Chronic Low Back Pain: The Athlete, the Weekend Warrior and the Desk Jockey
Joseph Rivieccio PT, DPT, OCS, CSCS
Board Certified Orthopedic Clincal Specialist
Just Stopping In – The Takeaways
- Current research supports that lack of strength and endurance of the “Core” musculature [abdominals, paraspinals, gluteals, diaphragm, pelvic floor, and hip girdle].
- Do strengthen these muscles as the primary focus in a plan of care developed to fix chronic nonspecific low back pain.
- Evidence dating back to 1992 has disputed the common claim that tightness in the iliopsoas leads to increased lumbar lordosis. Though commonly we still hear that we need to stretch the hip flexors for this very reason. Remember to always question current concepts.
- Do continue to stretch the hip flexors and quadratus lumborum, not for their effect on the lumbar spine mechanics which is still a hotly debated topic, but to help develop proper length-tension relationships, produce optimal force, and balance the muscles around the hip girdle.
- Scroll to the end of the article for actual exercises for your back pain.
I’m Here for the Long Haul……..
Chances are, regardless of your fitness status – professional athlete, a weekend warrior, or just your everyday 9 – 5 worker – you’ve had, or currently have, chronic low back pain. So whether you are training to become an exceptional athlete, play some recreational basketball, or just hope to work your damn job with no pain, this article is for you.
Non-specific low back pain is defined as “pain occurring at the low back that cannot be attributed to a recognizable pathology.” That means this article excludes treatment for pathologies such as herniated discs, stenosis of the spine, osteoporosis, spondylosis, etc. Chronic low back pain is the second most common reason for impaired function/disability in our society, and the issue is only getting worse. In fact, Freburger et al. found that the prevalence of low back pain in his home state of North Carolina has increased from 3.9% in 1992 to an alarming 10.2% in 2006. Considering the population of North Carolina is 10 million, that’s an increase of approximately 630,000 people per year that are now experiencing back pain. And assuming that no strange abnormalities are occurring in the state of North Carolina that would affect back pain, it’s safe to assume these types of increases are occurring across the entire United States. Possible mechanisms for this increase in back pain were unclear based on the study, but links to increasing obesity and depression have been noted1. Personally, as a health practitioner, I believe obesity, combined with a sedentary workforce, and lack of awareness of our bodies is what has led to this conundrum.
So, what are some common reasons for non-specific low back pain?
1. Significant mechanical trauma [not discussed in this article]
2. Repetitive stress injuries [such as repetitive jumping and landing, or receiving technique in the bottom of a snatch]
3. Postural stress injuries [due to a 9 -5 job where we sit all day]
In the latter two instances, you may wonder, “but why do I have low back pain from playing basketball or sitting down all day? I go to the gym, I work out, I’m fit, aren’t I?” The answer to that question may be as simple as reflecting on the questions, “Am I fit in the right areas?” and “Do I even know what those areas are?”
The Areas: Core Endurance & Strength and Muscular Tightness
Core Endurance & Strength
First, we will discuss core stability and strength, and the implications these may have on low back pain. The core described by Abdelraouf et al. includes the abdominals anteriorly, the paraspinals and gluteals posteriorly, the diaphragm superiorly, and the pelvic floor and hip girdle musculature inferiorly2. Poor functioning of the “core” can lead to impaired motor control and increased fatigue of the trunk muscles, in both the athletic and sedentary populations, making us predisposed to low back injury3,4. In his study, Abdelraouf et al. used the McGill Core Endurance Tests picture below to screen both asymptomatic athletes and athletes with no specific low back pain. They found significant difference (p<0.05) between the results for low back endurance test values between the two groups2. If that’s not enough, and you think to yourself, “well, I’m not an athlete so this doesn’t apply to me,” think again. In a recent study published in 2017, Sions et al. found, through muscle cross sectional analysis via MRI, that older adults with nonspecific chronic low back pain showed smaller trunk musculature, particularly in the erector spinae and higher muscle – to – fat index in their multifidi when compared to study participants without back pain. Furthermore, they also found that women had smaller trunk muscle cross sectional area (CSA) and higher intramuscular fat content when comparing spinal levels to men. Lastly, quadratus lumborum muscle quality was found to be the poorest amongst all the muscle groups studied in both men and women.
So, what exactly does this mean?
This essentially means that when compared to an athlete who is asymptomatic, the “core” muscles listed above of an athlete with nonspecific low back pain will falter first during activity. Proposed mechanisms for why this can be a problem include: hinging on ligamentous or other pain-sensitive structures of the lumbar spine due to lack of muscular control, aberrant motion of the lumbar vertebrae, and dysfunctional motor coordination/patterns leading to sub-optimal force translation through the lumbar spine. The findings in the recently published Sion et al. article regarding trunk muscle CSA are in agreement with other published studies indicating that trunk muscle endurance/strength play a primary role in nonspecific low back pain. Thus, improving the strength of the trunk musculature in all planes and reducing intramuscular fat content – which resistance training is suggested to promote – should be a critical focus of any low back pain intervention program5.
