Editor's note: This continuing series on the low back features this chiropractor-directed article and an accompanying lay article published in To Your Health, the monthly consumer magazine packaged with Dynamic Chiropractic. The companion to this article is titled "High-Risk Moments for Your Low Back" and appears in the June issue of TYH.
When it comes to rehabilitation, I have found it to be very useful to divide patient self-care exercises into the following categories:
- Category 1: Pain relief.
- Category 2: Self-mobilization. All of these exercises have to do with getting more normal movement into stuck muscles, stuck fascia and stuck joints. These could then be subdivided into functional activities: A. Stretching (length); B. Softening the fascia; and C. Self-mobilizing a stuck joint.
- Category 3: Stabilization; getting better stability for injured, degenerated or inhibited joints and muscles.
- Category 4: Strength training.
The first category of rehab exercises is pain relief. McKenzie comes to mind for the disc; Don Tigny's basic single-leg, hip and knee flexion for the SI, or for any flexion-biased patient. Cat and camel, done on all fours, is both a great warm-up and often gives relief. Also, let's not forget a simple rest position, lying on a carpeted floor with the knees and lower legs up on a chair. If all of our lower back patients took 10 minutes in the middle of the day and rested their backs, they would all do better.
The second broad category is self-mobilization. I am using this term in a broader sense than it is usually used. As mentioned, I have subdivided this category into three types:
Stretching is aimed at tight, short muscles. Janda laid out the model, which has stood both the test of time and more rigorous research. Too often, stretching is done poorly and can do more harm than good. Aim at the muscles and use co-contraction to maintain a neutral posture. One of the worst offenses I see here are patients who are trying to stretch the pectorals, but end up stretching the shoulder joint capsule instead. I also see many hip flexor stretches that are excessive, taking the lumbar spine into hyperextension and taking the ilium into its loose-packed anterior rotation position - very dangerous positioning for a hypermobile sacroiliac.
Softening the fascia. It could be self-massaging a tight area. It could be using a ball, either firm or soft, to rub on and roll over the tight area. I teach my patients a home version of Graston Technique, having them use a butter knife or spoon to self-massage a stiff or tight area. It could be using a foam roller on chronically rigid fascial zones, such as over the TFL, hamstrings or thoracic spine.
Stuck joint. When the fixation is recurrent, self-mobilization can be very helpful. Don Tigny's flexion works wonders for a stuck sacroiliac. For a disc, we don't want excessive rotation or flexion, as the segment is likely to be hypermobile due to inhibition and delayed firing patterns in its key stabilizers, the multifidi and the psoas. Decompression could be thought of as a form of self-mobilization for a disc or lumbar degenerative joint disease patient. When the patient displays a recurrent specific fixation pattern, such as L4 resisting extension and L rotation, I will attempt to show them a way to use contract-relax to release that area themselves.
The third category of rehab exercise is stabilization or core training, which could be subdivided into two types: motor control and functional training. Stabilization aimed at motor control focuses on waking up inhibited local and global stabilizers. One of the benefits of this is in quieting the irritability around a damaged joint, such as a disc or any part of the degenerated spinal segment. The damaged joint develops a vicious cycle. It tends to move too much, creating pain signals, which then shut down the smaller intrinsic muscles that are supposed to keep that joint from moving too easily.
The second type of stabilization includes variations on functional training, with the goal of strengthening the core musculature under the types of loads occurring in everyday life. This usually involves asymmetric challenges that give the core the responsibility of slowing or stopping excessive motion.
The final category of rehab exercise is strength training in a gym. If these exercises are done with free weights, they will create a challenge to the more proximal stabilizer muscles and will support stabilization.
So, what does your program for your lower back patients look like? If they are in pain, make sure they know what exercises will help decrease the pain. Watch them do their stretches, and correct obvious errors. You can show them how to soften their fascia. I know you are going to find the fixations and correct them with adjustments. If they recur, show the patient self-mobilization for their typical fixated areas. If they sit too much and/or if you suspect discogenic involvement, show them simple decompression tools to be used frequently. Use functional testing to assess what core muscles are not working properly and have them focus on addressing these issues.
Always emphasize form and quality of movement over repetitions and gross strength. Have them pay attention to their core through maintaining neutral spine and using co-contraction in their daily activities and in their strength-training. Don't forget breathing; emphasize proper abdominal and lower rib-cage inhalation, and encourage the patient to breathe fully during exercise.
OK, I know I never make it quite as simple as you would like, but a basic rehab program is doable. Who is better qualified to teach these exercises than you? For back pain patients, the ideal rehab includes addressing fixated areas; you are the only one who is going to do that accurately. For back pain patients, functional testing and determining a diagnosis add to the specificity of the rehab. Who else is going to integrate these into a rehab program? I know we are not reimbursed well for teaching exercise. This will remain a problem, but don't let it stop you from doing the right thing.
One of the main benefits of rehab in my practice is simple: I attract better patients. They are motivated, they want to take care of themselves, and they participate. Some come in just expecting to be fixed, but if you have a rehab-oriented practice, they can learn to be part of the solution.
Author's note: Thanks to Craig Liebenson, DC, and Jeffrey Tucker, DC, DACRB, for classes, conversations and inspiration for this article.
Click here for more information about Marc Heller, DC.