If I had to pick the one most important thing for preserving musculoskeletal health it would be maintaining full lumbar (low back) mobility. Of course it’s optimal to have normal mobility in every joint (including the mid back and neck joints) as well as normal strength, normal nerve length, and normal movement patterns throughout your body. But if I take into consideration prevalence of pain, amount of potential disability, and level of contribution to other disorders, then - if I had to prioritize one thing to focus on - maintaining low back mobility rises to the top.
Pain in the low back is one of the most common complaints among people, typically recurs, and often creates significant disability. Significantly, if a low back is not moving well then it can cause or contribute to any number of disorders from the low back down. A low back that is not moving well makes it hard for the lower extremities to move well (not to mention the rest of your spine) and can also cause the nerves exiting the low back to become irritated/pinched/compressed. Since these nerves control the lower extremities, if they are irritated there can be referred pain, numbness, or tingling into the lower extremities as well as weakness and poor balance. (Nerves control it all!)
So if you have full mobility of your low back (flexion, extension, left side glide, and right side glide), maintain it. Maintenance looks like different things for different people, but if you spend 10 seconds every day to at least check, you should have your full range of motion. If you don’t have your full mobility then we need to figure out what specifically you need to do in order to achieve it. (And if you don’t know if you have your full mobility, there are tests we can do to figure it out.) -- Laura
Your abdominal muscles (in the front of your trunk, not in your back) do the real work when it comes to sit-ups. Many structures are of course still involved with this exercise, though, as with any movement. When someone tells me that sit-ups hurt his back my thought is that repeated joint activity (flexion) causes his back pain. With sit-ups, the spinal joints flex, or bend forward. If repeated muscle activity was the problem causing the pain, we’d expect the pain to be in the abdomen, where the muscles actually are.
Location of pain and provoking factors are just two pieces of the puzzle when it comes to diagnosing, but they do tell me two important things. One, in this scenario the person likely has the diagnosis of joint derangement (versus a muscle or other problem). And, two, it’s unlikely the person will need spinal flexion to get better, since it is clearly provocative. (Thus it’s more likely he’ll need another spinal direction to get his joints working properly again - and therefore be able to soon tolerate all the flexion in sit-ups.) -- Laura
There’s a reason why if I’m treating spinal pathology, or if I’m curious about the relationship of the spine to the patient’s extremity complaint, I a) only prescribe one movement at a time and b) assess the effect of the exercise on the patient’s baselines before allowing it. Even though you may think the spine is in neutral or is not moving when an extremity exercise is being performed, there’s a strong chance that the spine is influenced. Sidelying clams, biceps curls, squats, rows, leg lifts, as examples, can easily impact the spine.
It should go without saying that a strengthening exercise for a hip muscle influences the hip joint, a rhomboid exercise influences the shoulder, and a triceps dip influences the elbow. But we must not forget about the influence on other nearby joints, namely spinal joints. And we must be deliberate when assessing cause-and-effect to determine whether an exercise is warranted. It's not difficult to take spinal baselines, implement an extremity exercise, and then re-test to see if the spinal baselines have changed. Knowing to do that, and how to do that, is where the skill lies. -- Laura
I wasn’t taught that lumbar spine range of motion (ROM) included left side glide and right side glide in physical therapy school. Now, however, I find it’s an indispensable part of my lumbar evaluation. In addition to lumbar flexion and extension, I evaluate side glides as a part of the simple range of motion tests. With any range of motion test for any joint in the body, both quantity and quality are assessed. And just like with any spinal or extremity joint, motion that is lacking or painful tells me a lot about the diagnosis and potential treatment options.
I often use repeated or sustained left or right side glides as part of treatment if I diagnose a lumbar derangement. Side glides are tested in free standing (feet under the shoulders, legs straight but relaxed) by pushing the pelvis to one side as far as possible. The lumbar spine therefore glides on the pelvis. This can also be tested on the wall. For treatment procedures, the wall variation is used most often, but I have also utilized side glides in free standing, in a doorway, and in sitting.
One of the several goals of orthopedic care is making sure a patient has full and pain-free motion in all planes of the joint. Maintaining full and pain-free motion is key to preventing recurrence of symptoms as well. If you're not testing this side-to-side motion of the lumbar spine, I think you're missing a lot of important information and treatment potential. -- Laura
When clinicians think of joint mobilizations, they think of clinicians moving joints at the level of the joint with their hands, which is true. This applies to the spine as well as the extremities. However, joints can be less-precisely mobilized - or moved - without that specific technique. In fact, if my goal for a movement is to move a joint versus, say, stretch something or strengthen something, I call it a joint mobilization. More loosely, we can just call it a movement or an exercise, but the intent is what matters - and the intent is to move the joint in a specific direction (its directional preference).
