In my last two blogs, I suggested these principles of Optimal Movement that we could be teaching our patients:
- Fascio-Skeletal Weight Bearing
- Appropriate Distribution of Movement
- Proportional Use of Synergists
- Minimization of Unnecessary Effort
I would now like get more specific by talking about the 800 pound gorilla of physical therapy; low back pain. According to that front of all medical wisdom, the internet, low back pain is the third most common reason for a doctor visit in the US. When coming out of PT school in 1983, lumbar stabilization wasn’t even on the radar screen. We stretched the back into flexion (William’s), extension (McKenzie’s), side-bending and rotation, then strengthened the back and belly muscles. The back hurt because it was stiff and weak; it would feel better if it were flexible and strong. A brief perusal of back pain books on Amazon will show that old ideas die hard; the stretch and strengthen paradigm is still alive and kicking.
Fast forward to the Age of Pilates and we have the more accurate idea that the back can hurt because of hypermobility. However, we tend to still have “if only” concepts of what it takes to stabilize the back. “If only” your multifidi and transverse abdominus were stronger you won’t have back pain. Hmmm. Even if you still sit habitually slumped at end-range flexion? Even if you still stand sway backed at end-range extension? If you twist with inadequate hip or thoracic rotation? If you bend with inadequate hip hinge? If you serve in tennis with a stiff thoracic kyphosis? There are larger forces at play in these scenarios which need to be addressed, along with a self-awareness component; what am I doing wrong/how could I move better?
Optimal movement principles germane to this topic are Appropriate Distribution of Movement and Proportional Use of Synergists. If your glutes/hams are tight and you are not using your hip flexors to prevent your pelvis from falling back into posterior tilt in sitting, you slump and over-stretch posteriorly. If your hip flexors are tight and you are not using your hip extensors to prevent your pelvis from falling forward into anterior tilt in standing, you lordose and jam. If your hip rotators are short, you twist too much at your lower back when golfing or working on an assembly line. If your thoracic spine has fossilized and the thoracic extensors are on permanent holiday, where might these deficits be made up?
There is current research that backs this up. For just a few examples, go to PubMed and type in:
- Relationship between the hip and low back pain in athletes who participate in rotation-related sports
- Hip stiffness patterns in lumbar flexion or extension-based movement syndromes
- Elimination of intermittent chronic low back pain in a recreational golfer following improvement of hip range of motion impairments.
- The hips influence on low back pain: a distal link to a proximal problem.
- Factors affecting shoulder-pelvic integration during axial trunk rotation is subjects with recurrent low back pain.
- The myth of core stability.
We’re not tossing out the baby with the bath water; core muscle activation has an important role, just not the only role. The game here would be to create situations where we simultaneously mobilize hips and thorax while keeping the back stable. This is much easier said than done; the types of exercise we have historically prescribed to improve hip or thoracic mobility are non-specific/global instead of pattern-specific/differentiated (more on these terms in the next blog). Because of the tendency to move in “paths of least resistance”, we need to be clever in how we position our patient to constrain lumbar movement and funnel movement and effort to under-performing areas.
Furthermore, our exercises should be linked to the specific functional contexts in which our patients run into trouble (bending, lifting, pushing, etc.) and should have a sensory training aspect; shape of the low back, location of movement or effort, etc. Motor adequacy (muscle length/strength), Sensory accuracy (proprioceptive acuity) and Intentional clarity (what’s my target) are the three indispensable aspects of human integrated movement; we can and should be including all three in our exercise programs.