Physiotherapy with 10 of 20 lateral abdominal basic exercises for low back pain (ep.1)

 

Abdominal muscle: anterior & lateral
(Ref: https://fitnessvolt.com/)

Low back pain rehabilitation from physiotherapists in patients with low back pain must provide efficient and safe exercises which will enhance stability of the vertebral column. Various exercises are used to restore the abdominal muscles function in the management of low back pain including other musculoskeletal disorders.

The key target muscles for low back pain exercise consists of the paravertebral, abdominal muscles, the pelvic musculature, and the diaphragm. All of them work together to support spine alignment and absorb load to spine structures. Individuals with low back pain undergo dysfunction in co - activation between the group of paravertebral muscles and the group of abdominal muscles which focus on the lateral abdominal muscles.

Major core stabilizer muscle group
(Ref: https://ssphysio.com.au/)

The lateral abdominal muscles including transversus abdominis (TrA), internal oblique (IO), and external oblique (EO) provide stability to the trunk in different functional activities. They were classified into the lateral or outward abdominal muscles because of their locality. The muscle fibers are outward of the torso that connect to fascia on abdominal and back regions.  

The efficacy of lateral abdominal exercises have been established in acute and chronic LBP patients. The Appropriate rehabilitation program seems to provide recovery within 6 weeks. If not, it is possible to recur within 1 year. In case they cannot recover from the acute LBP, they will turn to the chronic LBP condition. 

 

Lateral abdominal muscle left to right: EO - IO - TrA
(Ref: https://www.sciencephoto.com/)

The first basic 10 of 20 therapeutic strengthening exercises to activate lateral abdominal muscle for low back pain (Remark: If you feel severe pain and any numbness, I would like to recommend you to stop exercising and observe the symptoms. And consult your physiotherapists or doctors.)

 

Each exercise needs 10 - 15 reps with 3 sets for 3 - 5 days a week. (Remark: Keep breathing during exercise for more efficiency because the diaphragm is a member of core stabilizer muscle). 

 

Exercise #1: Abdominal brace: Flatten the abdominal belly by squeezing the muscle slightly that  is not by force inhale. Anyhow, you have to keep breathing normal during exercise. This exercise can apply in walking, standing, sitting, etc.

Exercise #2: Stand trunk rotation with band: rotate upper body only, not include leg, knee, and ankle.

Exercise #3: Dynamic side plank with knee bending: Lying down on the exercise side with set the torso and thighs on the straight line. Bending both knees to increase base of support and decrease the lever. Lift torso - pelvic - thigh up and down slowly with maintain the straight line by lateral torso and hip muscles.

Exercise #4: Static side plank with knee bending: Lying down on the exercise side with set the torso and thighs on the straight line. Bending both knees to increase base of support and decrease the lever. Lift torso - pelvic - thigh up and hold 10 - 60 seconds following physiotherapist recommendation with maintain the straight line by lateral torso and hip muscles.

Exercise #5: Dynamic side plank: Lying down on the exercise side with set the torso and thighs on the straight line. Lift torso - pelvic - knee joint up and down slowly with maintain the straight line by lateral torso and hip muscles.

Exercise #6: Static side plank: Lying down on the exercise side with set the torso and thighs on the straight line. Lift torso - pelvic - knee joint up and hold for 10 - 60 seconds following physiotherapist recommendation with maintain the straight line by lateral torso and hip muscles.

 

Exercise #7: Prone plank with knee support: This plank is supported by both elbows and knees to decrease load and lever. Keep flatten abdominal belly and spine that look like you make triangle space under the body. Do not arch back or drop pelvic or lift pelvic high. Hold for 10 - 60 seconds following physiotherapist recommendation.

Exercise #8: Basic prone plank: This plank is supported by both elbows and toes. Keep flatten abdominal belly and spine that look like you make triangle space under the body. Do not arch back or drop pelvic or lift pelvic high. Hold for 10 - 60 seconds following physiotherapist recommendation.

