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| 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.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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.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.jospt.org/doi/pdf/10.2519/jospt.2008.2865
Kendall FP., et al. Muscles testing and function. Fourth edition. Williams & Wiikins. USA.
1993.
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