So how do I know if my “core” muscles are up to par?
Two normative data charts can be used to determine the status of our core musculature: the McGill Core Endurance data charts and the Biering-Sorensen Test normative data. Via research, poor scores on either have been correlated to increased incidence of non-specific low back pain. Per Biering and Sorensen, a positional hold of 176 seconds or less for males predicted the onset of low back pain during the next year, while a hold of 198 seconds or more indicated no dysfunction over the year6,7. Unfortunately, Biering and Sorensen were unable to come up with any predictive norms for females. Included below is the normative data table for the McGill Core Endurance Test as well as pictures indicating testing positions.
McGill Core Endurance Tests & Normative Data
Muscular Tightness
Another commonly referenced reason for low back pain is muscular tightness of structures attaching to the pelvis and spine which, amongst many, include the two big ones: the psoas complex and the quadratus lumborum. Frequently, the idea is that through their articulations to the pelvis and the lumbar spine, tightness of these muscles can play into the size of lumbar lordosis or low back arching a person may have, which can lead to nonspecific low back pain. Though this is a common idea that is thrown around, in 2002 Nourbakhsh et al. determined, both through review of literature and their own study, that the iliopsoas or hip flexors play a compressive role on the spine and have a negligible role on rotatory motion of the low back, and thus do not increase lumbar lordosis. Essentially, they along with several other researchers, have started to raise doubt regarding this common idea about the role of the hip flexors and low back pain. Looking back through the available research, you can find studies dating back to 1992, when Bogduk et al. noted that the moment arm is too small to act to move the lumbar spine, and noting instead it acts to provide compression and shearing forces8. Frequently, hip weakness, lack of stability, and compensation by synergistic hip flexor muscles is the more prevalent finding, tying into our theme of a strength focus when programming for low back pain.
As a clinician, I am not trying to throw away a long-standing theory that both my clinical mentors and I learned during our schooling, but I do feel that as a good clinician, I should be following the evidence. If that evidence is beginning to point towards an alternate idea, or is disproving a previously held idea, then we should be considering these points. So, while I am not advocating against stretching the hip flexors, I am advocating that we provide our clients and patients with correct rationale as to why we are doing it. In regards to hip flexor and quadratus lumborum tightness, I would advocate for stretching the two muscle groups mainly because, despite the effect on the lordosis of the spine, we do know that most muscles function optimally at a certain length-tension relationship. If our iliopsoas or quadratus lumborum are shortened or hypertonic due to over-activity or posturing, they are certainly not functioning at optimal length-tension relationships, leading to dysfunctional movement patterns. As we found out above via Abdelraouf, aberrant movement patterns, combined with trunk muscle fatigue, are a mechanism for injury to the low back. We also know that if we are tight around a joint in one direction, it will impact our ability to move in the opposite direction. For example, if our hip flexors are tight, odds are our hip extension, particularly end-range, will be either unattainable or extremely weak. Nourbakhsh et al. did find significant links between abdominal, hip, and trunk extensor strength in clients with and without low back pain9, reminding us of the importance of keeping our hip girdle musculature balanced and strong. I would suggest keeping flexibility of these muscle groups in a low back pain program, though the primary emphasis should be on muscular endurance and strength.
Other common reasons for nonspecific low back pain that you may hear get thrown around are increased lumbar lordosis, foot pronation, pelvic tilting, foot arch, and various muscle length issues of the lower extremities. Interestingly enough, Nourbakhsh et al. found minimal to no correlation whatsoever with the above-mentioned deficits in function and non-specific low back pain. If you are interested, you can find the article below, which also cites several other studies coinciding with these findings9. My general take away is that we cannot forget to look at the big picture when assessing for injury because there are always outliers along the bell curve and exceptions to every rule, but when all the evidence points in the same direction, we should start there.
Now that we have determined the primary causes of chronic low back pain, what are we going to do about it?
Exercise, of course. Recently, an opioid and pain medication epidemic has taken over this country and people are as quick to reach for a needle to fix their pain as they are to reach for exercise. In fact, Freburger et al. determined in another study that less than 50% of the 684-people contacted in their study reported that they had received exercises from either a physician, PT, or chiropractor10. After all the research listed above, with correlating strength and endurance issues being the primary cause of back pain, it’s safe to assume we need to correct those deficits to reverse the pathology. Clearly opioids and analgesics make you feel a lot better, but do they improve the underlying issues and help prevent the problem from coming back in a few months? They answer is usually a resounding no.
