วันเสาร์ที่ 24 กันยายน พ.ศ. 2565

The second physiotherapy with 9 of 18 basic strengthening exercise for correct lumbar hyper - lordosis induce low back pain (ep.2)

    

Ref: https://www.naturallyfitlifestyle.com/a-guide-to-postpartum-hip-realignment-with-pelvic-tilting/


         Posterior pelvic tilting has been utilized as a rehabilitation method for improving the lumbar spine alignment in LBP patients because it improves lumbar lordosis. It is the pelvic exercise in the sagittal plane that is generally used to correct the alignment of the lumbar spine of patients with chronic lower back pain with lumbar lordosis. So, posterior pelvic tilt strengthening is important to reduce the posture causing lumbar lordosis. 

In my clinical experience, I have found painful structure more than one i.e., lumbar erector spinae muscle, thoracolumbar fascia, attachment at posterior iliac crest, upper gluteal, or SI joint.


Some of them can be improved by stretching, however, some of them must exercise to treat the disorders. One sample case with tenderness at posterior iliac crest, the patient could get better by strengthening exercise of transverse abdominis with less tenderness at posterior iliac crest and feel more comfortable.


Abdominal brace exercise
(Ref: https://www.semanticscholar.org/paper/Intra-abdominal-Pressure-and-Trunk-Muscular-during-Tayashiki-Takai/ca32668dad3abd7a346bc56617691edcfba134c5/figure/0)


Second basic 9 of 18 therapeutic strengthening exercise to posterior tilt (Remark: If there is tightness of the back extensors or hip flexors, it is necessary to treat these muscles to restore normal length before the abdominals can be expected to function optimally that can learn more on https://yimphysionearme.blogspot.com/2022/09/physiotherapy-with-6-stretching.html )

 

Each exercise needs 10 - 15 reps with 3 sets for 3 - 5 days a week.

 

Exercise #10: Quadruped abdominal bracing: lift abdominal belly up as flatten it with maintain spine straight. Keep breathing during exercise.



Exercise #11: Bird dog: lift abdominal belly up as flatten it with maintain spine straight. Straight one leg backward to hip level. Keep breathing during exercise. (Do not arch and numb the spine)



Exercise #12: Bird dog with hamstring curl: lift abdominal belly up as flatten it with maintain spine straight. Straight one leg backward to hip level and hold for moving knee joint. Keep breathing during exercise. (Do not arch and numb the spine)



Exercise #13: Basic prone plank: Spine must be straight that is not allowed to curve or arch during exercise. lift abdominal belly up as flatten it with maintain spine straight and keep breathing during exercise. . (Do not arch and numb the spine)



Exercise #14: Mountain climbers exercise: lift abdominal belly up as flatten it with maintain spine straight. Bend leg to chest and keep breathing during exercise. . (Do not arch and numb the spine)



Exercise #15: Prone plank with hamstring curl: Spine must be straight that is not allowed to curve or arch during exercise. lift abdominal belly up as flatten it with maintain spine straight and straight one leg backward to hip level and hold for moving knee joint. Keep breathing during exercise. . (Do not arch and numb the spine)



Exercise #16: The wall - sitting: Sit with back on the wall. Squeeze abdominal belly to flat spine to the wall and hold it. Keep holding muscle and breathing with lift both arm up to ear level.



Exercise #17: The wall standing: Stand with back on the wall. Squeeze abdominal belly to flat spine to the wall and hold it. Keep holding muscle and breathing with lift both arm up to ear level.



Exercise #18: Perpendicular Standing: Patients stood with the feet shoulder distance apart, tried to keep the trunk perpendicular to the ground as much as possible. While their eyes looked forward, slowly bent their knees and lowered the trunk. Then, they returned to the starting position.



 

Abdominal muscle weakness related faulty posture and low back hyperextension 

There are two types of posture that exhibit this weakness: (1) anterior tilt (lordotic posture) and (2) anterior displacement of the thorax (sway - back posture). The lateral fibers of the external oblique extend diagonally from posterolateral rib cage to antero - lateral pelvis. By this line of pull, they are in a position to help maintain good alignment of the thorax in relation to the pelvis, or to restore the alignment when there is displacement. 

