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Exercising for Lower Back Pain
Step Two Core Strengthening
by Emery Paredes, PT

Back pain, back pain, back pain. It either lingers and lingers or if it does clear up after a few days it seems like it “goes out” every few weeks or months, often for little or no apparent reason.

Every healthcare professional who specializes in back pain talks about strengthening your core. We hear a lot about this thing called your “CORE”. What exactly is the core and why on why is it so dang important?

By definition the word core refers to the center. But where exactly is the center of your body or center of your back?

On that note let me divert for just a second and let’s look at the structure of a pocket knife. Hang on hopefully it’ll make sense in a few sentences. A pocket knife has a blade, a handle and a hinge. What’s the most important part of that knife?

Some may argue the blade because without the sharp cutting or penetrating edge of the blade what is a knife at all? Some may say the handle because without the handle the user would have a lot of lacerations.

I would disagree with both and say the hinge because without a strong reliable hinge that locks the blade into a closed or open position the pocket knife becomes unpredictable and a potentially dangerous instrument. Without a good reliable hinge mechanism capable of holding the position set by the user the pocket knife would be highly unstable.

Okay back to backs. Your pelvis is the hinge. It hinges the lower part of your body to the upper part of your body. Just like the pocket knife both the upper and lower parts have very utilitarian functions. The lower part we tend to think of being used for ambulation (getting around) and the upper part for survival skills like preparing food and keyboarding sentences on back pain. The structure that hinges the lower part to the upper part is your pelvis.

The lower part and the upper part pivot on your pelvis. What attaches the upper and lower parts is a series of muscles, ligaments and tendons.  In our previous article on rehabbing the lower back we talked a lot about flexibility. If our pocket knife is rusty it isn’t going to open or close properly. In fact trying to open or close a rusty pocket knife is dangerous. In your back flexibility is the oil that allows for smooth, easy open and closing motions.

In this article we are going to show you how to strengthen the muscles, tendons and ligaments that hold the blade and the handle in the desired position while performing the intended tasks. The pocket knife is pretty simple because it opens and closes. The back is a little more complex because it opens (bends backward), closes (bends forward) but also twists and bends sideways. Natures Extremely amazing and extremely complex, but very fixable when the proper steps are followed.

I’m going to include a FOR GEEKS ONLY SECTION at a few points in this discussion. Some people have to know everything and will Google search them to death to look at muscle charts and review exercise physiology literature reviews (not that there’s anything wrong with that!). I get geeky about some things but mostly I’m the “Where’s the Beef” kinda guy. So, bear with me because otherwise we’ll get letters. For the rest of us who just want the meat and potatoes you can skip the paragraphs labeled “for Geeks Only” and don't feel overwhelmed with the big Latin muscle names. You can skip over them without missing the key points. Here we go . . .

For Geeks Only
The core consists of several groups of muscles including transversus abdominis (deepest abdominal muscle), multifidus (deepest back muscle), diaphragm and pelvic floor muscles. When we have injury or pain in our lower back these muscles are reflexively inhibited (shutdown). This forces the superficial muscles of our trunk (movers of the spine) to work harder, causing further pain and raising the susceptibility of re-injury due to our weaker core region. This is a problem caused by an error in our nervous system when there is disruption in communication between our brain and core muscles. This problem does not spontaneously improve once our pain resolved. Motor learning or neuromuscular reeducation must be employed through the use of core stabilization exercise.

ZZZZZ zzzz. . . Huh, oh sorry. Anyway the core muscles are responsible for stability, balance, posture and are the foundation for movement. They work together to allow us to perform our daily activities such as getting up from lying or sitting, putting on shoes, household chores, gardening activities, jobs that involve bending, lifting and prolonged sitting, and sport activities such as golf and tennis.

What Are we Going To Be Doing?
Rehabilitative exercise is generally classified as active or passive. Passive is when someone assists you in the exercise. Early in the rehab process we assist patients too weak or too inflexible to them on their own. This is passive exercise. Active exercise is doing the movements unassisted. Both are important but active is the key because once you are done with rehab you WILL have to do the basic exercises on your own to maintain core strength.

Core stabilization is an active form of exercise (you do them with little to no assistance from others). With core stabilization exercise our goal is to provide:

  • pain relief
  • provide spinal and postural alignment
  • regain stability
  • gain control of spinal and pelvic movements
  • reduce the risk of re injury in the back

The phases of core stabilization we will start with basic core exercises and transition to advanced core exercises. We've attempted to give you a pictorial description of the exercises needed to strengthen your core muscles but we've also provided a short video for a hopefully clearer picture of how to do the base exercises.

The Pelvic Tilt
The first step before starting any of the core exercises is determining your pain-free neutral spine position. This is the position that all subsequent exercises should be performed in. Start by standing erect and then rotating your pelvis by flattening or arching your lower back with your feet flat and legs straight. This procedure called the pelvic tilt helps find the best alignment given your back condition. The neutral spine position for you is the position that feels the least painful. You should make a mental note of that position and maintain during all exercises and as much as possible in all daily activities.

The pelvis is like a big bowl with no bottom. There are muscles that crisscross forming the bottom of the bowl. A strong bowl bottom is important because we all have a whole bunch of heavy organs that hang from the spine and rest on these bottom muscles. If the bowl muscles are weak the organs end up over-pulling on the spine (ouch!!)