 

Exercise #9: High hip abduction: Lying on the side which the target side is up. Set torso and thighs in straight line and do not let pelvic rotate, especially rotate backward. Lift target leg up & down slowly with maintain straight line and pelvic is neutral.

Exercise #10: Lateral leg swing: Swing both legs side way slowly by torso muscles. The range of swing is shoulder wide or further slightly.

 

Strengthening exercises are often prescribed to promote stability. Many of the exercises designed with strengthening in mind require the torso musculature to produce specific movements against gravity or other externally applied resistance. However, the lumbar stabilizers need to have a very low level of contraction about 2 - 3 % of their maximum voluntary contraction capacity. 

They are mainly composed of type I fiber compared to rectus abdominis which mainly consists of type II fiber. It is shown that the type II fibers will show greater shrink in size compared to type I fiber when they are opposed to atrophic situations although the loss of actual fibers themselves is similar for type I and type II. 

It is my reason to design an easy exercise for my patients. I have planned more repetitions in some exercises for some cases 10 - 20 reps a hour during the day that total 100 - 200 reps a day.  

 

The factor of lateral abdominal muscles size is not only muscle fibers type but also age and gender. The mass of transverse abdominis muscle may be maintained by this small amount of contraction regardless of the age. Age was significantly correlated with IO, EO, and RA muscle thickness. Males seemed to have significantly thicker abdominal muscles than females and also BMI was positively associated with muscle thickness in RA and EO.

My low back pain exercises program was designed by the muscle function. The EO consists of anterior fibers and lateral fibers. The anterior fibers flex the vertebral column when acting bilaterally. Acting unilaterally with the anterior fibers of the opposite IO can rotate the vertebral column, bring the thorax forward, or the pelvic backward (when the pelvic is flexed). For example, with the pelvis fixed, the right EO rotates the thorax counterclockwise, and the left EO rotates clockwise. That can say, the vertebral column will rotate to the opposite side of EO. Whereas, lateral fibers of EO result the same movement but add on tilting the pelvis posteriorly.

Heel tap workout
(Ref: https://www.hevyapp.com/)

The IO is the intermediate layer between EO and TrA. Their function flexes the vertebral column when acting bilaterally that same the EO. They work unilaterally with opposite EO anterior fibers to rotate the vertebral column that will rotate to the same side of IO. Moreover, they can bring the thorax backward or the pelvis forward (when the thorax is fixed). The lateral fibers of IO act to bend the torso laterally.  

Layer of lateral abdominal group: EO (outer), IO (middle), and TrA (Inner)
(Ref: https://human-movement.com/)

The TrA is the deepest layer of the lateral abdominal group. It has been of particular interest to many physiotherapists as a core stability muscle due to its anatomy. It acts like a girdle to flatten the abdominal viscera; the upper portion helps to decrease the infrasternal angle of the ribs as in expiration. This muscle has no action in lateral torso bending that it acts to bend the torso forward for compressing the viscera and stabilizing the linea alba. If it gets weak, the posture will permit a bulging of the anterior abdominal wall that may induce increased lordosis. And it has the potential to be bulging laterally as well.

Lateral abdominal weakness and fat
(Ref: https://www.pooyingnaka.com/)

The EO and IO contribute torso forward bending and rotation but lateral bending is moved by IO only. TrA makes the belly flatten and bend forward. Therefore, the exercise poses were designed in forward flexion, lateral flexion, and rotation that except extension.  

 

Reference: 

https://core.ac.uk/download/pdf/227985494.pdf 

 

https://www.researchgate.net/publication/23480146_Altered_response_of_the_anterolateral_abdominal_muscles_to_simulated_weight-bearing_in_subjects_with_low_back_pain

 

https://www.sciencedirect.com/science/article/pii/S0004951414605146

 

http://www.pnfchi.com/fotos/literatura/1233770497.pdf

 

https://d-nb.info/1114223050/34

 

Kendall FP., et al. Muscles testing and function. Fourth edition. Williams & Wiikins. USA.

1993.  

