The Lumbar Spine
Lumbar Spine Anatomy, Common Injuries and Postrehab Strategies.
The spinal cord begins as an extension of the brain. It is surrounded by the bony vertebral column, which acts as a protective mechanism. Any information (sensory or motor) that the brain needs to relay to the body travels via the spinal cord. Fortunately, the spinal cord is protected by vertebrae, so spinal-cord injuries are not common, and most clients in postrehabilitation for low-back pain will have lesser impairments.
Vertebral Bodies, Disks and Nerves. The lumbar spine consists of five articulating segments that move to flex, extend, side-bend and rotate the torso. The lower in the vertebral chain the vertebrae are, the larger they are, since the lower lumbar vertebrae are important in load bearing. Between the vertebral segments are intervertebral disks consisting of a central fibrogelatinous mass containing 80%– 90% water and a peripheral annulus formed by cartilaginous fibers. Individual nerve roots exit on each side of the vertebrae to become nerves that enable sensation and movement in the lower body (Kibler 1998).
Muscles. There are three groups of muscles in the back: superficial (trapezius, latissimus dorsi); intermediate (serratus posterior); and deep (erector spinae, multifidus). The superficial and intermediate groups are extrinsic muscles that are concerned with limb movements and respiration, respectively. The deep group consists of intrinsic back muscles that enable movements of the vertebral column (Moore 1992).
Muscle strains are a very common back disorder. They can result from a traumatic event or simply poor ergonomics with daily activities. In the early, or “acute,” stages of a muscle strain, exercise will aggravate symptoms, although gentle stretching may be indicated. A client at this stage must be under the care of a physician or other healthcare professional, who will say when the client can begin exercise.
Even a client who gets the go-ahead to resume exercise must avoid any movements that elicit pain. Extend the normal warm-up and stretching routines to ease the transition back to activity.
Early Postrehab (up to 4 weeks)
Core Strengthening. Perform these exercises within a comfortable range of motion.
1. Isometric abdominals (30 reps).
- Lie supine with knees bent.
- Contract abdominals by drawing two sides of ribs closer together.
- Hold for 7 seconds, then release.
- Lie supine with knees bent and feet planted under knees.
- Contract abdominals, tighten gluteals and push through heels up into bridge position.
- Hold for a count of 3. Then slowly relax down to starting position.
- Kneel on all fours, with spine in neutral position.
- Exhale, tighten abdominals and round the back, drawing belly button toward spine. Hold for full exhalation.
- Inhale in slightly arched or neutral spine position (as comfortable).
- Begin in side-lying position, with knees bent to 90 degrees and one elbow placed directly under shoulder.
- Exhale up into side bridge position (straight line from top shoulder to top knee).
- Hold for 7 seconds. Then relax down to starting position.
1. Hip flexors (3 reps per side).
- Kneel and lunge either leg forward while keeping spine upright.
- Hold for 30 seconds.
- In supine position, client raises one leg. Trainer manually stretches hamstrings of raised leg while client maintains neutral rotation of opposite leg.
- Hold near comfortable end range of motion for 30 seconds.
- In supine position, hug one knee to opposite shoulder.
- Hold 30 seconds.
- Treadmill/water walking.
- Recumbent cycling.
Modifications and Lifestyle Strategies
- Avoid lunges, step-ups, squats and other exercises that require increased use of core-stabilizing muscles.
- Perform leg extensions/curls unilaterally or bilaterally, according to tolerance. Depending on the muscles involved, a client may feel asymptomatic in one type of execution and not another.
- Initially avoid running and exercise on rowing machines and elliptical trainers with moving arm extensions. Begin with treadmill walking, recumbent cycling or aquatic activity, as tolerated.
Sciatica is a term used to describe pain felt along the distribution of the sciatic nerve, the longest nerve in the body, which exits from the lumbar spine and travels through the buttocks region and into the lower leg. Sciatica can cause numbness, tingling, muscle weakness and pain in the affected leg.
Afflicted individuals may complain of symptoms with flexion-based activities, such as bending or sitting. A diagnosis of sciatica can be made only by a healthcare professional, who may prescribe medication and physical therapy to ease the irritated or inflamed nerve. Causes of this irritation or inflammation can include a herniated (displaced) disk in the lower spine, or pressure on the nerve from arthritic growths.
To progress clients safely and effectively, stay in contact with their healthcare professionals, who may recommend rest, limited activities and specific exercise restrictions.
- Prone opposite arm/leg lifts (3 sets, 10 reps per side).
