Posted on Wednesday, February 17, 2021

Fitness Exercise Won’t Help Your Low Back Pain

It’s estimated that approximately 82.1 million adults in the United States spend an estimated $28.6 billion on gym memberships each year! Now combine that staggering number with the estimated $50 billion dollars plus spent annually on back pain related issues. Even with the general fitness craze we have seen over the past years, low back pain (LBP) remains one of the most prevalent medical conditions treated in the United States and throughout the western world. It affects nearly 80% of the U.S. population at one time or another. It’s one of the top reasons for physician visits and one of the most common reasons for missed work days.

With so many active individuals and crazy fitness trends you would think that all of this exercise would actually help reduce low back pain, right? Wrong…It turns out that not all exercise (and especially, not all “core” exercise) is created equally.

It’s time to address how to safely self-treat your low back pain through movement and exercise as well as some helpful methods for a speedy recovery. (Not to mention, possibly saving you time and money by avoiding a physician visits for pain you can manage safely and independently with a little instruction.)

To safely self-treat your low back pain, first take a moment to assess your symptoms and pain level. What led to your pain and/or injury? Did the pain come on suddenly or slowly? Evaluate the severity of the injury. If you’re experiencing any of the following, please seek immediate medical attention:

Loss of bowel/bladder function.
Uncontrollable pain. The pain is so severe you cannot function or move.
You are losing muscle function or control. The muscles in the legs will no longer work. (This is different than pain preventing the muscle from working.) This sensation of paralysis occurs when the muscles will not actually function.
Significant loss of sensation in the leg or groin area. This is not a tingling sensation, but an actual loss of sensation. For example, you cannot feel the toilet paper when you wipe after using the toilet.
Onset of pain without any known mechanism for the injury. (Thoroughly consider your activity. Many times, a slow onset of pain begins several hours after performing an activity.)

Fortunately, most LBP is mechanical–meaning it is from a physical or structural cause and isn’t related to conditions such as cancer or infections. Most LBP will have a directional preference for extension. A majority of injuries occur when performing a forward biased (flexed movement) like chronic slouching or a spinal flexion biased movement. For discussion purposes, I will be addressing an extension biased program.

With mechanically driven low back pain, you should be able to alter and change your LBP within a short period of time. First, establish a directional preference by identifying a pattern to the pain. Does the pain get worse when you bend over or does it improve? What happens when you repeat this movement?

Determine how your pain responds. If it spreads away from the spine and down into the leg, beware that you are moving in the wrong direction. Stop that particular movement, and instead try flexion biased movements. In my experience, most episodes of LBP tend to respond better to extension biased movements. If flexion or extension doesn’t help or change the pain in any way, then you may need assistance from a medical provider.

The rule of thumb for movement: If the pain worsens by spreading peripherally down the buttock and into the leg and/or foot, then the condition is worsening. We must stop that activity. If the pain centralizes and returns back toward the spine (even if the pain worsens slightly), then keep moving as the condition is actually improving.

Although most LBP isn’t considered serious, the pain tends to re-occur. One major reason for this is that the deep stabilizing muscles known as the multifidus muscles reflexively shrink, weaken, and lose function. Without proper rehabilitation, the muscles will not fully recover. This increases the risk of future episodes because the spine no longer has the ability to stabilize itself normally. Not all “core” work is created equally, so the strength of these muscles needs to be addressed.

How to Safely Self-Treat Low Back Pain:

Perform Press-ups

Once you have injured your back, immediately start press-ups. Perform this exercise with high repetitions and frequently throughout the day as long as the pain does not periperalize down the buttock and into the leg and/or foot. Lie on your stomach and perform 10-20 press-ups. Move slow and easy, but work your way up to full motion multiple times a day.

Perform Standing Back Extensions

After sitting, stand up and perform standing back extensions. Ideally, perform this exercise at least 10 repetitions each time you stand.

Activate the Multifidus

Start exercises to activate the multifidus muscles as soon as possible. Think spine extensor muscle activation. Again, perform this exercise frequently during the day after the initial injury. These Lumbar Extensor Exercises are designed to progressively activate the multifidus muscles (with the final exercise being the most challenging). Once the pain subsides and muscle function improves, more advanced lumbar extension strengthening and stabilizing exercises should be performed to decrease your risk of re-current low back pain.

