comfortable positions and postures, and recommended Pilates-influenced lumbar stabilization exercises.

With any client who is in postrehabilitation or has a history of a spine ailment, it is important to align yourself with the referring healthcare provider to optimize individual recommendations. The information here is generalized to the majority of individuals in each diagnostic population, but keep in mind that there are always outliers.

The spinal cord begins as an extension of the brain and is surrounded by the bony vertebral column, which acts as a protective mechanism. Any sensory or motor information the brain needs to relay to the body travels via the spinal cord. An injury to the spinal cord will interrupt this important communication, resulting in impairments of movement, sensation and/or organ function.

The lumbar spine contains five articulating segments that move to flex, extend, side-bend and rotate the torso. Individual nerve roots exit on each side of the vertebrae to become nerves that enable sensation and movement in the lower body (Kibler et al. 1998).

Clients who are familiar with the techniques of Joseph Pilates may wish to incorporate those techniques into their routines. People with low back pain and poor posture can benefit from Pilates exercise, but proper technique is key. You may have to modify exercises to allow for clients’ abilities and needs. Before you begin Pilates-based exercises with your clients, it is a good idea to review your techniques with a certified Pilates instructor—or perhaps have a certified instructor assist you initially. Although you can incorporate a few Pilates exercises into a client’s routine, individuals who wish to learn a complete Pilates program should be referred to an instructor who is certified in this area.

Spinal stenosis, which is the narrowing of spaces in the spine, can result in pressure on the spinal cord and/or nerves. Most cases of spinal stenosis occur in the low back (lumbar stenosis), affecting the nerves that run down the legs. Spinal stenosis may result from a variety of causes, including normal aging, heredity, tumors, a traumatic event and bone disease, to name a few.

Individuals with lumbar stenosis may have pain or discomfort in the legs, as well as weakness or “heaviness” in the lower extremities. Other symptoms may include numbness, tingling or hot and cold feelings in the legs.

Spinal stenosis is diagnosed by a physician. A magnetic resonance image (MRI) or computed tomography (CT) scan or a myelogram (an x-ray taken after a special fluid is injected into the spine) may be performed. These and other imaging studies can offer details about the bones and tissues and help the physician pinpoint a diagnosis (Cleveland Clinic 2005).

Surgery may be indicated as a treatment option, but it is usually viewed as a last resort. Lumbar stabilization exercises may also be a viable treatment option, depending on the severity of the stenosis.

As a general rule of thumb, individuals with lumbar stenosis are more comfortable in positions of spinal flexion, as opposed to extension. Exercises performed in a prone or standing position may be uncomfortable. If the client would like to lie prone, you might try placing a pillow under the stomach to create a small amount of flexion in the spine.

1. Single Leg Stretch (3 sets, 10–15 reps total)

• Lie supine on a mat with the right knee bent to the chest and the left leg extended at a 45-degree angle to the floor—or higher to begin with, to protect the back. (See “Beginners’ Modification,” below.)
• Place both hands just below the right knee and lift the head off the floor. Keep the head lifted throughout the exercise.
• Tighten the abdominals, exhale, kick the right leg out straight and bring the left knee in toward the chest. Inhale, exhale, and then continue to alternate legs.

Beginners’ Modification. Beginners should keep kicks high—toward the ceiling, at 90 degrees of hip flexion—since this is easier on the back, and advance to kicking out at a 45-degree angle as tolerated.

2. Double Knee-to-Chest Stretch (1 rep, hold for 10 seconds)

• Hug both knees to the chest to relax the spine.

3. Single Straight-Leg Stretch (3 sets, 10–12 reps total)

• Lying supine on a mat, extend the right leg toward the chest, placing the hands around the thigh or calf, and extend the left leg out at a 45-degree angle to the floor—or higher, if needed for comfort. (See “Beginners’ Modification” with Single Leg Stretch, below.)
• Tighten the abdominals while exhaling and then switch legs, pulling the left leg toward the chest.

4. Double Knee-to-Chest Stretch (1 rep, hold for 10 seconds)

The disks found between vertebrae have a gel-like center called the “nucleus pulposus” and an outer (tougher) layer known as the “annulus fibrosus.” With age and the loss of water content, a disk’s center may be displaced through a crack in the outer layer, causing a herniation. A physician will make this diagnosis by using imaging studies and the information in the patient’s history.

Most individuals with a herniated disk will improve without surgery. A physician will prescribe nonsurgical treatments, including medications, physical therapy and possibly injections.

Extension-based exercises are generally the most comfortable for clients with a herniated disk, as flexion-based exercises may aggravate symptoms. As always, individual conditions vary, so it is best to communicate with the physician or healthcare professional for individualized recommendations.