Sometimes the technique or the force applied by a clinician via mobilization or manipulation is necessary temporarily. But in the large majority of cases diagnosed as joint derangement, patients can learn how to mobilize themselves. In the trickier cases, we might have to figure out how to get assistance from some equipment at their home or from another person. When mobilizations (with or without a lot of force) are necessary as treatment, the results will be better the more often you do them. That said, in order to get those reps, it’s imperative we teach patients how to self-mobilize the best we can. The McKenzie method is predicated on teaching people how to self-treat in order to improve outcomes. My hands aren’t magic and I’m here to teach. -- Laura
If neck, mid, back, or shoulder blade symptoms are worse with driving or after driving, it’s worth considering your car posture. The same applies to symptoms anywhere in the head, face, shoulder or arm, all the way to your fingers. (The lower portion and bottom seat can play a role in low back and leg problems.) Most cars put the mid back in flexion and the neck in flexion and/or protrusion. In other words, the mid back joints are rounded and the joints of the neck are either bent forward or pushed forward.
If a posture has no effect on symptoms while you’re in the position nor after, and if your movement ability is not negatively affected, then there’s no problem. For a lot of patients with upper body complaints, though, posture in the car does warrant discussion. Many patients note driving is exacerbating and many patients spend a fair amount of time in their cars. The good news? With all of the patients’ cars I’ve assessed, adjusting the ergonomics of the car is easy and inexpensive. The theme is usually (if not always) to get the upper body straight, not flexed. The hardest part is for patients to get used to it - but that beats symptoms! -- Laura
So sit-ups flex your spine? So what? We flex our spine thousands of times a day and sit flexed an awful lot as well. As long as you (1) know how to discern if an activity (such as sit-ups) is harming you and (2) know how to correct it if it is, you are good to go. The best way to know if an activity is harming you outside of symptoms is ascertaining if it decreases your motion. (If we’re talking about the low back, that means flexion, extension, left sideglide, and right sideglide.)
I incorporate sit-ups into my workouts as well as other spinal flexion exercises. I like sit-ups with my legs straight and ones with my legs bent. But, what do I also do? I spend 10 seconds every day checking if I have my normal low back motion and also perform prophylactic movements. (I’m lying on my stomach propped on my elbows right now.) If I were just starting sit-ups, I would check right after to make sure they didn’t cause me to lose motion (they never did).
Are there certain things certain people can’t do? Of course. Sit-ups could hurt your back just like brushing your teeth could or a long car ride could; they’re not extra scary. By understanding the concepts of how to keep joints healthy, we don’t have to avoid nor fear specific exercises. I’m here to teach. -- Laura
If someone complains of foot symptoms - pain, numbness, and/or tingling - it can obviously be due to several causes. When investigating to find the source (that is, diagnosing), I collect many pieces of information. First, there’s a good verbal history during which I ask pointed questions. Second, is the physical exam. With the physical exam I look at various things; nerve tension is one of them. If you put the lumbosacral nerves on tension (there are a few ways to test this), and a patient’s symptom appears or increases in the foot, we need to investigate spinal nerve irritation as the potential source. To be clear, a negative tension test does not rule out the spine, but a positive test more strongly rules it in as a possibility. It is common that irritated nerves in the spine create pain, numbness, or tingling in the areas of the body they're responsible for, and the nerves specifically in the low back are responsible for sensation in the feet. -- Laura
A spondylolisthesis can be present and not be related to your symptoms - just like imaging can show non-painful degenerative changes, tears, etc. It sounds scary, but in the absence of recent trauma, there's a strong chance you have a spondylolisthesis that doesn't matter.
Competent clinical reasoning and testing can differentiate if a spondylolisthesis is or is not the generator of symptoms. I find repeated movement testing to be the most valuable method. Physical therapy will not fix a spondylolisthesis, which is a bony structural problem, but can help. However, physical therapy can usually fix other spinal problems, which may be producing your symptoms. An image shows you what’s there, but it doesn’t usually tell you what’s causing symptoms. That’s why you always need competent clinical reasoning and movement testing. -- Laura
The glutues maximus, gluteus medius, and gluteus minimus are innervated (powered) by the nerve roots L4, L5, S1, and S2, which exit the spinal cord in the low back. A muscle can only achieve optimal strength and efficiency if it’s getting an undisturbed supply of electricity. I hear loads and loads of people talk and talk about problematic weak glute muscles. I usually don’t find weakness. Instead, I find that it’s almost always inhibition - a fuse box (spine) problem. Most low back problems are at the levels L4, L5, S1. Is it any surprise then that the nerves to the glutes may be compromised? There does not have to be back pain for a nerve irritation to be present.
If we prove that your nerves are indeed working well (which we do by clinically moving your low back, and sometimes hip, repeatedly - not by looking at an image), and your glutes are still problematically weak, then we can begin all those glute exercises such as squats, lunges, donkey kicks, clamshells, crab walks, sidelying leg lifts, lateral step downs, bridges, and so on. If a professional wants to diagnose “weakness,” then he/she better have first at least ruled out inhibition. Not only does that save months of work, but it gets at the real diagnosis. When a muscle doesn't demonstrate the strength it should, I check the fuse box. -- Laura
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