 

Physiotherapy with (second) basic 10 therapeutic exercises in low back pain with flat back patients (ep.2)

 

Roman chair exercise
(Ref: https://barbend.com/)

      Flat-back syndrome is characterized by forward inclination of the trunk, inability to stand upright, and LBP that decreases the lumbar lordosis of the spine. The decreased lumbar spine lordosis induces changes in absorbing shock between vertebrae, and creating stresses in spinal muscles, tendons and ligaments. The ideal curvature of the spine in the sagittal plane serves to reduce loads on the vertebral discs and any shock to the spine, and it allows effective action of the spinal muscles.

The presence of a flat back is associated with malalignment in the spine, which could cause dysfunction of the deep lumbar muscles and result in chronic low back pain and deep muscle atrophy. Several studies have demonstrated atrophy of the lumbar multifidus muscles with infiltration of fatty tissue in patients with chronic LBP and atrophy at the dysfunctional lumbar level. 

Lumbar erector spinae and multifidus muscles
(Ref: https://centenoschultz.com/)

    The lumbar paraspinal muscles is the neighbor which can be progressively loaded during extension exercises by utilizing back exercise units that will tilt the pelvic to different degrees. As one progresses from a more upright position to a more horizontal position, the exercise becomes more intense for the back extensors. Once a patient can perform the exercise in the prone horizontal position. Sitting extension exercises performed with specialized equipment are also a good way to strengthen the low back musculature, because the resistance can be progressively increased. It has been demonstrated that the exercise activates the low back muscles better if the pelvis is mechanically stabilized so that the extension movement comes from the spine rather than from the hip extensors.

Some studies have shown that in individuals with LBP, moreover, there is also a decrease in the strength and lengthening of the iliopsoas, due to the connection of this muscle with the pelvis and the lumbar spine. As a result of this attachment, the iliopsoas possibly has a stabilizing role in the column. It is thought that tension in this muscle, formed by the union of the psoas major, psoas minor and the iliac acts bilaterally with the insertion, causing an increase in lordosis, whereas weakening of the muscle reduces its size where both these conditions result in pain. 

Force direction of hip flexor (iliacus & psoas) and lumbar back extensor 
(Ref: https://www.sydneyphysioclinic.com.au/)

All of these above muscles are members of pelvic and lumbar stabilizer or core stability muscles. Physiotherapists utilize exercise therapy as an intervention for patients with LBP. The spinal stabilization exercise approach has become popular with many therapists. Physical therapists tend to take different approaches when rehabilitating the muscles of the low back in patients. 

Due to the lumbar multifidus and erector spinae muscles have a relatively high proportion of type I (slow-twitch) muscle fibers. These muscles have fiber composition that makes them well suited for endurance or sustained contraction activities. 

Floor exercise for low back is low impact exercise
(Ref: https://www.popsugar.com/)

There is no evidence in the literature that one exercise program is superior to another. Using low-load stabilization exercise makes them well suited for endurance or sustained contraction activities. So, this topic maintained variation of basic lumbar exercise to treat LBP from flat back posture.  

The second basic 10 of 20 therapeutic strengthening exercises to activate anterior tilt (Remark: If there is tightness of the abdominal muscle or hamstring, it is necessary to treat these muscles to restore normal length before the abdominals can be expected to function optimally.)

 

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

Exercise #1: Supine hip external rotation with band: exercise with loop band or make band to be loop which need slight heavy resistance. Separate both knees to the floor with slight slow speed both downward and upward directions.

Exercise #2: Heel slide to hip flexion

Exercise #3: Supine hip flexion: In case of too short legs, I would like to recommend you to put some things under your foot at starting position.

Exercise #4: Upper back extension: If you exercise on the bench that will be call Roman chair exercise.

Exercise #5: Seat lumbar extension: If you exercise in fitness, you can exercise with back extension machine.

Exercise #6: Chair pose: During bending the knees, you have to maintain the space between both knees.

Exercise #7: Stand pelvic anterior tilt: Start with bend both knees slightly. Then arch your lumbar spine.

Exercise #8: Lunge: During lunge, do not let knee be inward direction that is keeping knee point to in front. Start with forward - backward stance and move body downward and upward vertically.