Don’t Sit

Walking is critical to your recovery! It’s the number one way your spine receives nutrients and disposes of metabolic waste products. Walk frequently, and try to avoid any prolonged sitting.

If you Sit, Use Good Posture

Use a McKenzie Lumbar Roll to help insure a good lumbar curve. If you can’t sit comfortably, listen to your body and don’t sit! Be sure to stand up and walk every 20-30 minutes. Stand with good posture as well.

Stretch the Muscles of the Legs and Pelvis

Hip flexor and hamstring stretches can help to reduce muscle spasms and tightness throughout pelvis area when performed daily. Stretch for at least 30 seconds at a time, 2-3 times each session.

Be as Active as You Can

Don’t stop moving, but avoid exercises that make your back hurt more. Typically, this includes flexion biased movements like sit ups. It’s important that you remain as active as you can. You may need to taper down certain activities that you know will increase your pain. This typically would be activities involving heavy loading of the spine such as squats with weight, deadlifts, and other activities that may cause forward flexion (particularly under a load).

As you are able to, continue to work on cardiovascular conditioning and core muscle activation (particularly, the lumbar extension exercises). Basically stay as active as you can, even lifting weights if you are able. Just remember the concept of peripheralization and centralization. If your pain progresses from the area of the injury into your leg, then you need to stop that activity. If the pain remains constant or is progressing out of the leg, then continue with the activity as you are helping the body to heal.

Developing adequate strength in the lumbar extensor muscles and core musculature is the primary way to prevent initial episodes and to prevent reoccurring episodes of LBP. Research clearly indicates that the right targeted exercises are the most effective way to manage LBP.

If you’re not sure how to effectively and safely exercise your back or if you’re already experiencing low back pain, be sure to check out my Treating Low Back Pain (LBP) during Exercise and Athletics Book and Video Package. USE DISCOUNT CODE LBP AT CHECKOUT FOR 15% OFF!

For the approximate price of just one co-pay to see a doctor, you will receive my easy to read book with step-by-step instructions and a complete video package designed to help you prevent and self-treat reoccurring low back pain episodes.

Want to peek inside the video content? Watch now as I describe what really the “core” is and why it matters.

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If you have a question that you would like featured in an upcoming video or blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com. In case you haven’t already, be sure to subscribe to my e-mail list and YouTube channel as well as join our community on Facebook by liking The Physical Therapy Advisor!

Posted on Wednesday, February 10, 2016

Q & A: How to Manage Spondylolisthesis Pain

Q. What are some tips on how to decrease pain caused by spondylolisthesis? -Lisa

A. Excellent question, Lisa! A spondylolisthesis (spondy) is a certain kind of back injury that is associated with a pars interarticularis defect which is part of the vertebrae. It’s often called the “scotty dog” fracture because of its shape. This condition can be congenital (from birth) or happen from trauma. It’s diagnosed slightly more in males (5% of the male population versus 3% in the female population).

It is important to note if the fracture is stable or not. If the spondylolisthesis is unstable during active motion, such as bending forward or backward, the vertebrae can actually slip and move forward or backward.

Spondylolisthesis injuries are graded I, II, III, IV, and V.

A Grade I defect occurs when 25% of the vertebral body has slipped forward.
Grade II occurs when 50% of the vertebral body slips forward.
Grade III occurs when 75% of the vertebral body slips forward.
Grade IV occurs when 100% of the vertebral body slips forward.
Grade V occurs when the vertebral body completely falls off which causes a spondyloptosis.

In many cases, you will never know if you have this particular condition unless an X-ray is taken. For most people, this condition is completely benign and painless (particularly, in Grade I defects).

If you have a Grade I or II spondylolisthesis and are experiencing pain, conservative treatment (including formal physical therapy) is usually the first form of treatment. Surgical intervention may be performed as needed in the case of a Grade II spondylolisthesis. Surgical intervention is almost always necessary in cases of Grade III or higher.

