Best practices for managing lumbar spine degeneration
By Jennifer Illes
Low back pain (LBP) is one of the most common diseases, with a prevalence rate of nearly 80 per cent of the population. Since there is a high potential for recurrence, successful rehabilitation is important in preventing the return of LBP.
Though there are various causes of LBP, the primary factors include damage to the soft tissues of the trunk and weakening of the muscles, leading to pain, decreased muscle endurance and flexibility, and restriction of spine movement.
Specifically, the deepest layer of lumbar spine muscles experiences more atrophy in patients with LBP, when compared with healthy controls. In addition to muscular atrophy, the contraction speed of their muscles is decreased. This type of muscle weakening may give rise to disc and joint degeneration, and potentially cause instability of the spine.
Another study reported that excessive mechanical load when applied to the spine caused irreversible alterations of cellular tissues. Therefore, a hypothesis of what then occurs is that once disc degeneration (i.e. alteration in the cellular tissue) had progressed, the vertical height of the disc decreases, instability of the spine develops, and the deep intrinsic muscles undergo atrophy, taking on a major role in destabilizing the spine.
It is important to keep in mind that there are many factors that contribute to the way each individual experiences degeneration in the spine. These can include mechanical, traumatic, nutritional, biochemical and genetic influences. Mechanical factors that can contribute to disc degeneration include extreme or excessive bending, lifting and twisting. Other factors can include age, occupation, cigarette smoking and gender.
Although some chiropractors may refer to other health practitioners or therapists for rehabilitative exercise, it’s important to use best-practice knowledge to guide patients toward correct management or co-management options. Recent studies have shown that spinal stabilization exercise for acute, subacute and chronic lower back pain patients produced a positive effect in terms of relieving pain, improving spinal function, and increasing functional activities of daily living.
Lumbar stabilization program
The lumbar stabilization program is a program of back exercises designed to teach patients strengthening and flexibility in a pain-free range. It not only improves the patient’s physical condition and symptoms but also helps the patient with efficient movement. It provides the patient with movement awareness, knowledge of safe postures, and functional strength and coordination that promote management of LBP. The basic concept of these spinal stabilization exercise programs is to enhance musculoskeletal capacity, which maintains the neutral posture of the spine by preventing excessive movement. Some researchers have focused on activating the transversus abdominis, multifidus, and psoas major muscles, because strengthening these deep muscles helps in stabilizing the spine quickly.
Stabilizing and strengthening the lumbar spine through a lumbar stabilization program is also an important part of a rehabilitation program for the patient with low back pain. It can be very confusing for the chiropractor because there are many different opinions and strategies involving spinal rehabilitation. Additionally, these exercise programs differ depending on a patient’s severity of the condition, ability to perform the exercises, and even stage of care.
Exercises for lumbar spine stability
This guide has two sections: flexibility and strengthening. These exercises should be performed daily or every other day for best outcomes. Although flexibility may seem boring to the patient – even the doctor – there needs to be muscular inhibition through post isometric relaxation (PIR), post facilitation stretch (PFS) or even static stretching to increase mobility. Ideally a more passive approach is best suited. However, since this program is to be done on a near daily basis, it’s best to just provide the patient with static stretching.
A lack of flexibility through the hips (hamstring, hip flexors, gluteus muscles) can contribute to low back pain, therefore it is important to work on this if the patient is experiencing back pain. Please make sure all stretches are pain-free. If the patient feels discomfort, he or she may not be ready to do that specific stretch.
- Quadriceps stretch. Have patient lie on stomach. Using a towel or band, pull the heel of the affected foot toward the buttock. Hold this stretch for one minute. Repeat three times each leg.
- Hip flexor stretch. Kneel with affected knee on the ground, same side arm goes back causing pelvis (hips) to shift forward, and back to extend. Hold for 20 to 30 seconds. Repeat three times each leg.
- Adductor stretch. Prop the inside of the ankle up on a table. Lean into the side being stretched. Hold for 20 to 30 seconds. Repeat three times each leg.
- Hamstring stretch. Prop the back of the heel up on a table, keep back straight, and lean forward at the hips. Hold for 20 to 30 seconds. Repeat three times each leg.
- Sidelying ITB/TFL Stretch. Lie on one side, use a towel or band and pull foot back as if stretching quadriceps. Use opposite foot to push down on distal part of leg. Hold this stretch for one minute. Repeat as needed.
- Supine abdominal draw in. Lie on your back on a table or mat, knees up with feet flat on table/mat. Pull the abs in and push your low back to the table/mat. Repeat 20 times.
- Abdominal draw in with knee to chest. Lie on your back on table or mat. Draw one knee to the chest while maintaining the abdominal draw in. Do not grab the knee with your hand. Repeat 10 to 20 times each leg.
- Abdominal draw in with double knee to chest. Lie on your back on table or mat. Bring both knees to your chest at the same time. Maintain the abdominal draw in throughout the entire exercise. Repeat 10 to 20 times.
- Abdominal draw in with heel slide. Lie on your back on table or mat. Draw the heel back towards the buttock while maintaining the abdominal draw in. Maintain as you return to the start position. Repeat 10 to 20 times each leg.
- Prone bridging on elbows. Using forearms/elbows on the table/mat, rise up so that the forearms and toes are resting; maintain the abdominal draw in. The back should be straight. Hold this position for 15 seconds to a minute. Progress to 15-second increments. Repeat five to 10 times.
- Supine dead bugs. Lie on your back on table or mat with arms perpendicular to floor and hips and knees bent to 90 degrees. Draw in abdominal muscles and maintain throughout exercise. Extend one arm above head while simultaneously lowering the opposite foot to the floor. Contract abdominal muscles to bring arms and legs back to starting position. Repeat on opposite side. Repeat 10 to 20 times.
Before commencing a lumbar stabilization program, the patient should first be evaluated by the chiropractor. The doctor will then design a comprehensive rehabilitation program with the above-mentioned techniques, along with any additional lumbar stabilization program specified to the patient. Since every patient is an individual and presents with different conditions, a chiropractor (or co-management with a PT) is needed to design and monitor the rehabilitation program.
Dr. Jennifer Illes, DC, is assistant clinical professor at D’Youville College’s Chiropractic Program. She has practised in Ontario, Florida and New York. She can be reached at email@example.com.