Exercise #9: Deadlift: The movement consists of bend knees slightly and straight lumbar with bend over. 

Exercise #10: Unidedal deadlift: It combines of straight lumbar bend over with elevate leg to hip level and opposite hand touch the floor.

The system of local stabilization involves deep intrinsic muscles which are directly attached to the lumbar vertebrae, and the global system comprises the great superficial muscles originating in the pelvis which insert in the thoracic cavity, with both systems necessary for stability and control of movements.

The erector spinae and multifidus muscles are the primary muscle groups responsible for controlling lumbar motion and forward inclination of the trunk. It is estimated that the erector spinae and multifidus contribute up to 85–95% of extensor moment during manual handling tasks, with these muscles playing an important role in resisting anterior shear forces during lifting and lowering.

Load on lumbar spine in different lifting posture
(Ref: https://ouhsc.edu/)

The erector spinae and multifidus muscles are thought to play an important role in the prevention of back injuries, and these muscles are often targeted during the rehabilitation of patients with such injuries. For example, during vocational activities such as lifting, the erector spinae and multifidus muscles are the major contributors to the extensor moment and serve to resist anterior shear forces acting on the lumbar spine.

Core stabilization exercises aim to maintain this stability, improve strength, resistance, improving neuromuscular control  of the abdominal and lumbar muscles, and attenuating recurrent LBP. Stabilization exercises are essential in order to provide a base for movement of the arms and legs when supporting weight and to protect the medulla and spinal nerves. Exercise stabilization programs emphasis on the transverse abdominis and multifidus (deep trunk muscles). Paravertebral and abdominal muscles such as the pelvic musculature and the diaphragm are also important targets for exercise. 

Upright with torso bending contributes increased lumbar disc pressure and multifidus workload
(Ref: https://ergonomictrends.com/)

80% to 90% of patients with acute LBP seem to recover within 6 weeks, regardless of the treatment received. In spite of this, there is about a 60% recurrence rate of LBP in patients within 1 year of the initial episode. Some patients do not recover from the acute LBP episode and go on to have a chronic condition. LBP is one of the leading causes of incapacity and the high cost of treatment renders preventative strategies paramount. Therefore, proper LBP prevention and treatment can help you to maintain daily life living capacity and save money. 

Lifting stuff properly is one of low back pain prevention
(Ref: https://reliva.in/)

Reference

Kendall FP., et al. Muscles testing and function. Fourth edition. Williams & Wiikins. USA.

1993.  

https://www.researchgate.net/publication/258825540_Effect_of_Individual_Strengthening_Exercises_for_Anterior_Pelvic_Tilt_Muscles_on_Back_Pain_Pelvic_Angle_and_Lumbar_ROMs_of_a_LBP_Patient_with_Flat_Back

 

https://www.mdpi.com/1660-4601/18/20/10923/htm 

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5342962/ 

https://www.scielo.br/j/rbfis/a/HjjyDzqVhbvDxkCSHqnWkjs/?format=pdf&lang=en

 https://drrobertlaprademd.com/wp-content/uploads/2015/07/rehabilitation-exercise-progression-for-the-gluteus-medius-muscle-2011.pdf 

 

https://www.researchgate.net/publication/333795080_Evaluation_and_comparison_of_electromyographic_activity_in_bench_press_with_feet_on_the_ground_and_active_hip_flexion 

 

https://www.scielo.br/j/fm/a/z6pw7PhWLtMQDGWyZCmYP7c/?lang=en&format=pdf 

 

https://www.researchgate.net/publication/272516106_The_Effectiveness_of_Lumbar_Extensor_Training_Local_Stabilization_or_Dynamic_Strengthening_Exercises_A_Review_of_Literature

 

https://paulogentil.com/pdf/The%20progression%20of%20paraspinal%20muscle%20recruitment%20intensity%20in%20localized%20and%20global%20strength%20training%20exercises%20is%20not%20based%20on%20instability%20alone.pdf 