So, which exercises should I use? [Here are some simple ones for starters]
The important thing is to remember that all of these drills can be regressed or progressed to challenge the client/athlete. Remember, assessment and form are the most important factors when determining where to start with any exercise.
Bird Dog
McGill Curlup
Side Plank
Hip Flexor Stretch QL Stretch
Have Fun with It! Core Training Comes in Many Different Shapes
Suit Case Carry Overhead Carry
Anti-Extension Dead Bug Dead Bug
Quick Thought: Relative Stiffness for Athletes and Chronic Low Back Pain
Relative stiffness is essentially the idea that tightness or stiffness around one joint, whether it be from capsule, muscular, or arthrokinematic faults of the joint, will affect what happens at an adjacent joint. For example, if we are deadlifting, as an athlete we want relative stiffness in our low back when we move to ensure we are not creating too much lumbar flexion or cranking into lumbar extension with a heavy load. In order to ensure this occurs, we need less relative stiffness in our hamstrings to ensure we can get ourselves into a proper start position with our hamstrings loaded and our lumbar spine in neutral. If we cannot load our hamstrings in our set up because they are too tight, and in fact tighter than the stiffness we have at our lumbar spine, we will most likely get the motion from somewhere else. That somewhere else is often our low back, leading to poor movement patterns and eventually some sort of low back injury whether it be muscular, facet, or disc.
Quick Thought: Immobility for the Older Adult and Low Back Pain:
Another big issue I often see in the clinic is periods of immobility with chronic low back pain. Now, don’t get me wrong. I don’t see any problem with resting following an acute back injury. It’s usually necessary, especially if the pain is so severe that movement is killing you. But often what occurs after all the acute management of an initial back strain, is that a period of immobility sets in where older adults tend to fear movement, or are apprehensive that they will elicit back pain again, so they become immobile for long periods of time. Eventually, they end up coming to the clinic and they are fearful of motion and usually in worse pain than they started with. The take away here is that yes, rest is critical following an acute injury, but we need to reintroduce motion once we are able. Especially considering all the evidence above that shows that weakness is the primary culprit for nonspecific low back pain. Sitting around all day, allowing ourselves to get tight around all of our joints, and worse, becoming weak, is no way to cure back pain. In fact, we are probably making it substantially worse. We are humans, we are meant to move. Immobility is death!
References
1. Freburger JK, Holmes GM, Agans RP, et al. (2009) The Rising Prevalence of Chronic Low Back Pain. Archives of Internal Medicine 169(3): 251 – 258.
2. Abdelraouf OR, Abdel-Aziem AA. (2016) The Relationship Between Core Endurance and Back Dysfunction in Collegiate Male Athletes With and Without Nonspecific Low Back Pain. Internal Journal of Sports Physical Therapy 11(3): 337 – 344.
3. Tsao H, Druitt TR, Schollum TM, et al. (2010) Motor Training of the Lumbar Paraspinal Muscles Induces Immediate Changes in Motor Coordination in Patients with Recurrent Low Back Pain. The Journal of Pain. 11(11): 1120 – 28.
4. Sung Ps.(2013) Disability and Back Muscle Fatigability Changes Following Two Therapeutic Exercise Interventions in Participants with Recurrent Low Back Pain. Medical Science Monitor. 19: 40 – 48.
5. Sion JM, Elliot JM, et al. (2017) Trunk Muscle Characteristics of the Multifidi, Erector Spinae, Psoas, and Quadratus Lumborum in Older Adults With and Without Chronic Low Back Pain. Journal of Orthopedic and Sports Physical Therapy. 47(3): 173 – 179.
6. Latimer J, Maher CG, Refshauge K, et al. (1999) The Reliability and Validity of the Biering-Sorensen Test in Asymptomatic Subjects and Subjects Reporting Current or Previous Nonspecific Low Back Pain. Spine Journal. 24: 2085 – 2090.
7. Demoulin C, Vanderthommen M, Duysens C, et al. (2006). Spinal Muscle Evaluation Using the Sorensen Test: A Critical Appraisal of the Literature. Joint Bone Spine. 73(1): 43 – 50.
8. Bogduk N, Pearcy M, Hadfield G. (1992). Anatomy and Biomechanics of the Psoas Major. Clinical Biomechanics. 7: 109 – 119.
9. Nourbakhsh MR, Massoud A. (2002). Relationship Between Mechanical Factors and Incidence of Low Back Pain. Journal of Orthopedic and Sports Physical Therapy. 32: 447 – 460.
10. Freburger et al. (2009) Exercise Prescription for Chronic Back or Neck Pain: Who Prescribes It? Who Gets It? What is Prescribed? Arthritis & Rheumatism. 61(2): 192.