- Quadruped opposite arm/leg lifts (3 sets, 10 reps per side).
- Bridges (3 sets, 10–15 reps).
- Assisted hamstrings (hold 30 seconds, 3 reps per side).
- Piriformis (hold 30 seconds, 3 reps per side).
- Abdominals (10 reps): In prone position, with hands gently tucked under shoulders and pelvis down on mat, press up through palms until stretch is felt in abdomen or until pelvis begins to lift. Hold for 3–5 breaths, then lower.
- Treadmill/water walking.
- Recumbent cycling.
Modifications and Lifestyle Strategies
- Practice good posture throughout the day. Increased spinal flexion can aggravate the sciatic nerve.
- Avoid sitting or standing for long periods.
- Avoid wearing high heels.
- When lifting, use hips and legs with good ergonomic positioning, even if the weight seems light.
- Stretch, stretch, stretch!
Lumbar spinal stenosis is generally recognized by radiating pain in the buttocks and lower extremities and is aggravated by standing or walking. Lumbar spinal stenosis is a narrowing of the space in the spine that contains the nerves going to the lower extremities. This space is very small to begin with and may become even smaller when additional bone and tissue grow inside it. Arthritis, trauma and years of wear and tear on the bones and joints can also play a role. The lessened space for the nerve may result in pressure on the nerve and cause back or leg pain, or leg weakness.
1. Supine marching (3 sets, 10 reps per side).
- Begin supine with neutral spine, arms resting at sides, knees bent and feet planted.
- Contract abdominals and lift one foot off mat without altering spine position. Lift only as high as possible while maintaining neutral spine.
- Begin in same position as supine marching but with arms extended overhead.
- Raise one knee and move opposite hand toward that knee while maintaining neutral spine and contracting abdominals.
- Perform in supine position, with knees bent and feet planted.
- Single knee to chest (hold 30 seconds, 3 reps per side).
- Double knees to chest (hold 30 seconds, 3 reps per side).
- Seated hamstring stretch (hold 30 seconds, 3 reps per side).
- Water aerobics.
- Stationary cycling.
- Elliptical training.
- Choose seated weight exercises instead of standing ones.
- Avoid long periods of standing or walking.
- Take breaks between exercises: Sit, or stretch knees toward chest.
All postrehab low-back clients should progress gradually back into their normal exercise routines, paying special attention to any return of discomfort. Always begin with exercises that do not require high levels of abdominal or low-back stabilization to complete the movement; for example, begin with a leg press before progressing to squats. Clients whose symptoms return should be referred back to their healthcare professionals for further evaluation.
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As the client in postrehab for low-back pain progresses, you can integrate spinal stabilization exercises into the program to optimize strength and protect the spinal segments from overload or chronic, repetitive stress. Muscular support of the spine will give the client a stable base to produce efficient force transfer in the lumbar spine (Kibler 1998). There are many effective core stabilization exercises and methods of delivery.
- An exercise should never elicit pain. (There is a difference between fatigue and pain!)
- Begin with exercises in neutral spine position. Strengthen the smaller postural muscles before progressing to the erector spinae and abdominal muscles.
- Once neutral spine exercises are mastered, use a mix of extension (prone leg/ arm lifts), flexion (curls) and rotation (bicycle crunches), as tolerated, to recruit all the core muscles.
- Keep in touch with your client’s healthcare professional to make sure you understand any mechanical limitations the client may have. Some conditions preclude exercises in a particular direction or range of motion.
- Progress to multiple-plane exercises only when all single-plane exercises can be done without pain.
- Add resistance only when the client has mastered an exercise without resistance.
Hover (3–5 reps)
- Begin in modified plank position (propped up on elbows positioned under shoulders; hands clasped; feet extended back so there is a straight line from shoulders to heels).
- Hold 15–60 seconds.
- Begin on all fours in neutral spine position.
- Extend an opposite arm and leg and lower them to tap floor, then contract abdominals and lift arm and leg back until they are parallel to floor.
- Maintain neutral spine throughout.
- Begin in side-lying position with elbow propped under shoulder, legs extended in line with body.
- Exhale and press up to form one straight line from top shoulder to top ankle.
- Hold 5–20 seconds.
- Begin in supine position with knees bent and heels under knees.
- Extend one leg, tighten abdominals and extend up to a bridge position by pushing through weight-bearing heel.
Moore, K.L. 1992. Clinically Oriented Anatomy (3rd ed., pp. 330–60). Baltimore: Williams & Wilkins.
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