 

https://www.jospt.org/doi/pdf/10.2519/jospt.2008.2865

https://www.researchgate.net/publication/285939823_Influence_of_Stretching_and_Strengthening_of_the_Iliopsoas_Associated_with_Lumbar_Segmental_Stabilization_Exercises_in_Patients_with_Low_Back_Pain_The_pilot_study 

Physiotherapy with basic 10 of 20 therapeutic exercises in low back pain with flat back patients (ep.1)

Dhanurasana with lumbar extension
(Ref: https://www.winnews.tv/news/5607)

            Lower lumbar lordosis is typical sagittal alignment of the spine. The ideal curvature of the spine in the sagittal plane serves to reduce loads on the vertebral discs and any shock to the spine, and it allows effective action of the spinal muscles.

Some patients with low back pain have flat back posture that decreases the lumbar lordosis of the spine. The decreased lumbar spine lordosis induces changes in spinal discs, creating abnormal pressures when absorbing shock between vertebrae, and creating stresses in spinal muscles, tendons and ligaments. 

Ideal posture that normal lumbar lordotic curve
(Ref: https://www.researchgate.net/figure/1-Ideal-Postural-Alignment-In-answer-to-the-question-Is-there-an-ideal-posture-we_fig6_335946477)

Flat-back syndrome is characterized by forward inclination of the trunk, inability to stand upright, and LBP pain. The presence of a flat back is associated with malalignment in the spine, which could cause dysfunction of the deep lumbar muscles and result in chronic low back pain and deep muscle atrophy. 

Improving the lordotic curve in the lumbar region after exercise intervention contributes to a decrease in the overload on the lumbar vertebrae and increases the lumbar muscle activity. The exercises for flat back syndrome include trunk backward extension and pelvic anterior tilt exercises that involve erector spinae, multifidus, gluteus maximus, iliopsoas, and rectus femoris.

 

Spine flexion opens facet joint and the rear structure are lengthen.
(Ref: https://www.caringmedical.com/) 

First basic 10 of 20 therapeutic strengthening exercises to activate anterior tilt (Remark: If there is tightness of the abdominal muscle or hamstring, it is necessary to treat these muscles to restore normal length before the abdominals can be expected to function optimally.)

 

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

 

Exercise #1: Seat hip flexion exercise

Exercise #2: Leg extension exercise: you can apply some weight equipment at the ankle or exercise with a leg extension machine.

Exercise #3: Four - point kneeling: bend a lumbar spine to stop at 3 angles that are neutral, arch, and hump. Start at neutral and breath out with a hump spine, then breath in with a return to neutral position. Start at neutral again and breath out with an arch spine, then breath in with a return to neutral position. 

Exercise #4: bird dog: elevate opposite arm and leg that arm elevation is shoulder level and leg elevation is hip level.

Exercise #5: Basic bridging

Exercise #6: Chair bridging hip extension outer range

Exercise #7: Chair bridging hip extension inner range

Exercise #8: Alternate superman exercise: Pillow is under the abdominal and pelvic to prevent shear force on spine. Elevate opposite arm and leg that arm elevation is over shoulder level and leg elevation is over hip level.

Exercise #9: Superman exercise: Pillow is under the abdominal and pelvic to prevent shear force on the spine. Elevate all limbs at the same time that are over torso level.

Exercise #10: Prone double hip extension exercise: Pillow is under the abdominal and pelvic to prevent shear force on the spine. Elevate both legs at the same time that are over torso level.

 

Mention to muscle strength imbalance in the kyphosis - lordosis posture and the military - type posture which are pelvic anterior tilt. They demonstrated very strong hip flexors and lower back muscles that are opposite of flat back posture. So, if we want to reverse flat back, we will strengthen hip flexors and lower back muscles.

Anterior pelvic tilting strengthens lumbar lordosis whereas posterior pelvic tilting has the opposite effect. The posterior pelvic tilting has been utilized as a rehabilitation method for improving the lumbar spine alignment in low back pain with lumbar lordosis because it improves soft tissue and joint compression and shear force to the structure. The anterior pelvic tilt contrasts the posterior pelvic tilt that it uses to solve the lumbar spine alignment in low back pain with flat back due to it helps to release the overload on the lumbar vertebrae and increases the lumbar muscle activity.