The kyphosis - lordosis posture consists of lumbar spine hyperextension (lordosis), pelvic anterior tilt, and hip flexion. In part of weakness cause kyphosis - lordosis posture, there is weakness of neck flexors, upper back erector spinae, and external oblique. Hamstrings are slightly elongated but may or may not be weak.

Dark black area represents weakness of muscles in kyphosis - lordosis posture
(Ref: https://www.pinterest.com/)
 

The sway - back posture is a combination of lumbar spine flexion (flatten), pelvic posterior tilt, and hip hyperextension that The pelvis is in posterior tilt and sways forward in relation to the stationary feet causing the hip joint to extend. The effect is equivalent to extending the leg backward with the pelvis stationary. There is weakness of iliopsoas, upper back extensors, neck flexors, and external oblique.

 

Dark gray area represents muscle weakness in sway - back posture
(Ref: https://www.pinterest.com/)

Moreover, the military - type posture has lumbar spine hyperextended (lordosis) and pelvis anterior tilt, as well. As the result of anterior abdominal weakness and hamstring muscles are somewhat elongated but may or may not be weak, allow pelvis rotated anteriorly.

The military type posture is demonstrated muscle weakness by light red areas.
(Ref: https://www.pinterest.com/)


The type of postural deviation that occurs depends to a great extent on associated muscle weakness. In the anterior tilt, lordotic posture, there is often hip flexor tightness along with the abdominal weakness; in the sway - back posture there is hip flexor weakness, specifically, iliopsoas.


In supine, patients with marked weakness of abdominal muscles and strong hip flexors can hold the extended extremities in flexion of the pelvis and lower them slowly but the low back arches, increasingly, as the legs approach the horizontal. The force exerted by the weight of the extremities, and by the hip flexors holding the extremities in flexion on the pelvis, pull the pelvis in anterior tilt overcoming the force of the weak abdominal muscles that are attempting to pull in the direction of posterior tilt. In stand, patients will demonstrate lumbar hyperextension (or forward abdominal belly) and hip flex.


External oblique in torso flexes
(Ref: https://www.physio-pedia.com/)


The external oblique muscles that hold the pelvis in posterior tilt during leg lowering are chiefly the rectus abdominis and external oblique. In many instances, abdominal strength is normal on the trunk - raising test, but the muscles grade very weak on the leg - lowering test. Since the rectus must be strong in order to do the trunk curl, the inability to keep the low back flat during the leg lowering cannot be attributed to that muscle. It is logical to attribute the lack of strength to the external oblique not to the rectus. Furthermore, the postural deviations that exist in persons who show weakness on the leg - lowering test are associated with elongation of the external oblique.


During posterior pelvic tilting, the activity of the Transverse abdominis was greater than that of other muscles. Previous studies examining abdominal muscles during posterior pelvic tilting using EMG were performed in several positions, including the supine position, the sitting position and the standing position. Therefore, not only the Transverse abdominis but also the internal oblique might be attributed to posterior pelvic tilting with external oblique.


Squeeze abdomen is done by transverse abdominis contraction
(Ref: https://shopc.off63.cf/)
 

Therapeutic exercise to posterior pelvic tilt

It becomes very clear in such situations that the trunk - raising exercise does not improve the ability to hold the low back flat during leg lowering. Indeed, it appears that repeated and persistent trunk flexion exercises may contribute to continued weakness of the lateral fibers of the external oblique.


Proper exercise of abdominal muscles could be a part of a preventive medicine plan. Good strength in these muscles is essential to the maintenance of good posture, but caution should avoid overdoing both the trunk curl and the pelvic tilt exercises. 


Mention to the recent article (on https://yimphysionearme.blogspot.com/2022/09/physiotherapy-with-9-of-18-basic.html ), posterior pelvic tilt in supine position, with hands up beside the head, tilt the pelvis to flatten the low back on the table by pulling up and in with the muscles in the lower abdomen. 

Do not tilt the pelvis by contracting the gluteal muscles

Without depressing the rib cage, hold the low back flat and breathe in and out easily, relaxing the upper abdominal muscles. There should be good chest expansion during inspiration but the low back should not arch upward from the table to raise the chest and make it appear like chest expansion. 