1. Swimming (1–2 sets, 10–20 seconds each) (See above.)

• Lie on the stomach with arms straight out in front.
• Lift both arms and legs off the mat.
• Flutter the arms and legs in opposition (right arm and left leg, left arm and right leg). Alternate while inhaling for 5 counts and exhaling for 5 counts.

Beginners’ Modification. Beginners can modify this exercise by lifting an opposite arm and leg while keeping the other arm and leg on the floor. They should alternate Opposite-Arm-and-Leg Lifts for 2–3 sets of 10 reps and then progress to the Swimming movement as tolerated.

2. Double Leg Lift (3 sets, 10 reps)

• Lie on the stomach, exhale and lift both legs slightly off the mat.
• Inhale and lower the legs.
• Arms can be outstretched overhead or supporting the neck by resting under the forehead.

The sciatic nerve runs from the low back/pelvic area through the hip and buttocks region and down each leg. It controls various muscles in the legs and is also responsible for sensation in aspects of the thighs, legs and feet. According to the Mayo Clinic, sciatica refers to “pain that radiates along the path of this nerve—from your back into your buttock and leg. The discomfort can range from mild to incapacitating, and may be accompanied by tingling, numbness or muscle weakness” (Mayo Clinic 2005b).

Sciatica results from pressure placed on the sciatic nerve. The pain is a symptom of another problem—for exam- ple, spinal stenosis, a herniated disk, spondylolisthesis, trauma or piriformis syndrome.

Symptoms may include:

• pain from the low back to the knee
• pain from the buttocks region to the outside of the calf and into the top of the foot
• pain from the inside of the calf to the sole of the foot
• numbness along the nerve pathway
• tingling, or “pins and needles,” in the feet
• a loss of bladder or bowel control

A physician will make the diagnosis by using the information given in the client’s history; imaging studies; and manual tests performed in the doctor’s office.

Generally, individuals with sciatica find extension positions (standing, lying prone) most comfortable. Some individuals, however, find comfort in a flexed (knees-to-chest) posture. A physician will typically recommend exercises to help posture, strengthen the muscles of the back and abdomen, and improve flexibility in the muscles of the hip and knee.

1. Opposite-Arm-and-Leg Lift (3 sets, 10 reps each side)

• Lie on the stomach with arms extended overhead. Exhale while lifting the right arm and left leg.
• Inhale while lowering the arm and leg.
• Exhale and switch to the opposite arm and leg.

2. Four Points (3 sets, 10 reps each side)

• Begin on hands and knees with the spine in a neutral position. Exhale while extending the right arm and left leg and lifting them off the mat until they are parallel to the floor.
• Inhale and return to the starting position.
• Exhale and switch to the opposite arm and leg.

3. Piriformis Stretch (3 sets, 15–30 seconds each side)

• Begin on hands and knees and bring the right foot in front of the left thigh until the lower right leg is perpendicular to the torso and resting on the mat.
• Extend the left leg straight back on the mat.
• Sit tall, using the arms for balance. Hold, then switch sides.

Daniels, D. 2003. Pilates Perfect: The Complete Guide to Pilates Exercise at Home (pp. 130–96). Long Island City, NY: A Healthy Living Book.

American Association of Neurological Surgeons, www.neurosurgerytoday.org

Cleveland Clinic, www.clevelandclinic.org

Mayo Clinic, www.mayoclinic.com

National Institute of Neurological Disorders and Stroke, www.ninds.nih.gov

Single Leg Stretch

Swimming

Double Knee-to-Chest Stretch

Single Straight-Leg Stretch

Double Leg Lift Four Points

Opposite-Arm-and-Leg Lift

Many things can cause low-back pain—muscle strains or spasms, joint disorders, herniated disks, etc. Not all low back injuries are completely preventable, but here are some tips to reduce the overall incidence and severity of low back pain.

1. Don’t lift by bending over. Instead, bend the hips and knees and then squat to pick up an object. Keep the back straight and hold the object close to the body. Avoid twisting the body while lifting.

2. Push heavy objects instead of pulling them.

3. When sitting for long periods, break up the time by stretching every 30–45 minutes.

4. Exercise regularly. Inactivity contributes to back pain!

5. When sitting, try to use chairs with straight backs or with low-back support. Keep the knees at hip height or slightly higher. If necessary, use a low stool to prop up the feet.

6. If standing for long periods, rest one foot on a low stool to reduce the pressure on the spine. Every 15 minutes or so, switch the foot that is resting on the stool.

7. Always, always maintain good posture.