The spine consists of 24 small bones held together by ligament and muscles (rubber bands). There are a lot of very strong muscles that line the back of your spine but very few that line the front of it. To support the front we rely on strong abdominal muscles. The abdominal muscles act just like girdle, pushing the abdominal organs up against the front of the spine to give support.

A few decades ago we used to think that giving patients lumber supports (abdominal corsets) was the answer. While they often made the back feel better, what we found out was that the corsets actually allowed the core muscles to get weaker. (The abdominal muscles went on vacation while the corsets did all the work). Strong abdominal and pelvic floor muscles are a key to supporting the low back.

Activation vs Isotonic Exercise
We are going to be teaching you two different types of exercises. Activation is refers to isometric exercise. Isometric is a contract and hold type exercise. There is classically no movement involved just a tightening up experience. This type is used when we force a bowel movement or deliver a baby. Isotonic exercise is muscle contraction with movement. Walking or lifting weights would be isotonic exercises.

Step 1: Isolated Pelvic Floor and Transversus Abdominis activation.
This first exercise is usually performed in a back-lying position. To gently contract the pelvic floor, imagine having to urinate but needing to control your bladder. Once you have good ability to activate the pelvic floor muscles, begin to pay attention to transversus abdominis (abdominal muscles). Gently pull your abdomen straight back toward your spine. Be sure to maintain the spine in neutral position and do not flatten your spine against the floor. You can feel if you are tensing the muscles by placing your fingers just inside the front corners of your pelvis. You will feel like a light, deep tension under your fingertips without the feeling that a muscle is bulging up into your fingers. You must be able to breathe quietly and normally while holding these gentle contractions.

Hold each contraction for 8-10 seconds and perform 10 repetitions. Maintain normal breathing pattern while holding the contraction. No actual movement of the hip, pelvis and spine should occur. Once you have good ability to do this contraction in one position, try it in different positions such as on side-lying, hands and knees, sitting and standing.

Step 2: The Combined Pelvic Floor, Transversus and Multifidus activation.
Ever get through a bout of low back pain only to have it return weeks or months later. Want the solution? (Of course you do, dah?!) There’s a big muscle along the back of your spine that functions together with the two muscles mentioned above called the multifidus muscle. It helps to stabilize the low back and pelvis before any movement occurs.

The multifidus isn’t always a team player and when he decides not to participate BAM the spine misaligns or the disc gets pinched or the other muscles get caught off guard and end up spasming. Just like a navy seal the multifidus has to drilled in team work and respond properly in unusual circumstances.

The multifidus is a deep muscle located along the back of the spine. It functions together with transverus and pelvic floor muscles to stabilize the low back and pelvis before any movement occurs. Low back pain causes a delay or absence in the contraction of the multifidus. If this problem is not corrected, the dysfunction will remain even after your pain has subsided increasing the incidence of re-injury. Contract pelvic floor muscles, transversus and multifidus all together without any other muscles activating at the same time. Place the tips of your fingers close to your spine to palpate the multifidus. You will feel like a slow, firm and swelling under your fingers.  Take the time to focus on your technique in achieving correct co-activation of your core muscles before moving on the next step.

Hold each contraction for 8-10 seconds and perform 10 repetitions. Maintain a normal breathing pattern while holding the contraction. No actual movement of the hip, pelvis or spine should occur. Once you have a good ability to perform co-contraction of core muscles in one position, try it  in different positions such as on side-lying, on hands and knees, sitting and standing positions.

Step 3: Strengthening the core muscles (Pelvic floor, Transversus and Multifidus).
Once you are able to perform co-contraction of core muscles, you can start challenging them to do exactly what they are designed to do, stabilize the trunk while you move your arms and legs in some way.  Adding loads through the trunk, legs and arms will functionally strengthen an optimal pattern for stabilization. This pattern of muscle activation can be integrated into any exercise you do.

These exercises require you to maintain the activation of your core muscles

Video Summary  . . . Click Here To Watch

Step 4: Integrating into other activities.
The final step is to learn to use the core during regular life activities. Each time you get up from the chair, put on shoes, push or pull anything, pick-up a pen, lift or bend, this stabilization pattern should be working correctly. The goal is to teach the body to continue connecting to the core before movement begins.

Strengthening Exercises To Improve Muscle Imbalances
Low back pain can be caused by muscle imbalances in the lower kinetic chain or postural problem. One of the most common postural problems is lower crossed syndrome also referred to as sway back or anterior pelvic tilt. This syndrome can be found in individuals who sit too long or perform tasks for extended periods of time with poor posture. Basically, it is an imbalance of tight and weak structures around the pelvis, hips and lower back. This imbalance of muscles will result in postural changes and movement dysfunction.

The individuals with lower crossed syndrome will likely show excessive arching of the lower back, a protruding stomach due to weakness in the deep abdominal muscles, and a flat butt due to weakness in the glutes. The treatment for this postural problem is to restore the flexibility of the tight structures ( back extensors and hip flexors) and strengthen the deep core muscles and gluteal muscles.

Below are examples of gluteal strengthening exercises.
•    Bridges
•    Side bridges
•    Clamshell
•    Side hip abduction
•    Squats
•    Lateral band walk
•    Forward and side lunges

You should not feel any pain while performing these core and gluteal exercises. Pain is not a good thing nor is it something which must be worked through to get better. It is advisable to always consult a medical professional prior beginning any exercise program.