Physiotherapy with 6 stretching recommendations for non - specific low back pain in patients with hyper - pelvic anterior tilt

Lumbar hyperlordosis and pelvic anterior tilt
Ref: https://www.medicalnewstoday.com/

Postural observation in patients with low back pain is one of my gold standard physical evaluation protocols which is investigated by physiotherapist visual and postural grid charts. Most of them showed faulty lumbar spine and pelvic alignment. 

Postural grid chart
(Ref: https://www.pinterest.com/)

Many cases have presented low back pain with hyper lumbar lordosis or hyper pelvic anterior tilt which is one of poor posture that can develop low back musculoskeletal disorders. When a combination of faulty alignment and muscle tightness is present, both position and constant although it may vary in intensity with change of position. Stresses which would not be excessive under ordinary circumstances may give rise to pain. An apparently inconsequential act may cause an acute onset of pain. 

However, some cases have chronic back pain from this posture, as well. It is true that some individuals with lordosis complain of low back pain while others with a more severe lordosis may not complain of any pain. A lordosis may be habitual, but if the muscles of the back are flexible enough that position can be changed from time to time, symptoms may not develop. However, a back so tight that the lordosis position is fixed tends to be a painful back in any position of the body.

Lumbar hyperlordotic makes soft tissue and joint compression
(Ref: https://osteopathy.colganosteo.com/hyperlordosis/)

 "There is undue compression posteriorly on the vertebrae and the articulating facets, and there is undue tension on the anterior longitudinal ligament in the lumbar area."

The lumbar hyperlordosis or the hyper pelvic anterior tilt is in result of muscle imbalances that associated with an anterior tilt may include all or part of the following: weak anterior abdominal muscles, weak hip extensor muscles, tight hip flexor muscles (chiefly iliopsoas), and tight low back muscles.

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

We will discuss only muscle tightness induced hyper lumbar lordosis in this article. Referring to above, the tightness of low back extensor muscles and hip flexor muscles cause shortened distance of anterior hip and posterior lower torso. Hip flexors consist of iliopsoas, rectus femoris, and tensor fascia latae (TFL) where the most important muscle is iliopsoas. 

However, sometimes I found an association of origin of rectus femoris and hip adductor tightness with iliopsoas tightness. I have always seen TFL tightness in flat back posture more than hyper lordosis posture. 

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

Basic 6 stretching to correct anterior pelvic tilt. (Please stop stretching and consult a physiotherapist or doctor if you feel worse pain and/or numbness.)

Exercise #1: Supine double knees to chest

Exercise #2: Child pose

Exercise #3: Prone on ball: Ball is under lumbar and hip level.

Exercise #4: Standard half kneeling stretch where the target muscle is on the rear leg. The pose needs to keep back straight with a shift pelvic in front that no need to arch the back.

Exercise #5: Chair stand posterior pelvic tilt

Exercise #6: Half kneeling with toe touch stretch: the target leg is on the knee with set ankle at neutral with toe tips touching the floor. Lean back and pelvic posterior tilt slightly without arching the lower back. We need the hip joint to be neutral or extension.

If you would like to have more stretching exercise information please follow the link include;

(1) Back muscle: https://yimphysionearme.blogspot.com/2022/09/physiotherapy-with-7-basic-lower-back.html 

(2) Hip flexors: https://yimphysionearme.blogspot.com/2022/05/physiotherapy-with-6-tips-to-stretch.html 

(3) Proximal quadriceps: https://yimphysionearme.blogspot.com/2022/07/tips-of-proximal-quadriceps-stretch-for.html 

 

Pelvic tilt is defined as the angle between the horizontal and a plane passing through the posterior superior iliac spines and anterior superior iliac spine. Lumbar lordosis is defined as the curve assumed by the lumbar spine, where the lumbar spine forms an anterior convexity. The degree of lumbar lordosis is variable among individuals and is the result of the lumbar vertebrae, especially L5. 