Exercise and Treatment Considerations

In case of a stable Grade I and some Grade II spondylolisthesis, exercise is an important part of the treatment strategy. There are a few items of consideration. First, obtain clearance from your medical physician. Often, a series of X-rays will be taken while you are standing and standing bending either forward or backward. This can determine if the area is stable. If so, then conservative treatment can be initiated.

When determining which motions to guide your treatment, always let pain and directional preference guide your movements. A directional preference is simply a method to identifying a pattern to the pain. Does the pain get worse when you bend over or does it improve? What happens when you repeat this movement? Determine how your pain responds. If it spreads away from the spine and down into the leg, beware that you are moving in the wrong direction. Stop that particular movement. If the pain improves then continue with exercises in that direction. Never do anything that worsens your pain or symptoms.

On average, I tend to have my clients be less aggressive with lumbar range of motion, especially press-ups and backward bending. Although it’s not prohibited completely in the case of a stable injury, it’s merely a precaution as some research indicates that it may have the potential to cause more pain and worsen the pars defect.

It’s also entirely possible that the cause of pain has nothing to do with the spondylolisthesis. A thorough physical therapy evaluation should help to determine the actual cause of the pain (although, sometimes it is never truly known). The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to hear your physician’s opinion as well).

The focus of the treatment and exercise is on the strengthening of the inner and outer core muscles and lumbar extensors. With the only caveat being that you may need to avoid excessive loading with the spine extended. In this instance, I recommend that you work with a highly qualified trainer or sports medicine professional to insure that you are performing your particular exercise and sport in a manner that will keep you safe and the fracture stable.

It is also important to insure proper hip and pelvic mobility so that the spine is not over worked. In cases of spondylolisthesis, insuring a normal amount of hip extension in addition to proper hamstring length and hip rotation is important. If the hip cannot fully extend during walking and running, it will cause excessive lumbar extension. You may even want to focus on having less of a lumbar curve (a posterior pelvic tilt) if your tendency is to hyper extend with an anterior pelvic tilt. Be sure to work on thoracic mobility to insure the entire vertebral chain can move freely.

Exercise is the critical component to the management of this condition. I would highly advise that you consult with a local physical therapist that has a Lumbar MedX exercise machine. This particular machine can isolate the lumbar multifidus during exercise better than any other exercise that I am aware of.

Other exercises can be utilized to activate the multifidus. These Lumbar Extensor Exercises are designed to progressively activate the multifidus muscles (with the final exercise being the most challenging). Generally improving your core strength is a critical component to the overall treatment. My only caution is to once again avoid excessive loading in hyper extension and to take your strength progression more slowly while monitoring your symptoms. If you perform an activity that causes worsening pain, then you will need to modify or eliminate that particular activity until it can be performed pain free.

In some cases, more flexion biased stretches would be indicated. This would be determined by the directional preference. If extension biased exercises worsened the pain and flexion biased exercises improved the pain, then initially you would proceed with flexion biased exercises to help control pain while you progress into your core and lumbar stabilization program. Examples of flexion biased stretches would be a single knee to chest (below left) or a double knee to chest exercise (below right). Hold these for 20-30 seconds at a time and perform 4-5 repetitions each.

Good luck, Lisa! I hope you find this information to be helpful and provide some relief from the pain you’re experiencing. For more information on treatment strategies for low back pain, please refer to How to Safely Self-Treat Low Back Pain.

Do you suffer from spondylolisthesis? Please share your best tips for pain management.

If you have a question that you would like featured in an upcoming blog post, please email contact@thephysicaltherapyadvisor.com. For additional health and lifestyle information, join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer: The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No health care provider/patient relationship is formed. The use of information on this blog or materials linked from this blog is at your own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Do not disregard, or delay in obtaining, medical advice for any medical condition you may have. Please seek the assistance of your health care professionals for any such conditions.

Posted on Wednesday, December 10, 2014

How to Self-Treat IT Band Syndrome

Pain in the lateral (outside) leg or knee is commonly associated with a condition known as Iliotibial Band Syndrome (ITBS). (Iliotibial Band Syndrome is also known as IT Band Syndrome, ITB Syndrome, or IT Band Friction Syndrome.) Pain can range from the lateral side of the leg up toward the hip area to just below the lateral side of the knee joint (where the head of the fibula bone begins). The pain can be very debilitating to the point that running or hiking activities have to be stopped. Even walking becomes difficult. I will address the many potential causative factors for IT Band Syndrome and offer advice on how to self-treat this condition.

