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1. STABILIZE: The Essential
     Exercise For Your Back
2. Science of Back Exercises
3. Spinal Segmental            
     Stabilization
4. Ultrasound Imaging Of
     Deep Stabilizing Muscles
5. Integration of Inner &
     Outer Units
6. Roman Chair Back
    Exercises For Strengthening
7. Functional Exercises For
     Your Back
8. Back Stiffness: Exercises
    And Stretching
9. Inversion Tables For
     Vertebral Distraction


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 Back Stiffness: Exercise and Stretching
by Howard A. Knudsen, PT
Doctor of Physical Therapy

Back Stiffness: Exercises And Stretching

Some researchers report that back stiffness is a symptom of low back pain, rather than the cause of it.  This concept makes sense if you understand how the muscles of your back work.  In recent review in Manual Therapy, Mark Comerford, PT and S. L. Mottram propose a new model of muscle classification.  They divide muscles into three groups:

(1) Local stability muscles.

(2) Global Stability muscles.

(3) Global mobility muscles.

Global mobility muscles are the large, strong, torque-generating muscles that produce range of motion.  A global mobility muscle will react to pain and pathology with spasm.  They also become overactive for low threshold recruitment during low load activities.  Examples are:

  • erector spinae (longissimus, iliocostalis),

  • quadratus lumborum (lateral fibers),

  • piriformis. 

So if back stiffness is a result of excessive activation or spasm of global mobility muscles, then we have to ask another question before we decide how to treat it.

Why does back stiffness occur?

On previous pages on this website, I explained that inner unit muscles become impaired with pain and pathology.  (The inner unit is synonymous with local stability muscles).  Local stability muscles react to pain and pathology with motor control impairments that may include: delayed timing, recruitment deficiency, decreased muscle stiffness, poor segmental control, and loss of control of joint neutral position.  These problems have been found to persist after lower back pain symptoms have resolved and the patient has returned to normal activities.

Limited ultrasound scanning allows us to visualize specific findings of impairment or dysfunction of the deep stabilizing muscles (local stability muscles), these may include the following:

  • A significant reduction of cross-sectional area of a segmental portion of multifidus on the painful side.

  • Poor recruitment of deep fibers of segmental portions of multifidus.

  • A significant unilateral loss of muscle tissue with increased fatty tissue infiltration within the multifidi.

  • Poor ability to recruit transversus abdominis, independently (from internal oblique).

When the local stability muscles are impaired or dysfunctional, the brain changes its strategy for low threshold recruitment during low load activities by compensating with excessive activation of the global, outer unit muscles for stability.  This may also lead to other problems, such as a change in the postural curvature of the spine. 

When the thoracic portion of the erector spinae muscles are overactive and the multifidi are impaired, we observe a long lordotic curve with the apex at the thoracoclumbar junction.  This may be thought of as a "bow-string" effect.  If the string of a bow is shortened, then the curve of the bow will increase.  This also happens with the spine and because these muscles attach to the thoracic spine, the lordotic curve becomes longer than it should be. 

Another complicating factor occurs when the upper thoracic spine becomes more kyphotic and stiff and the individual attempts to become more upright by extending through the hypermobile segment (typically the thoracolumbar segment).  Again this emphasizes the erector spinae over multifidus recruitment. 

During the initial evaluation of this type of patient (with long lordosis), we would expect to observe that there is no reversal of lordosis of the lumbar spine during forward flexion.  This is an obvious sign of lumbar spine stiffness. 

So how do I treat this type of lower back stiffness?

The initial focus should always be on the local stability muscles, if impairment is identified.  Multiple studies indicate that these impairments are reversible with specific muscle training.  As the patient progresses, we typically see a relaxation of the global muscles (in this example, the thoracic portion of the erector spinae) and the ability to reverse the lumbar lordotic curve while forward bending is re-established.  Your patients will subjectively confirm that they feel less stiffness in the lower back during daily activities.  But this is only the first step.

Next, we focus on "controlling the give" or hypermobile mechanical stress point, and "moving the restriction" or the joints that are stiff and have limited ROM (Comerford). 


 

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 Saturday April 21, 2007

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