Lower Back Pain:
Management and Prevention
Jon Rowe, Bkin, CEP
Objectives
• Review specific anatomy in relation to
the lower back (lumbar spine)
• Touch on a few spinal injuries and
mechanisms of injury
• How to determine some causes of lower
back pain (LBP)
• Action after identifying cause of LBP
• Management and Prevention
Sources
• McGill, Stuart; Lower Back Disorders,
2nd edition
• McGill, Stuart; Ultimate Back Fitness
and Performance, 4th edition
Anatomy of the Lumbar Spine
Highly vascular, with the exception
of the disk – only they remain
avascular
Circular vertebral body,
filled with cancellous bone
Pedicle attaches body
to posterior elements
“Neural Arch” is composed of
laminae and pedicles;
transverse processes
and spinous process
attach to neural arch
Neural arch is relatively flexible
while body is more rigid
Intervertebral Disks
• Rigid annuli surrounding
viscous nucleus
• Notice cross fibers of
annulus rings – allows for
greater protective forces
under compression in
multiple planes
Interspinous Ligaments
Some Key Musculature
•
•
•
•
Iliocostalis and longissimus both act
as thoracolumbar extensors; also
posterior shear force protectors,
moreso in the lumbar region
Thus, they are essential for
maintaining a neutral spine
Multifidus also act as extensors, but
more local to lumbar spine
Function can change through
thoracic flexion, hip flexion, and
lumbar flexion – erectors to shear
force protectors
Latissimus Dorsi
•
•
•
Involved in lumbar extensor moment
generation; often acts as a major
stabilizer
Originates at each lumbar spinous
process and inserts on humerus –
giving it a very large extensor
moment arm
Active during pulling and lifting,
which has implications for training
proper functional motion patterns
Abdominal
Complex
• rectus abdominus
• internal oblique
• external oblique
• transverse abdominus
• responsible for trunk
flexion, lateral flexion,
rotation, and stabilization
“Hoop”
Stresses
Psoas
• acts mostly as a hip
flexor
• when the hip is flexed,
psoas can also act as a
lumbar stabilizer
Quadratus
Lumborum
• lumbar
stabilizer
How does a normal spine
function?
• “[compression]…tolerance of the lumbar
spine in an average healthy young man
probably approaches 12 to 15kN (26883360 lb)”, LBD, p. 82
• Competitive weight lifters have safely
exceeded 20kN (4480 lb)
• The lumbar spine can withstand up to
2000-2800 N of shear force
When does injury occur?
Tolerance Until Failure
• “Injury, or failure of a
tissue, occurs when
the applied load
exceeds the failure
tolerance (or
strength of the
tissue)”, LBD, p11.
When the tissue fails…
Optimal Loading
• “…very few back
injuries…result from
a single event”,
LBD, p11
• Just as most
systems of the body,
the spine needs
appropriate loads to
improve capabilities
What are some causes of tissue overload?
• “…jobs characterized by manual handling of
materials, sitting in vibrating vehicles, and
remaining sedentary are all linked with lower back
disorder”, LBD, p 29.
• Though these risk factors do not necessarily
determine LBP/LBD, they are part of a list of
surrogate factors: “static work posture; seated work
postures; frequent bending and twisting; lifting;
pulling and pushing; and vibration (especially
seated)”, LBD, p 29.
The Spine Itself
• A purely ligamentous spine buckles
under 90 N of compression, about 20
lbs (LBD, p. 114)
• Since we know the spine can withstand
much more compression, this shows
how the musculature greatly increases
compressive load potential by acting as
“guy wires”
What are some specific injuries?
• Bulge/Herniation
• Compression +
flexion, especially full
flexion = herniation
• Add rotation and the
disk tends to bulge
away from the axis of
rotation
• Spondylolisthesis
• Full cycling of flexion
and extension can
fatigue the neural
arch (laminae and
pedicles)
• Excessive shear
force can cause
damage to posterior
elements
Lower Back Pain vs. Injury
• Assuming spinal injury is not present, ie:
fracture, bulge, spondy, avulsion,
neural, etc.
• Assess each client to see what
movement causes the pain or where
deficiencies lie
After Injury
• It is necessary to identify the mechanism of injury,
ascertain potentially injured tissues (bone, ligament,
muscle, etc); and develop the next plan of action
• There is strong evidence to support that after a lower
back injury, muscle activation patters are altered
• “…stability comes from stiffness, passive stiffness is
lost with tissue damage and active stiffness
throughout the range of motion is lost with perturbed
motor patterns following injury”, LBD, p. 119
McGill’s 5 Steps
1. Groove motion patterns, motor
patterns, and corrective exercise
2. Build whole-body and joint stability
3. Increase Endurance
4. Build Strength
5. Develop speed, power, agility
1. Grooving Patterns
• It is important to begin corrections pain
free
• Neutral spine is desired and should never
be compromised in this phase
• Proper motor control is correct muscles
engaged for corresponding movement
• Eg: gluteal amnesia following injury
• Eliminate the faults in testing movements
2. Spinal Stability
• “Big Three”
1. Curl-Up
2. Side Bridge
3. Birddog
• Abdominal bracing vs. hollowing or
protruding
• Fascial raking
Why the “Big Three”?
•
•
•
Curl up imposes minimal
compressive loads to the
lumbar spine and allows neutral
lordodic curve
Side Bridge activates entire
abdominal complex, plus lower
back stabilizers like QL and lats,
while maintaining neutral spine
Birddog activates entire set of
spinal extensors, though not to
MVC, while keeping the spine in
neutral
• Compressive forces reach
~3000N
•
•
Traditional sit up imposes
~3300N (~730lbs) of
compression on lumbar spine;
plus add full flexion!
“Superman” extension exercise
can impose up to 6000N (over
1300lbs) of compression on
spine; Roman Chair extension
can impose over 4000N
(~890lbs), LBD, p. 91
3. Building Endurance
• Do not take muscles to fatigue failure
• Complete repetitions while muscles are
still strong: McGill advocates reverse
pyramid reps/sets
• Side plank, birddog, chin ups, squats
4. Building Strength
• This is where you get creative
• Know what will be required of your client
and train them accordingly
• Be sure to maintain proper progression
• Never let a regression of technique
occur: DO NOT compromise neutral
spine!
• Can introduce labile surfaces: SB,
wobble boards, Airex pads, etc.
5. Develop Speed, Power, Agility
• Once sufficient endurance and strength
are achieved, performance skills should
be integrated into training regime
• Olympic Lifting, MB work, sport specific
exercises
“The motor control system is able to
control stability of the joints through
coordinated muscle coactivation and to
a lesser degree by placing joints in
positions that modulate passive
stiffness contribution. However, a faulty
motor control system can lead to
inappropriate magnitudes of muscle
force and stiffness, allowing … for a
joint to buckle or undergo shear
translation”, LBD, p. 119.
Be wise…
…and be careful