The IT Band is a very thick fibrous band of tissue that spans from the hip’s origin point at a muscle known as the Tensor fasciae latae (TFL). The TFL transitions into the IT band and progresses down the lateral thigh and ends at the head of the fibula. The IT Band’s primary function is to provide additional lateral support for the knee joint (particularly when standing or landing on one leg). IT Band Syndrome is often associated with an over use injury. It can be very painful, but it can be easily self-treated if you handle your pain and symptoms quickly.

How to Self-Treat IT Band Syndrome:

Improve your mobility. Mobility issues and myofascial restrictions are highly correlated with ITBS. Tightness in the IT Band or in the deep hip internal or external rotators is a contributing factor to ITBS. The tighter the IT Band, the more likely it will rub on the femoral condyle and develop into pain. Bowlegged describes a medical condition known as a varus deformity, an inward rotation of the tibia resulting in a leg that looks like it is bowed out. It can develop due to chronic friction of the IT Band along the femoral condyle. ITBS may also occur after a total knee replacement (TKA). I recommend using a foam roller to address tightness in the quadriceps or IT Band. To learn how to use a foam roller, please refer to Foam Rolling for Rehabilitation. I also recommend a Thera-Band Standard Roller Massager, which is very firm and allows for a deep amount of pressure. You may also utilize a tennis or lacrosse ball to mobilize the Tensor fasciae latae (TFL) appropriately. The foam roller and roller massager don’t work as well because the greater trochanter of the hip (the boney part of the hip that sticks out) tends to be in the way. Stretching the IT band or the TFL is very difficult, so I tend to utilize other mobilization techniques. However, I recommend a few pelvic and hip stretches. Please refer to IT Band Syndrome Rehabilitation Exercises for my top stretches, foam rolling, and self-mobilization techniques to address IT Band related issues.
Strengthen your hip muscles. Weakness in the hip external rotators and the hip abductors, like the Gluteus medius and the Tensor fasciae latae (TFL), can lead to IT Band Syndrome. Strengthening of these muscle groups can help avoid future ITB issues as well as reduce your risk of developing Patellar Femoral Pain Syndrome (PFPS). Please refer to Hamstring, Hip Flexor, and Piriformis Stretches for LBP for additional hip and lower leg stretching exercises.
Over use injury due to downhill running? IT Band Syndrome is often associated with an over use injury. For runners, a common cause of ITBS is running downhill. Few runners actually train appropriately for a race with downhill running. Afterward, they end up with a case of ITBS. I have been guilty of improper training in the past. If you have ever run in the Robie Creek Half Marathon, then you understand the importance of downhill training. To avoid ITBS, adequately train for the downhill portion of the race. Also, vary your running routine and surfaces while training. Although ITBS is often associated with over use, always address other contributing factors as well.
Check your shoes. Your shoes may be worn out and may be the cause of the pain. If you wear a shoe that helps to limit overpronation, remember that the inner cushion and structure of the shoe can wear out before its outer appearance. If this occurs, the shoe can no longer adequately control inappropriate foot and heel movements such as overpronation. This could result in IT Band Syndrome or other hip, knee, or ankle related issues. Shoes typically only last 350-500 miles. If you are nearing those miles, then it may be time to change. If you’re unsure if your shoes are performing correctly, visit your local running shoe store. The trained staff can inspect your shoes for wear and tear. They may ask you to walk or run in order to watch your gait to fit you in the appropriate shoe. Another option to help control overpronation is an over-the-counter orthotic such as Superfeet Blue Premium Insoles. The blue tends to fit most feet, but a variety of options are available for customization. In my experience, these insoles can last 1,000 to 1,500 miles easily. If the over-the-counter options aren’t helping you, please see a physical therapist or podiatrist for custom orthotics.
Did you progress too quickly into a minimalistic shoe? If you are used to a standard built up shoe, progressing into a minimalistic shoe may be more difficult and take more time. Unless you are a child or teenager, expect a safe transition to take at least three months. Don’t transition during a period of intense sports. I highly recommend waiting until the off season as progressing slowly is always a better choice.
Have your gait analyzed while running. Gait or running abnormalities can increase your risk of developing IT Band Syndrome. Over striding tends to occur while running downhill. Scissoring occurs when your leg crosses over the midline with each step. Both over striding and scissoring are easily recognized by a professional. Check with your local running store or a physical therapy clinic for a monthly gait analysis clinic. If you’re unable to obtain a gait analysis, ask your spouse or a friend to video record you (from behind) while you’re running. Then watch the recording to see if you notice either over striding or scissoring.
Don’t forget to ice. IT Band Syndrome is typically is due to a specific event. Afterward, there is usually an active inflammatory process occurring. I typically apply ice to the lateral part of the knee, but place it on your most painful location. The rule for icing is to apply ice no more than twenty minutes per hour. Don’t place the ice directly against the skin, especially if you are using a gel pack style. Individuals with poor circulation or impaired sensation should take particular care when icing. A bag of frozen peas can be a cheap alternative or you could use one of my favorite gel pack style cold packs.
Start a supplement. ITB Syndrome is typically associated with a specific event and an active inflammatory process typically occurs. I am a supporter of natural supplements and remedies. Many supplements include herbs which are designed to help reduce inflammation. Phenocane Natural Pain Management combines the following: Curcumin, an herb that reduces pain and inflammation; boswellia, a natural COX2 inhibitor that also reduces pain and inflammation; DLPA, an amino acid that helps to increase and uphold serotonin levels in the brain; and nattokinase, an enzyme that assists with blood clotting and reduces pain and inflammation. If you are taking blood thinner medication, please consult with your physician prior to taking Phenocane Natural Pain Management.