Anterior pelvic tilt, the low back arch forward into a position of lordosis. The vertebral spine has regional curves on the sagittal plane designed to absorb impact, reduce its longitudinal stiffness, and intensify muscular function.

There are no normative lumbar lordosis angles. Values of sagittal curves measurements on the spine present great variability in normal individuals. One study compared the measurement of lumbar lordosis, as well as of its components (vertebral bodies and intervertebral discs) showed a high variation in studied subjects. The result illustrated the lumbosacral curvature measurements (L1S1) ranged from –33.0° to –89.0° (average –60.9° ± 10.65). The values for lumbolumbar curvature (L1L5) ranged from –15.0° to –78.0° (average –45.1° ± 10.8).

Lumbar lordosis curve measurements
(Ref: https://www.scielo.br/j/aob/a/PnpKbZMb7P7cPDrTTcmcH3L/?format=pdf&lang=en)

Janda has written about standing posture with lumbar hyperlordosis that we can see in Military - type posture which is common in soldiers and kyphosis - lordosis posture which is seen in my clinic often, especially in swimmers.

The Military - type posture was named following the traditional discipline standing of soldiers. The standing order to the straight torso with open chest and shoulder is a component of hyperextension/ hyperlordosis of lumbar spine and pelvic anterior tilt. This chain of movement can develop tightness of low back and hip flexor muscles. 

The military - type posture
(Ref: https://www.pinterest.com/) 

Kyphosis - lordosis posture was indicated by over - kyphosis of thoracic spine and over - lordosis lumbar spine that we can see a big S curve from lateral view. Lumbar spine is hyperextension/ lordosis, and pelvic anterior tilt, and flexion of hip joint. Muscles tightness of lower part including hip flexors. In part of the low back extensors are strong and may or may not develop shortness.

The Kyphosis - lordosis posture (Ref: https://www.pinterest.com/) 

Tight one - joint hip flexors (chiefly iliopsoas) is a crucial factor because it causes an anterior tilt of pelvis in standing. The low back goes into a lordosis as the subject stands erect. Occasionally, a subject inclines forward from the hips, avoiding an erect position that would result in a marked lordosis.

The severity of the lordosis depends directly on the extent of tightness in the hip flexors. Stress on the low back in the lordotic position is often relieved by giving in to the tight hip flexors. In standing, this is accomplished by bending the knee slightly. 

Tightness of iliopsoas
(Ref: https://blog.voltathletics.com/home/2015/3/25/psoas-talk-with-christye)

In sitting, the hips are flexed and hip flexors are slack. Some people can sit for long periods of time without pain or discomfort but have pain when standing for brief periods. One should examine for hip flexor shortness in such cases. 

Lying on the back or on the side with hips and knees flexed relaxes the pull of the tight hip flexors on the low back. 

When knees are bent to relieve discomfort in the back, an effort should be made not to bend them more than necessary. After the hip flexors are stretched through appropriate stretching exercises, it is not necessary to flex the hips and knees in order to be comfortable when lying on the back.

Tightness of hip flexors can pull spine into lordosis in supine
(Ref: https://learnmuscles.com/blog/)

In the supine lying position with hips flexed enough to allow the back to flatten, the patient is more comfortable on a firm mattress than on a soft one. On a soft mattress, the pelvis sinks down and tilts anteriorly, causing a lordotic position of the low back. 

Prone lying is not tolerated because the tight hip flexors hold the back in a lordotic position. However, the prone position can be made comfortable by placing a firm pillow directly under the abdomen to help flatten the low back and allow slight flexion of the hips.

(Ref: https://commons.wikimedia.org/)

Rectus femoris and TFL are the two - joint hip flexors that the degree of tightness usually does not cause lordosis in standing. 

The reason is that the muscles are not elongated over the knee joint when the knee is straight. (tightness would have to be severe to be tight over both joints). And when the quadriceps muscles are overworked, the muscle becomes tight and inelastic. When the rectus femoris is tight, it will pull the hip bone and continue to turn the whole pelvis moves downward or forward. This position is said to be the anterior tilt of the pelvis. Muscle tightness may be linked to postural disturbance. Both can contribute to multiple musculoskeletal conditions. By the way, the tightness of quadriceps are accompanied by weak hamstrings. That’s why the onset of low back pain was also associated with quadriceps muscle tightness. 

