- Kiley Holmes, PT
The Hinge: A Very Low Back Problem
The low back was designed to be stiff and stable - it's supposed to keep a very important part of your spinal cord safe. The design leaves little room for movement: the joints overlap significantly making rotation incredibly limited, and forward/backward bending less than in other parts of your spine. So what happens when other parts of your spine get stiff? Your body gets creative! Your body picks one of the other segments in your low back, usually between L4 and S1, and just moves from there instead. Great in the short term -- horrible repercussions in the long run.
It’s easy to spot this in a client: there is an indent in their back, like a real indent, and when they lean back it just hinges from there.
Early in this condition people will usually complain that they “throw out their back.” These individuals are usually initially fine, until they do a little too much or move a little too far and then that segment gets inflamed and the muscles around it spasm to protect the segment. Later on they'll generally have pain most of the time - they'll just say they have a bad back.
The concern is that the issue is stability and the last thing you should do is rest, however, that's what most of these individuals do. When people throw out their backs they usually rest in bed for several days. This is literally the worst thing that you can do.
The worst part is when the segment continues to be the only thing moving it becomes less and less stable. The next thing you know they're looking at a fusion for a Spondylolisthesis (which usually sounds and looks significantly worse than it really is). For some reason people think of back surgery as the answer to their problem. What most don't understand is that a fusion has a 50% success rate with success defined as the patient not being worse afterwards. Just to be clear that means that 50% of people who have a fusion will be worse afterwards. This explains all of the individuals that I have treated after 5+ back surgeries… that's insane! That's the definition of insane… doing the same thing over and over again expecting different results.
Look at this issue from a simple mechanical standpoint: you have one area that is moving too much and 20 plus other areas that are moving too little. All we really need to do is stabilize the area that is moving too much, and move the parts that aren’t moving.
While the fusion gets the unstable segment to stop moving, your body is just going to find another segment to move instead. This explains the fusion at L5 S1, that becomes a fusion from L4 to S1, that becomes a fusion from L3 to S1, and so forth. I have actually seen a fusion from T11 to S1. Unless you start getting the rest of your back to move the fusion is just a short term fix to a very big problem.
So what do you do?
As always, the answer is a combination of stability work and mobility work.
When it comes to mobility focusing on the hip and the thoracic spine generally provide the biggest bang for your buck. Simply adding in a couple of things for your hips and your thoracic spine can decrease this type of pain pretty significantly.
My favorite thoracic mobility exercises are the yoga wheel thoracic extension rolling, and the open book:
For the yoga wheel extension rolling, start off by putting the wheel behind you while you are sitting on the floor. Next, just lean back into the yoga wheel while supporting your neck. Over several days or weeks you'll slowly be able to put more weight onto the yoga wheel, and eventually, you will be able to roll back and forth.
The open-book is very simple - just lay on your side with your knees towards your chest. The more that you can bring your knees up the less pressure you will put on your low back. Once you are in position, reach forward with your top arm and then all the way back taking your head with you, like you are reaching into the back of your car for something. This one feels wonderful and there is no such thing as doing too many. Take your time and enjoy the stretch.
As far as hip mobility goes, depending on how tight your hips are, you may want to start with a hip opener. This requires a heavy band (available on Amazon). Attach the band to a heavy or immovable object, like a door or a stair rail, then bring one leg into the band. Walk away from the band allowing tension to build. This is a good place to start, however, as you build tolerance to the distraction you can add any sort of movement you can think of - forward bending, lunges, squats, hip rotation, etc.
Next I would recommend the side lying hip rotation. Laying on your side with your knees toward your chest drop the bottom leg off of the side of the bed allowing your ankle and foot to drop down towards the ground and back up. This should be difficult at first but will get easier as time goes on. In fact, it is a great one to add a weight to as you progress.
Next, it is a good idea to loosen up the front of your hips. I personally enjoy doing a Thomas stretch, bridges, and, if possible, the hero.
The Thomas stretch is a great start I will set you up for success for your other exercises. Laying on a couch go ahead and bring the leg further from the edge to your chest and give it a hug and at the same time drop your leg closer to the edge off the edge and onto the floor letting your knee bend as much as possible go ahead and hold this for 30 seconds to a minute.
Bridges are quite easy - I prefer the Pilates style bridge. Go ahead and lay on your back with your knees bent and feet on the floor lifting one segment off the table at a time until your butt is all the way up in the air followed by lowering one segment back down onto the table. Doing about 10 of these should loosen things up quite nicely
The hero is my absolute favorite hip stretch. In a high kneel position (see picture) bring your arms over head, keeping your upper body and hips completely straight, and bend your knees leaning your body back holding for a count to 5 and then come back up. This hip stretch loosens up everything and feels amazing afterwards.
Now let's talk about stability. Usually your bigger back muscles are quite strong in this condition, but the little guys, the muscles that connect each segment to each other called the rotatores and the multifidi, are weak and lack the coordination to provide stability to your spine. Just like the muscle, little movements are the answer. But beware, they require a ton of brain power so pay attention while doing these exercises.
I love to start with quadruped hip lifts. Start on all fours, putting a book underneath one of your knees. Once you are all set up go ahead and lift your opposite hip to match the hip with the book underneath it. Not too high and not too low - you would be surprised how difficult this is to do. I would recommend asking someone for help the first couple of times you do this exercise. Ask somebody with a discerning eye. We are looking for a very small movement.
Once you feel like you have that lift down, which usually takes a couple of weeks, you are ready to keep that book underneath your knee while completing more complex movements such as bringing the other knee up to your chest, straight back, or to the side while maintaining that hip lift that you've learned. This will take quite a long time to master.
Believe it or not that Pilates bridge we talked about earlier is a great stabilizing exercise as well.
I should also say that completing some glute strengthening and planks would be beneficial in this situation - message me or check out my instagram if you need some ideas.
There are quite a few manual therapy techniques that physical therapy can provide as well as plenty of other exercises to get things going. Please do not hesitate to message me with questions about this blog post or any ideas for other posts!