If you’re not experiencing relief after a week or two of aggressively managing the symptoms, contact your local physical therapist for an assessment and help in managing IT Band Syndrome. The American Physical Therapy Association offers a wonderful resource to help find a physical therapist in your area.

Has a specific treatment for IT Band Syndrome helped you? Which treatments haven’t worked for you? Additional discussion can help others to manage this condition more effectively. Please leave your comments below.

Looking for that exercise or book I mentioned in a post? Forgot the name of a product or supplement that you’re interested in? It’s all listed in the new Resource Guide. Check it out today!

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com. Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Posted on Monday, October 20, 2014

How to Safely Self-Treat Low Back Pain

Did you know that an estimated $50 billion dollars is spent annually on back pain related issues? Low back pain (LBP) is one of the most prevalent medical conditions treated in the United States and throughout the western world. It affects nearly 80% of the U.S. population at one time or another. It’s one of the top reasons for physician visits and one of the most common reasons for missed work days. The previous post, 12 Sure Fire Ways to Injure Your Back, addressed potential risk factors for low back pain. This follow-up post includes how to safely self-treat your low back pain and helpful methods for a speedy recovery. (Not to mention, possibly saving you time and money by avoiding a physician visit for minor pain!)

Loss of bowel/bladder function.
Uncontrollable pain. The pain is so severe you cannot function or move.
You are losing muscle function or control. The muscles in the legs will no longer work. (This is different than pain preventing the muscle from working.) This sensation of paralysis occurs when the muscles will not actually function.
Significant loss of sensation in the leg or groin area. This is not a tingling sensation, but an actual loss of sensation. For example, you cannot feel the toilet paper when you wipe after using the toilet.
Onset of pain without any known mechanism for the injury. (Thoroughly consider your activity. Many times, a slow onset of pain begins several hours after performing an activity.)

Fortunately, most LBP is mechanical–meaning it is from a physical or structural cause and isn’t related to conditions such as cancer or infections. Most LBP will have a directional preference for extension. A majority of injuries occur when performing a forward biased (flexed movement) like chronic slouching or a spinal flexion biased movement. For discussion purposes, I will be addressing an extension biased program.