Therefore, sometimes this tightness is very marked, and stretching should be done in a manner that does not put stress on the patella during knee flexion. For that reason, it is recommended that the knee be placed in flexion, so the patella can ride over the knee joint before starting further stretching. Proceed to stretch hip flexors by pulling up and in with the lower abdominal muscles to posteriorly tilt the pelvis and extend the hip joint.

Force direction of rectus femoris and back extensor in pelvic anterior tilt
(Ref: https://mskneurology.com/)

Tight low back muscles cause an anterior tilt of the pelvis and hold the low back in a position of lordosis. Due to the low back extensions pull upward on the pelvis posteriorly. While these muscles cross over joints of the vertebral column, they do not cross over another joint at which the muscles can give in to the tightness. Regardless of what position the body assumes, the low back will remain in a degree of extension that corresponds to the degree of tightness of these muscles. If forward bending, the low back remains in an anterior curve and does not straighten.

In cases in which tightness of the low back muscle is the primary factor, pain may be chronic but often has an acute onset. Pain is increased by, and tends to have its onset in, movement rather than standing or sitting positions. The problem tends to be more common among men than women.

Combination of muscle impairment in pelvic anterior tilt
(Ref: https://file.scirp.org/)

To correct pelvic and lumbar lordosis posture needs not only flexibility as above but also strength in the involved muscle. Abdominal musculature is a major contributor to excessive anterior pelvic tilt and an increased lumbar lordosis. And the hamstring pulls the pelvic downward posteriorly. Any one of the above may be the primary factor but the tight low back and weak hip extensor muscles are least likely to be the primary cause.

Reference:

https://www.researchgate.net/publication/244940588_The_effect_of_abdominal_muscle_strengthening_on_pelvic_tilt_and_lumbar_lordosis 

https://novyimir.net/gallery/nmrj2606%20f.pdf 

 

https://www.scielo.br/j/aob/a/PnpKbZMb7P7cPDrTTcmcH3L/?format=pdf&lang=en 

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

1993.

Physiotherapy with 7 basic lower back stretching for flexibility and release pain

Ref: https://www.dnaindia.com/cricket/

             Low back pain or lumbar region pain is one one the most cause of daily function limitations. There are risk factors including weakness, stiffness, trauma, degenerative, overuse, or poor posture.

        Biomechanically, the joint flexibility is also determined by the resistance

caused by the tissues surrounding them and can be reduced due to adaptive

shortening of the soft tissues. This shortening can be caused by immobilization,

sedentary lifestyle, and the aging process of collagen, which leads to less

elasticity of the fasciae near the spine.

        Changes in the connective tissue involving tendons, ligaments, and muscle

fasciae caused by factors that directly influence the range of motion (ROM) of a

joint (aging, work, immobilization, injuries, metabolism disorders, or nutritional

deficiencies) can predispose an individual to low back pain (LBP). In addition, low

levels of flexibility of passive muscle structures (tendons, ligaments, and fasciae)

may be associated with LBP. In conditions of LBP, the muscles become spasmodic

even at rest and the accumulation of metabolites can cause irritation in the nerve

endings of the area, generating reflex spasm and increased pain. 

Ref:https://cck-law.com/

        The treatment for chronic LBP may involve physical exercises, medication,

injections, physical therapy treatment, and, as a last resort, surgical intervention.

Regarding the use of physical exercises, despite the lack of clinical trials, there is

theoretical support that suggests stretching exercises are an effective alternative

for the treatment of chronic LBP.

        Despite the multifactorial etiology, physical therapies that result in analgesic

effects, such as stretching exercises, could be viable alternatives as

non-pharmacological therapies for reducing pain intensity in individuals with LBP

through biomechanical and neurophysiological mechanisms, besides improving

body posture, musculoskeletal disorders, and muscle pain.