Posterior pelvic tilt and leg sliding in supine position, bent the knees and placed the feet flat on the table. With hands up beside the head, tilt the pelvis to flatten the low back on the table by pulling up and in with the muscles in the lower abdomen. 

Do not perform the pelvic tilt by pushing with the feet and rocking back on the buttock.

Hold the back flat and slide the heels along the table. Straighten the legs as far as possible with the back held flat. Keeping the back flat, return the knees to a bent position, sliding one back at a time. 

“Trying to breathe in and out all the time while doing exercise is very important to prevent Valsalva maneuver.” 

Posterior pelvic tilt provides back flats on the floor
(Ref: https://moundcitychiropractic.com/)


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วันพฤหัสบดีที่ 15 กันยายน พ.ศ. 2565

Physiotherapy with 9 of 18 basic strengthening exercise for correct lumbar hyper - lordosis induce low back pain (ep.1)

 

McGill curl up exercise
(Ref: https://www.pinterest.com/)


The lumbosacral region is the most important region in the vertebral column in terms of mobility and weight bearing. Mechanical disorders of this region cause LBP. One of the most common causes of LBP is lumbar spinal curve change. Spinal curvature in the lateral view is necessary for effective weight bearing, increasing efficiency of paraspinal muscles, and maintaining erect posture. 


Normal lumbar lordosis angle ranges from 30º to 45º. An abnormal curve of the spine can increase stress on the body which can lead to muscle imbalance. One of the most important postural deformities of the spinal column is lumbar hyper-lordosis which means exaggerated curve of lumbar spine. 


Normal lumbar lordosis angle
(Ref: https://www.jssm.org/volume10/iss2/cap/jssm-10-355.pdf)


Some studies have shown that muscles can provide segmental stabilization by controlling motion in the neutral zone. Weakness in any of the muscles of the lumbar-pelvic belt can cause diversions of back arch by impairing muscular balance in this area. The balance of the muscles around the pelvis is an important factor in maintaining lumbar lordosis. Because  of the relationship between the sacrum and the pelvis through the spine, any change in the biomechanics of the sacro-pelvic region leads to changes in spinal curvatures, especially lumbar lordosis.


Following are some causes for hyper-lordosis i.e. bad posture, obesity, Lack of exercises, sedentary lifestyle, shifting of line of gravity during pregnancy, use of footwear with high heels. Bad posture causes hyper-lordosis can be corrected with exercises that should focus stretching on hip flexors and back extensors and abdominal muscles and hip extensors will be strengthened.


Muscle imbalance in lumbar hyper-lordosis and anterior pelvic tilt
(Ref: https://www.semanticscholar.org/paper/Effects-of-a-massage-therapy-program-on-functional-Wong/59d1cdb704700562cd73e420cfb73ead2eda8e67)


Therapeutic exercise to posterior pelvic tilt, the lower abdomen is pulled up and in, and the pelvis is tilted posteriorly to flatten the low back on the table by action of the external oblique, especially the posterior lateral fibers. Patients should avoid using the gluteus maximus to tilt the pelvis when doing this exercise. Pelvic tilt may be done with the rectus abdominis, but should not be done in this manner when emphasis is on strengthening the external oblique.


To correct anterior pelvic tilt, posterior pelvic tilt exercises are indicated. The movement should be done by the external obliques, not by rectus nor by hip extensors. The effort must be made to pull upward and inward with the abdominal muscles, making them very firm, particularly in the area of the lateral external oblique fibers.

Basic 9 of 18 therapeutic strengthening exercise to posterior tilt (Remark: If there is tightness of the back extensors or hip flexors, it is necessary to treat these muscles to restore normal length before the abdominals can be expected to function optimally that can learn more on https://yimphysionearme.blogspot.com/2022/09/physiotherapy-with-6-stretching.html )


Each exercise needs 10 - 15 reps with 3 sets for 3 - 5 days a week.

Exercise #1: Basic supine posterior pelvic tilt: Supine with both knees bending, then

squeeze belly for flatten lumbar spine with floor. Do not roll pelvic backward by feet

pushing or glut contraction.



Exercise #2: Supine posterior pelvic tilt with raise arms to ears: Supine with both knees

bending, then squeeze belly for flatten lumbar spine with floor. Hold this pelvic position, and

raise both arms to ears. Do not roll pelvic backward by feet pushing or glut contraction.