Erector spinae function for back extension and pelvic anterior tilt
(Ref: https://glamorousluxurypassion.wordpress.com/)

One public case report was a 37 year-old male, who has complained of low back pain in L3-5 levels with flat back for 10 months continuously. In the recent rehabilitation program, he performed individual strengthening exercises for the anterior pelvic tilt muscles (erector spinae, iliopsoas, rectus femoris). The strengthening exercise for erector spinae was as follows: stand with the feet shoulder width apart with both hands holding 5 kg weights; then flex the trunk slowly (5 seconds) until parallel with the floor while keeping the natural arch of the back with the shoulder blades back; then slowly return (5 seconds) to the starting position. The strengthening exercise for the iliopsoas was an above 90° hip flexion where there is to be 120 degrees (so-called psoas isolation) exercise for both legs with 10 kg weights. The strengthening exercise for the rectus femoris was an 80° knee extension exercise for both legs with 10 kg weights on a NK table. The subject performed the three individual strengthening exercises for two weeks in three sets of 30 repetitions per day. After the exercise intervention, the anterior pelvic tilt angle increased, compared to the initial angles. The pain intensity score of back pain decreased 50%. This recent report indicated no need for very heavy resistance in exercise to increase lumbar lordosis. 

Iliopsoas force vector that related lumbar spine - pelvic - hip motion
(Ref: https://www.lower-back-pain-answers.com/)

For athletes as well as the general population alike, conditioning the muscles of the lower back could be considered an important aspect of overall fitness. It has been suggested that deconditioning of the lumbar extensor musculature is a high risk factor for low back injury and pain, and that conditioning these muscles through exercises might offer an effective means of reducing this risk. The literature supports the effectiveness of active reconditioning exercises in the treatment by reducing pain and improving function in activities of daily life both groups of them.

I have seen many cases of prolonged deformity that have the potential to change length and strength of soft tissue structures. Some of these types of cases cannot restore posture and alignment to normal that is explained by the creep and stress relaxation phenomenon. However, therapeutic exercise can help to reduce pain and the stronger muscle can take the enhanced load and force.  

Back posture deformity
(Ref: https://novachirowellness.com/)

There are many exercise poses that some of them look like core stability muscle exercise concepts. The core stability muscle exercises focus on abdominal muscles, back muscles, and hip extensor muscles. Nevertheless, exercise to increase pelvic anterior tilt adds on hip flexor muscles that involve iliopsoas and rectus femoris. 

 

Reference:

https://www.researchgate.net/publication/258825540_Effect_of_Individual_Strengthening_Exercises_for_Anterior_Pelvic_Tilt_Muscles_on_Back_Pain_Pelvic_Angle_and_Lumbar_ROMs_of_a_LBP_Patient_with_Flat_Back

 

https://www.mdpi.com/1660-4601/18/20/10923/htm 

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5342962/ 

https://www.scielo.br/j/rbfis/a/HjjyDzqVhbvDxkCSHqnWkjs/?format=pdf&lang=en

 

https://www.researchgate.net/publication/272516106_The_Effectiveness_of_Lumbar_Extensor_Training_Local_Stabilization_or_Dynamic_Strengthening_Exercises_A_Review_of_Literature

 

https://paulogentil.com/pdf/The%20progression%20of%20paraspinal%20muscle%20recruitment%20intensity%20in%20localized%20and%20global%20strength%20training%20exercises%20is%20not%20based%20on%20instability%20alone.pdf 

 

https://www.jospt.org/doi/pdf/10.2519/jospt.2008.2865

https://www.researchgate.net/publication/285939823_Influence_of_Stretching_and_Strengthening_of_the_Iliopsoas_Associated_with_Lumbar_Segmental_Stabilization_Exercises_in_Patients_with_Low_Back_Pain_The_pilot_study 

Kendall FP., et al. Muscles testing and function. Fourth edition. Williams & Wiikins. USA.

1993.