Low Back Pain

Roughly 85% of the general population experiences back pain at some point in their lives. Anyone who has endured serious back pain, has most likely heard all their friends' and neighbors' back pain stories — what worked for them and what didn't. The low back is mechanically one of the most complex areas of the human body. So, one person's back pain may be due to different structures being injured than another person's. The treatment for each type of back pain should be unique.

ANATOMY
The anatomy of the lower back region is rather complex and will be touched on in Part II. However it is important to understand that there are many different structures which can be injured, and this will dictate the type of exercise which is appropriate. Inappropriate exercise may further damage the low back.ANATOMY

The eleven bones of the low back area consist of the lumbar spine (which are the last five vertebrae, or moveable segments, of the spine), the sacrum and tailbone (the bony area between the buttocks), the pelvis and, to a certain extent, the hips (femurs). Joints are surfaces where bone meets bone. Without going into excruciating detail, there are approximately 20 joints included in the low back area. Each joint is surrounded by ligaments. Ligaments act similarly to tape by holding the joints together, allowing movement in some directions while restricting it in others. Muscles not only move the bones, and consequently the trunk, but they also stabilize the trunk when the extremities are moving. The lower back area has large muscles extending more or less from the sacrum all the way up to the arms (i.e. latissimus dorsi), as well as many smaller muscles which only span one or two joints. Between the vertebral bodies are discs, which act as shock absorbers. The spinal canal runs inside the vertebrae and includes the spinal cord and spinal nerve roots. The nerve roots exit in-between the vertebrae and travel to all different parts of the body. The nerves which exit between the lumbar vertebrae supply the buttocks, thighs, legs, feet, as well as organs such as the intestines.

PATHOLOGY
A person experiencing low back pain may have damaged any of the structures mentioned above. Some of the most common problems are:

Joint locking/subluxation
If the joints are not moving symmetrically in all possible directions, an imbalance is created. The locking itself may be painful or may lead to compensations, such as tight muscles, improper body mechanics, irritation of the structures adjacent to the locking. The lumbar facet joints and the sacroiliac joints often exhibit this problem. A slight joint dislocation or malposition of bones is often called a subluxation (although chiropractors will also often include joint locking under the term subluxation as well). This is commonly seen in the sacroiliac joints. Joint locking or subluxations predispose one to many of the following problems. Treatment: chiropractic adjustments. Assess for predisposing factors, such as muscle imbalances.

Muscle strain
A tear in the muscle fibers. Usually a mechanical cause, such as lifting a couch awkwardly, or spending a long period of time doing an unaccustomed activity, such as gardening. Muscle strain may also result from poorly functioning joints (see above). Treatment: Initially ice, then alternate ice and heat, rest the muscle, physical therapy modalities (such as ultrasound, interferential current), assess for predisposing factors such as joint locking, muscle imbalances.

Ligament sprain
A tearing of the ligaments. Similar causes as above, but usually associated with trauma. Ligament injuries may lead to instability, especially of the sacroiliac joints. This in turn may cause muscles to tighten, and nerves to become irritated. Treatment: Same as above, although my preference is to stick with ice, and only use heat if you find it helps, assess for predisposing factors as above.

Facet Syndrome
An irritation of the posterior joints of the lumbar vertebrae. This may cause localized pain and muscle spasm, as well as sciatica (see below). People with Facet Syndrome often find swimming in a long course pool irritating to their low back. Short course allows them to flex their spine on each flip turn. Dolphin kicking or butterfly swimming may also aggravate this problem. Treatment: Same as above. The MacKenzie exercise protocol tends to aggravate Facet Syndrome. Stick with flexion exercises until asymptotic.

Piriformis Syndrome
A tightness/spasm of the piriformis muscle (connects the sacrum to the top of the femur/hip; a muscle deep in the buttocks). Typically this will cause pain into the buttocks, which may radiate down the thigh to the leg (sciatica). Treatment: Stretch the piriformis muscle, physical therapy modalities to the muscle, acupuncture or triggerpoint work to the muscle, stretch the piriformis muscle.

Disc related problems
Discs may bulge, herniate, or prolapse. However, this kind of problem may also result in all sorts of symptoms such as sciatica (nerve pain into the buttocks, thigh, often to the foot), tingling, numbness, and/or weakness of those same areas, muscle spasm, and in severe cases paralysis of the lower extremities. Treatment: Most cases are amenable to chiropractic treatment with the use of physical therapy modalities and rehabilitation exercises (MacKenzie protocol often very helpful here). It is only the rare case that requires surgery. It is important to note that about 40% of the population not experiencing low back pain will show some disc bulging on an MRI study. Swimmers with disc problems need to be especially cautious when diving. Unless it is extremely important that you dive, start from the water. Also, during the acute phase be gentle during or avoid flip turns.

Low Back Rehabilitation Exercises
Generally, one can break down low back rehabilitation exercises into four schools of thought:

McKenzie — The Lordosis Theory
Low back pain is due to a flattening of the normal lumbar curve (also known as a lordosis), thereby stressing the pain sensitive muscles and other lower back components (such as joints or ligaments). Treatment is directed toward low back extension (backwards leaning, Cobra position in yoga), thus accentuating the lordosis. These exercises are often given to people with a herniated disc.

Williams — The Flexion Theory
There is a lower incidence of back pain in agrarian cultures in which people regularly assume a "squat" position, thus flattening the lumbar spine. Low back flexion exercises and treatment maneuvers were developed based on this observation. People with pain in their posterior lumbar joints (facet joints) or those who've strained their lower back muscles benefit from these exercises.

Muscle Imbalances
Tight muscles, such as hip flexors (psoas, rectus femoris) inhibit weaker muscles, such as abdominal muscles. The treatment is first directed toward stretching the tight muscles and then strengthening the weak muscles. Although certain patterns exist, each patient must be assessed individually.
An example from swimming: A good strong flutter kick requires strong hip extensor muscles (gluteus maximus, hamstrings). If yours are weak (due to any number of factors which should be diagnosed), you will tend to use your inappropriate low back muscles instead (lumbar erector spinae muscles). Needless to say, you will probably not be the swiftest flutter kicker, and you'll probably experience low back pain after long kick sets.

Proprioceptive Deficits
Proprioception is the ability of the brain/nervous system to assess the position of a joint in space. Good proprioception is important for balance. While many rehabilitation exercises are floor exercises (on a stable surface), most people injure themselves when their body is off balance (i.e. pulling clothes out of the dryer). Proprioceptive exercises train the body to maintain stability and balance in different situations. These exercises are often done with the Swiss ball and/or rockerboards and wobbleboards.