As practitioners we can sometimes focus so much on what is wrong that we forget what is actually relevant. When I was first out of my masters I had my ‘go-to’s’ when anyone attended with back pain. Upon reflection my assessment process was effective at identifying weakness and tightness but whether changing these identified factors actually had a profound effect on the clients pain, beyond natural healing progression, was unbeknownst to me. Our goal as practitioners is to speed the healing time, decrease pain and get you back to moving freely and easily. With time I have come to find a number of common things that clients are told from other practitioners that are often completely irrelevant or the result of an underlying cause rather than the cause itself. If you’ve been told any of the following, it may still be correct, but if it’s not changing your symptoms quickly then there is a chance that it isn’t completely relevant to your back pain.
1. Your core isn’t strong.
I hear this so often. “My ‘insert professional’ has told me I have back pain because I have a weak core and I need a program to get that working.” During client assessments I often discover that there is an imbalance in the core / abdominal musculature, but not all of it is weak. Often there is so much guarding and tension from an underlying issue through certain core muscles that the client is already active through their core. Is your lower back tight? Do you find it hard to relax your lower back? Do you feel you have to be tense through your back as you walk and move? The answer should be ‘no’ and we should be relaxed and moving freely like we always were before back pain. So why would we want to do more to tense it up? I’m purely talking from an acute stage of back pain. Once you have learnt to relax, which reduces compression through the spine, we can get back to learning how to use your core the way it was intended to be used and to work on any imbalances that may be affecting your posture.
2. My deep core muscles (transverse abdominus) isn’t working.
If you’ve ever done deep core muscle exercises with pilates or in other various modalities you’ll realise it is really boring, time consuming and difficult. You’re also probably wasting your time. This reason as a cause for back pain was developed after numerous studies were completed and the researchers found a correlation between people with low back pain and a delay in the timing and 'switching on' of the deep core muscles. My first placement many years ago at a pilates physiotherapy clinic was very much a subscriber to this theory. I remember we would sit there with an ultrasound machine on someone’s abdomen so they could see the layers of their core muscles. They would then be cued to tense these deep muscles and perform movements until they had trained them successfully without activating the big superficial muscles. It was time consuming and I never saw an immediate relief in anyone’s pain. Once again the natural progression of tissue healing and repair was not observed to be any slower. Years later there is an abundance of good quality evidence to disregard this method of treating back pain, with one systematic review stating it being no better than a general graded exercise program. If there is a marked weakness in these deep muscles, then perhaps this still has its place. However; research has shown that the transverse abdominus is often more active in people with low back pain and there was a lack of correlation to its delayed activation or strength with back pain.
3. Your glutes don’t work.
“I’ve been told I have back pain because my glutes are lazy.” What I came to realise early on was that the majority of people suffering from back pain had glutes that were under active. Initially I prescribed vast amounts of glute exercises but there was never any indication that they were decreasing low back pain symptoms. First year physiology lectures taught us that if we have pain, we have inhibition, meaning certain muscles will be less active and others more active when pain is present. This inhibition comes from guarding or protecting the underlying reason for the back pain. Meaning your body switches on muscles to try and protect an injury causing the muscles that do the opposite action, to the switched on muscle, to switch off. This contracting and relaxing of muscles is normal, in fact it is necessary for all our movement; when one muscle contracts and shortens the opposing muscle relaxes and lengthens . So here I was straight out of university trying to get glutes switched on, frustrated that the client reported symptoms either worsening or being no better afterwards. What I have learnt from this is if we can address the underlying issue of pain first, then the guarding and muscle inhibition reduces and our bums become less lazy. This does not mean not to do your glute exercises, glutes are often in need of a solid workout, but they are probably not the key to your back pain in the acute stages.
4. Your hip flexors are tight.
In some cases this is possibly true, but often not the only cause of back pain. Your hip flexors are the muscles that cross over the front of your hip and allow you to bring your leg up towards your chest. After repeated periods of prolonged sitting, these muscles can tighten and become short. It makes a lot of sense that if these muscles are short and tight it will create more tension in your low back as one muscle in particular attaches to your lumbar spine and the others to your pelvis. Imagine attaching ropes from the ground to the bony parts on the front of your pelvis as you are standing. Now tighten them and try to stay standing. Can you imagine how that puts tension into your lower back? While tight hip flexors could be contributing to your lower back pain, your posture also has a lot to do with it. In fact, those hip flexors may actually be weak and long rather than short and tight. Correct assessment of your hip flexors is really important in making sure that any issues are addressed and also relevant to your back pain.
5. Your hips are out of whack.
Sure, they might be, but why? Often clients will come in explaining they have one leg longer than the other and that their hips are out of whack. If your hips are out of alignment then one leg will be longer than the other and it makes sense; lift one pelvis (hip bone) higher or tilt it back and that leg is going to get shorter. It will change how we walk and your body will begin to compensate in various ways to keep you upright and moving. Now imagine you have guarding and tension in your lower back muscles on the left hand side. Your left glute may be inhibited and not working as it should because of this tension which would cause your left hip to be lifted or tilted forward and therefore your left leg would feel shorter than your right. We can adjust your hips and trigger point/massage all we want but if we don’t address the cause then it’s a futile treatment. You can imagine how this may lead to sacroiliac joint pain (where your sacrum moves with your pelvis), and this is another common diagnosis that is often the symptom rather than cause.
6. Knee hugs, while lying on your back are good for sciatica
NO. JUST NO. Please stop this. If any exercise that you do moves your pain further away from your back and down your leg, you are making it worse. Knee hugs, or bending forward through your lower back will often make this worse. It may be one of the most over prescribed poor exercises for acute low back pain with radiating symptoms. Think about it, does sitting make it worse, does bending forward make it worse with repetition or maybe that was the cause of your pain... lifting something? Then why would we do more of that same movement through our spine to try and fix it? After sciatic symptoms have been relieved then we want to get back into bending our spine and moving as normal, it's actually an integral part of the program, so don't avoid it altogether, just not when it is the cause of radiating pain.
So what should you take from all this?
All exercises and stretches have a place in treatment of low back pain but it’s too common how a one-size-fits-all approach is taken. Pilates can be great, gym exercise can be great, relaxation techniques can be great but an individual assessment of your back needs to be done to determine the underlying drivers and what specific elements of your posture and lifestyle need to be addressed for you to get back to moving freely and naturally again. If you would like more information, please feel free to email us or call on the details below.
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