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Title of blog post - How to Prevent Low Back Pain

How To Prevent Low Back Pain

Prevent Low Back Pain by Looking/Treating Elsewhere

Low back pain is one of the most costly health care conditions in the world.  It is my opinion that we, providers, have managed it poorly over the years.  We are in the middle of an opioid crisis and low back issues are one of the many reasons people seek relief.  There is no excuse for prescribing addictive medications for pain that can be helped and eliminated with conservative measures.  However, I believe even the conservative methods are less than optimal because not enough of us try to prevent low back pain.  Simply adjusting someone's low back is not going to get the job done.  We need to evaluate the system as a whole. Click Here to read about the Functional Triage approach to evaluating pain and dysfunction.  In this blog post, I will outline 4 key things to consider when trying to prevent low back pain.

Image highlighting the alternating pattern of mobile and stable joints.

The "Joint-By-Joint" Approach

Low Back Pain and Core Function

Have you been banging out 500 sit ups a day for the past 25 years?  Can you do leg raises with 30-pound ankle weights plus a medicine ball in between your legs because of your super shredded “lower abs”?

A meme of Morpheus explaining about the core.

It is super common for me to find that my patients with chronic lower back discomfort tend to over work their ANTERIOR core.  Needlessly crunching yourself into oblivion to sculpt that perfect 6 pack is counterproductive.  Here’s the thing, your core is actually a 3-dimensional container instead of a flat sheet of abs so the way we train it must be varied.

The Most Important Core Muscle (The One)

The most crucial muscle for the core also happens to be the most crucial muscle with respiration, and we never use it!  I am speaking of the diaphragm of course.  Proper core stability should begin with an inhale to create intra-abdominal pressure.  In addition, the act of breathing should continue throughout the whole movement/exercise.  This may be a shocker to some since they can barely think let alone breathe during a rep in the gym.
Image showing how core stability is generated from the inside.
Image showing the creation of intra abdominal pressure.

It's All About That IAP!

An ideal scenario involves eccentrically activating ALL the quadrants of the core simultaneously rather than concentrically bracing the abs.  In other words, when you inhale with a tad bit of abdominal stiffness, the air/pressure in turn forces the abdominal wall to contract.  Think of it as “inside-out” core stability.  Many people find this concept abnormal.  Hell, the act of correctly breathing with their diaphragm feels abnormal.  However, we all learned it this way many, many years ago.  In fact, we can trace most of what we do movement wise back to when we were babies.  Creating proper intra-abdominal pressure is the foundation of Dynamic Neuromuscular Stabilization (DNS) and is absolutely crucial when trying to prevent low back pain.  Once the foundation is set, proper movement can be “re-trained” by revisiting the primitive positions that we spent our time in as cute little babies.  In this fashion, we are training the core to do what it is supposed to do, which is transfer load/power/force through the body.

How To Create Intra Abdominal Pressure (IAP)

Beginner Core Stability Routine

Low Back Pain and Thoracic Spine Stiffness

The thoracic spine, I feel, is supremely underrated when it comes to many conditions and ailments and is usually needing some TLC when trying to prevent low back pain.  Even with a bulky rib cage attached to it, the thoracic spine should be fairly mobile especially compared to the lumbar spine.  With saying that, I need to point out that the lumbar spine is capable of plenty of movement.  However, its relationship to the core is that it helps create “Good Stiffness” in the mid-section with most physical activities.  Or in other words, we want the thoracic spine to move more during movement and the lumbar spine to move less.  Take the golf swing for example.  If you tend to wield your driver like Thor’s hammer, and in doing so, tend to “reverse spine angle” then you are at a much higher risk for low back pain.  On the flip side, if you rotate more through your hips/pelvis and T-spine you will allow the lumbar spine to do its job which is help the core transfer energy.

Image of the rib cage, spine, and pelvis.


Thorax, Lumbar Spine, and Pelvis

Image of the muscles of respiration.

Muscles of Inhalation and Exhalation

Netter's Anatomy Flash Cards - 3rd Edition

Simply telling somebody to move more in the T-spine rather than the L-spine is easier said than done.  It just so happens that our society influences poor thoracic mobility due to the positions we are in most of the day.  When working with patients that need more thoracic spine mobility (most of them), we are using a combination of treatment to physically loosen up the joints and muscles and rehab/corrective exercise to teach the patient how to utilize this newfound motion.

Exercises to Improve Thoracic Mobility

This routine looks to improve mobility in the thoracic spine and rib cage using a combination of passive and active exercises.