Ref: https://www.verywellhealth.com/

        Stretching is possible to reduce low back pain after performing stretching

exercises. Such exercises can be performed with different possible organizations

regarding the stretching techniques used, mainly passive-static, passive-dynamic,

active-dynamic, and proprioceptive neuromuscular facilitation (PNF). 

Tight low back muscles cause an anterior tilt of the pelvis and hold the lower back in a position of lordosis.

        The principle to stretch this muscle is the same as the others: stretch to the

point where “tightness with pain” or “noticeable tension without pain” will hold at

the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

Ref: https://www.freepik.com/

The 7 basic options to stretch lower back muscle

Exercise #1: Supine double knees to chest

Exercise #2: Supine single knee to chest

Exercise #3: Longed sitting bending: Sit against the wall then bend torso forward with keep sacrum

at the wall.

Exercise #4: Cat pose: hump lumbar spine. Do not hump thoracic spine.

Exercise #5: Child pose

Exercise #6: Prone on ball: Ball is under lumbar and hip level.

Exercise #7: Seat pelvic posterior tilt: Do lumbar spine, not thoracic spine.

              Anatomy of back muscles are organized in layers and divided into intrinsic

muscles and extrinsic muscles categories: 

(1) The extrinsic muscles (latissimus dorsi and serratus muscles) cover the

intrinsic muscles and are mostly responsible for limb motion that we do not

discuss in this article. 

Latissimus dorsi & serratus anterior muscles as extrinsic muscles
(Ref: https://www.acropt.com/)

        (2) The intrinsic muscles regulate the tonus and motion of the spine. Intrinsic

muscles are divided in three groups and represent a muscular column with a

cross-sectional area of approximately 10 cm2 to 25 cm2: a deep layer (rotatores,

interspinalis and intertransversarii muscles), a middle layer (multifidus muscle) and

a superficial layer (sacrospinalis muscle formed by the longissimus and iliocostal

muscles). 

        The deep layer muscles are short and small that refer to their location. The

Intertransversarii and interspinalis muscles connect to the transverse and spinous

processes, respectively, of two adjacent vertebrae. They can be considered as

proprioceptive transducers helping in spinal positioning. The Rotatores muscles

connect transverse processes and laminae of two adjacent vertebrae. 

Rotators & interspinalis & intertransversarii muscles
(Ref: https://www.chegg.com/)

        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.

        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.

Multifidus muscles
(Ref: https://learnmuscles.com/)

        The multifidus muscles are installed in the middle layer. The multifidus consists

of multiple overlapping layers of fibers that can be clearly divided into five bands.

        Each fascicle arises from a common tendon attached to the spinous process of

individual lumbar vertebrae with fascicles attaching to the mamillary process of the

inferior vertebrae, the iliac crest and the sacrum. Fascicles of multifidus arise from a

common tendon and create a force vector that acts vertical and perpendicular to the

spinous process. This orientation and the segmental innervation of fiber bands not

only allows the multifidus to control lumbar curvature at a segmental level but

provides good mechanical advantage when applying an anti-flexion (extension)

moment.

Muscle activity study of erector spinae (ES) and multifidus (MF)
(Ref: https://www.mdpi.com/2077-0383/10/18/4039/htm)

           The multifidus exerts a relatively small horizontal force vector when compared

to the lower erector spinae and the obliquity of its fascicles varies between segments.

However, the net effect of its fascicle arrangement in upright standing is to produce anterior

shear on the L5–S1 segment. The multifidus has twice the physiological cross-sectional

area of other erector spinae muscles, despite having a similar mass. This relatively large

cross-sectional area, in combination with its short fiber length, enables the multifidus to

produce large forces over a short range of motion. These properties make the multifidus

better suited to intersegmental stabilization, as opposed to generating large amounts of

lumbar motion.