Exercise #3: Supine heel slide: Supine with squeeze belly for flatten lumbar spine on the

floor. And hold this pelvis position all the time when bend knee by drag heel on - off buttock.



Exercise #4: McGill curl up: Supine with squeeze belly for flatten lumbar spine on the floor.

And hold this pelvis position all the time when lift up and down head and upper rib from the

floor.



Exercise #5: Single knee to chest: Squeeze belly and hold the muscle all the time when lift

the knee up and down. During lifting knee to chest, need elevate distal hip in the same

time.



Exercise #6: Double knees to chest: Squeeze belly and hold the muscle all the time when

lift the knee up and down. During lifting knee to chest, need elevate distal hip in the same

time.



Exercise #7: Single bridging



Exercise #8: Squat: Stand with both feet parallel, about shoulder’s width apart. Attempting

to maintain the trunk as perpendicular as possible to the floor, eyes focused ahead, and feet

flat on the floor, the subject slowly lowers his body by flexing his knees.



Exercise #9: Cable trunk rotation: rotate rib level - do not include pelvic. You can apply this exercise

with weight cable machine or elastic band.




Muscle weakness of pelvic anterior tilt or hyper - lordotic lumbar spine

(1) Anterior abdominal muscles

Weakness of anterior abdominal muscles allows the pelvis to tilt forward while the low

back is drawn into a position of lordosis. The muscles are incapable of exerting the upward

pull on the pelvis that is needed to help maintain a good alignment. 


Abdominal wall muscle contraction induce pelvic posterior tilt & flatten back
(Ref: https://knotry.com/)


The patients with lumbar lordosis who have abdominal muscle weakness is the main

problem and usually complains of pain across the low back. It is described as fatigue in the

early phase, and later as an ache which may or may not progress to being acutely painful. 

Pain always gets worse at the end of day and is relieved by recumbency to such an

extent that after a night’s rest the individual may be free of symptoms. Sleeping on a firm

mattress allows the back to flatten and this change from the lordotic position gives relief and

comfort to the patient.

Prolonged abdominal muscle lengthening can develop muscle weakness that is

present during pregnancy and obesity. Physiotherapists often give patients a list of

exercises intended to strengthen these muscles. Unfortunately, these lists have included

sit - ups and double - leg - raising exercises that should not be given when abdominal

muscles are very weak.


double - leg - raising exercises with back arch indicated weakness of abdominal muscle (Ref: http://www.smscs.dreamhosters.com/wp-content/uploads/201601/ablegloweringtest.pdf)


(2) Hip extensor muscles

Hip extensors consist of the one - joint gluteus maximus and the two - joint hamstring

muscles. Weakness of these muscles is seldom found as the primary factor in anterior

pelvic tilt, but when found in conjunction with hip flexor shortness or abdominal muscle

weakness, the pelvic tilt and lordosis tend to be more exaggerated than if the hip extensor

weakness were not present.

Slight to moderate weakness if the gluteus maximus and hamstring muscles will allow

the pelvis to tilt forward in the standing position. Weakness of the hamstrings alone would

not affect the pelvic position to the same extent. 


Sway - back posture
(Ref: https://pamofit.wordpress.com/2014/09/08/case-study-cystic-fibrosis-the-impact-on-posture/)


In extreme weakness, the only stable position of the hip is obtained by the sway - back

posture that displaces the pelvic forward and the upper trunk backward for distributing the

body weight over the center of gravity with the hip joint locked in extension and the pelvis in

posterior tilt. 

Exercise to strengthen hamstrings can then be added in the form of resisted knee

flexion with the hip flexed, or prone knee flexion with the hip extended. In a prone position

the knee should not be flexed to the extent that this two - joint muscle is at an angle of

approximately 50 deg to 70 deg of knee flexion in the prone position.


Hamstring and low back stretching
(Ref: https://www.verywellfit.com/)


In the standing position, hamstring muscles may feel taut whether they are stretched

or short. Faulty postural alignment is indicative of hamstring length consisting of a

lordosis of stretched hamstrings; inflat - back and sway - back postures, hamstrings

tend to be short.


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