Breathing Exercise to Improve Thorax Mobility

Practice breathing with the diaphragm in different positions to learn how to expand the rib cage.

Low Back Pain and Hip Function

The hips, in my opinion, must be evaluated when attempting to prevent low back pain, even if there is no hip pain.  Unlike the thoracic spine where the issue is usually hypomobility, the hips can have a multitude of dysfunctions.  To make matters more complex, both hips in one individual may have different issues!  In a perfect world, the hips move freely throughout their range of motion with proper muscle activity.  Sadly, the world is not perfect.

Let’s outline a few scenarios:

  • Desk worker has “tight” hip flexors and “weak” glutes due to sitting all day. I put tight and weak in quotes for a reason (more on that in a sec).
  • Dancer has trouble stabilizing on one leg and when doing so, you witness their knee collapse and their pelvis hike.
  • Cross fitter gets a pinching type pain at the deep aspect of their squat.
  • Soccer mom is super strong with glute bridging and other hip corrective exercises but they don’t seem to know how to utilize that strength with actual human movement.
I just listed 4 scenarios for hip dysfunction and all of them are different but similar in that the hips are dysfunctional.  In addition, all four of them may also have low back pain.  It’s simply not enough to say, “oh your glutes are weak” or “my hip flexors are tight”.  The single most important thing that I can do for a patient is get them to FEEL proper hip function during actual activities.  In order to do that, there needs to be some critical thinking and evaluation involved.  I need to know the reason WHY you have reduced internal rotation (IR).  Reduced hip IR due to posterior hip tightness is in a different universe than reduced motion due to some type of impingement.  One can be taken care of with self-stretching and exercise while the other needs to be managed clinically.

Exercise To Improve Hip Rotation Mobility

Hip rotation, especially internal rotation, is often limited and can lead to poor pelvic function and subsequent low back pain

Exercise To Improve Hip Stability and Glute Strength

Single leg stability is crucial for pelvic function and preventing lower back pain.

Low Back Pain and Daily Activities

Factoring in one's daily activities is a must no matter what the condition is.  Knowing what you do on a daily basis should be the foundation for any treatment and rehab plan.  This concept ties everything mentioned above together.  Lets list two scenarios for low back pain:

  1. Desk worker that sits all day and has a chronic, achy, tight low back
  2. Carpenter that is up and down all day has frequent episodes of low back pain a year

Different Problems. Different Solutions.

Back pain with manual labor.
Both individuals have totally different job requirements and different pain mechanisms.  They probably each have different goals for themselves as well.  Both patients get a thorough work up.  I might find that patient #1 has a stiff thoracic spine and shortened hip flexors.  My goal with treatment and rehab would be to "reverse his posture".  I would treat his back and hips but also build a daily regimen for him to work on while at work.  As long as I can get him moving in the right direction, things will go well.

Patient #2 may be a different story.  It's the same song and dance with these guys.  They "throw" their back out 4 times a year leaving them handicapped for several weeks.  However, when I question them about it they call it "normal" and don't see any issues with that mindset.  I will have to dig a little deeper and figure out what is causing their back to flare up.  It may be a lack of hip hinging when bending down.  It may be a loading strategy (don't lift a 200 lb fridge by yourself doofus).  The point is, we have to think several steps ahead in order to prevent low back pain and injury from recurring.  Sure, treatment of the above issues is warranted but if we don't get a wrangle on the actual MECHANISM of pain then all we are doing is applying band aids to the problem.

Hip Hinge to Prevent Low Back Pain (sometimes)

Below is a simple video on how to teach yourself to properly hinge through your hips.  I'm not saying that you have to always bend over like this.  However, if you are going to pick up something up heavy I would recommend getting your hips involved.

Bending over without a hip hinge.

Hip Hinge Exercise Routine

Chesterfield Chiropractor Will Help Your Low Back Pain! 

If you are a little confused by all of this then I have done my job.  The human population needs to have a better understanding for how their body works so that they can have a better grasp on how to handle whatever life throws at it.  The point is that those grueling lacrosse ball/foam roll sessions may not be helping you.  In fact, it could be hurting you.  Getting the same ole treatment over and over again is no better.

Alternatively, if you are used to banging out the same corrective exercise routine with no regard to how those clam shells apply to human function, then you are in REHAB PURGATORY.  It’s a pitiful place to be.  My challenge to you is to expect more from your body as well as those treating/coaching you.  Don't settle for chronic low back pain!  Learn how to not only manage discomfort, but how to prevent low back pain in the first place!

Dr. Signature

Originally posted 11/28/2018

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