    Erector spinae muscle is a vast musculotendinous mass formed by two muscular

groups: the longissimus muscle, medially, and the iliocostal muscle, laterally. Longissimus

muscle fibers arise from the lumbar and inferior thoracic transverse processes, while

iliocostalis muscle fibers arise from the angles of the lower ribs and from the lateral one

quarter of the lumbar transverse processes. In the lumbar region, both muscle fibers

attach to a robust aponeurosis, the erector spinae aponeurosis, attached to the medial

sacral crest, lumbar spinous processes and ilium. During flexion, the erector spinae muscle

controls rather than produces motion and prevents excessive motion. During lateral bending

and twisting, the erector spinae muscle both controls and produces motion.

Erector spinae muscles group
(Ref: https://yogamedicine.com/)

            The erector spinae muscles consist of the iliocostalis muscle (lateral column

extending from the ilius to the ribs), the longissimus dorsi (intermediate column extending

from the sacrum to transverse processes), and the spinalis, a medial group that courses

along the spinous processes. The multifidi are an extensive group of smaller muscles that

extends along the spinous processes from the sacrum to the axis. 

Longissimus muscles are divided into 3 parts as thoracis & cervicis & capitis
(Ref: https://www.getbodysmart.com/)

                The upper erector spinae consist of the thoracic fibers of longissimus and

iliocostalis lumborum. Its muscle fascicles arise from the thoracic transverse processes

and lower seven ribs and span the entire lumbar spine forming the erector spinae

aponeurosis. The erector spinae aponeurosis has no direct attachment to the lumbar

vertebrae and connects to the posterior pelvis and sacrum. In upright standing, the upper

erector spinae has the greatest moment arm of all the lumbar extensors muscles which

allows it to generate a large extensor moment at a relatively low compressive cost. As the

upper erector spinae fibers run almost parallel to the long axis of the lumbar spine, they

have limited influence on shear forces.

Spinalis muscle consists of capitis & cervicis & thoracic part
(Ref: https://www.kenhub.com/en/)

            The lower erector spinae consist of the lumbar fascicles of longissimus thoracis

and iliocostalis lumborum. The lower erector spinae has two distinct architectural

differences that differentiate it from the upper erector spinae. First, it connects to the

lumbar vertebra and this enables the fascicles to directly exert forces on the vertebrae to

which they attach. Second, the lower erector spinae are more obliquely oriented than the

upper erector spinae and therefore are better suited to generating forces that oppose

anterior shear. Lower erector spinae obliquity is more pronounced at the level of L4 and L5,

and in this region the fascicles of the muscle are capable of generating 40–49% of their total

resultant force in the posterior direction.

The iliocostalis consists of cervicis & thoracic & lumbar part
Ref: https://bodybuilding-wizard.com/

      

              A number of low back intervention programs have been developed to improve the

strength and function of the erector spinae and multifidus muscles. However, a limitation

often associated with these programs is that they assume the erector spinae to be a single

muscle that extends the length of the lumbar spine and ignore the biomechanical role played

by the different divisions of the erector spinae and the multifidus muscle.

Reference: 

https://www.researchgate.net/publication/358014814_Mechanisms_of_muscle_stretching_

exercises_for_reduction_of_low_back_pain_narrative_review 

https://www.researchgate.net/publication/276425136_Lumbar_posture_biomechanics_

and_its_influence_on_the_functional_anatomy_of_the_erector_spinae_and_multifidus 

https://www.researchgate.net/publication/5387495_Disorders_of_paravertebral_lumbar_

muscles_From_pathology_to_cross-sectional_imaging 

https://www.ajronline.org/doi/pdf/10.2214/ajr.138.1.93 

https://www.jospt.org/doi/10.2519/jospt.2019.8827 

https://www.researchgate.net/publication/306146670_Iliocostalis_Thoracis-Lumborum_

Myofascial_Pain_Reviewing_a_Subgroup_of_a_Prospective_Randomized_Blinded_Trial_

A_Challenging_Diagnosis_with_Clinical_Implications

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1256533/