You should be able to alter and change your LBP within a short period of time. First, establish a directional preference by identifying a pattern to the pain. Does the pain get worse when you bend over or does it improve? What happens when you repeat this movement? Determine how your pain responds. If it spreads away from the spine and down into the leg, beware that you are moving in the wrong direction. Stop that particular movement, and instead try flexion biased movements. In my experience, most episodes of LBP tend to respond better to extension biased movements. If flexion or extension doesn’t help or change the pain in any way, then you may need assistance from a medical provider.

How to Safely Self-Treat Low Back Pain:

Perform Press-ups – Once you have injured your back, immediately start press-ups. Perform this exercise with high repetitions and frequently throughout the day as long as the pain does not periperalize down the buttock and into the leg and/or foot. Lie on your stomach and perform 10-20 press-ups. Move slow and easy, but work your way up to full motion multiple times a day.

Perform Standing Back Extensions – After sitting, stand up and perform standing back extensions. Ideally, perform this exercise at least 10 repetitions each time you stand.

Activate the Multifidus – Start exercises to activate the multifidus muscles as soon as possible. Think spine extensor muscle activation. Again, perform this exercise frequently during the day after the initial injury. The Lumbar Extensor Exercises are designed to progressively activate the multifidus muscles (with the final exercise being the most challenging). Once the pain subsides and muscle function improves, more advanced lumbar extension strengthening and stabilizing exercises should be performed to decrease your risk of re-current low back pain.
Don’t Sit – Walking is critical to your recovery! It’s the number one way your spine receives nutrients and disposes of metabolic waste products. Walk frequently, and try to avoid any prolonged sitting.
If you Sit, Use Good Posture – Use a McKenzie Lumbar Roll to help insure a good lumbar curve. If you can’t sit comfortably, listen to your body and don’t sit! Be sure to stand up and walk every 20-30 minutes. Make sure you stand with good posture as well.
Stretch the Muscles of the Legs and Pelvis – Hamstring, Hip Flexor, and Piriformis Stretches for LBP help to reduce muscle spasms and tightness throughout pelvis area when performed daily. Stretch for at least 30 seconds at a time, 2-3 times each session.
Reduce Inflammation and Support the Healing Response – I recommend starting a thirty day course of CapraFlex by Mt. Capra. CapraFlex is an organic glucosamine and chondroitin supplement which also includes an herbal and spice formulation designed to naturally decrease inflammation and support healing. I recommend it to anyone recovering from an injury or attempting to prevent injury when performing at a very high level. I personally use it, and in my practice, it has helped clients recover faster and prevent injury. It can interfere with some blood thinning medication, so if you are on this type of medication, please check with your physician.
Ice as Needed for Pain – The rule for icing is to apply ice no more than twenty minutes per hour. Do not place the ice directly against the skin, especially if you are using a gel pack style. Individuals with poor circulation or impaired sensation should take particular care when icing.
Use Topical Analgesics for Pain – There are many topical agents which can be used for pain. My two favorites to help manage pain and stiffness are Arnica Montana (an herbal rub) and Biofreeze.
Be as Active as You Can – Don’t stop moving! It’s important that you remain as active as you can. You should taper certain activities that you know will increase your pain. This typically would be activities involving heavy loading of the spine such as squats with weight, deadlifts, and other activities that may cause forward flexion (particularly under a load). As you are able to, continue to work on cardiovascular conditioning and core muscle activation, particularly the lumbar extension exercises. Remember the concept of peripheralization and centralization. If your pain progresses from the area of the injury into your leg, then you need to stop that activity. If the pain remains constant or is progressing out of the leg, then continue with the activity as you are helping the body to heal.
Ask for Help – Yes, even physical therapists have to ask for help sometimes! Many useful manual techniques can help to manage LBP. You just can’t perform them on yourself. If your pain is not improving, I highly suggest seeking a qualified and competent physical therapist who works with clients suffering from LBP. The American Physical Therapy Association offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to seek your physician’s opinion as well).

Low back pain is a serious and debilitating condition. It will either most certainly affect you or someone close to you. Be pro-active in maintaining a healthy back by incorporating these helpful methods for a speedy recovery. Don’t let LBP affect your ability to stay active and keep enjoying your favorite activities!

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