The concept of ‘core’ conditioning has evolved significantly since the millennium and there have often been some common misunderstandings of the mechanisms, which can increase the prevalence of back pain. I know because I taught them in an inappropriate way, that’s the way that I was taught. But times change and increased knowledge and application go a long way for someone to determine what works and what doesn’t. Many people still have back pain despite participation in core conditioning regimes, pilates and other types of 'core' workouts. Many lay peoples understanding of the core is that a strong set of abdominal and back muscles prevents back pain. This statement is false and I have seen hundreds of people with strong trunk muscles all still prevent with back pain. Overtraining of the core is responsible for increasing back pain in many individuals. Many focus on strength, skipping key elements such as flexibility and stability paving the way for muscular dysfunction. Neuromuscular retraining should often be the focus for optimal core function but for many throwing big weights around, worrying about weight loss or how many spin classes they can get to takes precedence over dysfunctional movement and pain .
Then there is the concept of the inner unit which was touted by Richardson, Jull and Hodges, a good book and one that was part of the curriculum at the CHEK Institute (where I learnt a lot about rehabilitation) and no doubt many other institutions and how, by isolation of the Transversus Abdominus or TrA created an increase in Intra-Abdominal Pressure (IAP) co contracted with the multifidus and worked intrinsically with the pelvic floor.
Training the TrA in isolation fails to offer the complete picture and treatment for segmental stability. The diaphragm working in co-contraction with the TrA, pelvic floor and lumbar multifidus present a more appropriate method for stabilising not only the lumbar spine but provide a foundation for a more efficient methodology of rehabilitation which covers stability.
The Rehabilitation School of Prague’s model of Dynamic Neuromuscular Stabilisation offers a compelling model of stabilisation via developmental kinesiology. How the developing child moves and integrates stability is an effective method for re-integration of the intrinsic stabilisation system which comprises of the diaphragm, pelvic floor, TrA and spine flexors and extensors. The image below of the open scissors position of the rib cage and pelvis details the oblique angle that can occur when poor stability is mediated by poor diaphragmatic action.
With DNS technique the flare of the rib cage and optimal contraction of the diaphragm can be corrected in the space of minutes to provide an optimal pathway for diaphragmatic breathing.
This concept is an effective method for rehabilitation but in my opinion there remain questions when utilising the concept of stability from the trunk. The diaphragm has the capacity to work segmentally too much or too little based upon a client’s injury history. Here are just some of many scenarios where the intrinsic stabilising system could become dysfunctional.
• TMJ or jaw dysfunction • C section or other significant scars on the body • Pelvic floor dysfunction • Any other muscles has the capacity to affect any other muscle in the body. • Local inhibition of synergistic, functional opposites or stabilising muscles • Emotional distress • Broken bones • Functional slings such as the posterior oblique sling, lateral sling and others • Why you get neck pain
Use of a joint by joint approach to testing such as Neuro Kinetic Therapy ™ helps to establish a baseline for dysfunctional patterns of facilitation (overworked muscles) and inhibition (underworking muscles). Decisions should be made as whether a mobility or a motor control issue exist. Motor control or the ability of the muscles to be efficiently recruited by the nervous system can be rectified by understanding patterns of inhibition and rewiring the nervous system for optimal control. Integration between both NKT and DNS techniques allows for a progression from pain and dysfunction to integrated movement patterns that can be hard wired with practice of developmental kinesiology exercises.
Many traditional and rehabilitation conditioning exercises often serve to increase dysfunction. Extension and even neutral load training based exercises such as deadlifts, bird dogs and horse stances can increase activation of the thoracolumbar fascia which serves as a conduit for force transfer especially for the posterior oblique sling.
A release of the thorocolumbar fascia and integration of the posterior oblique sling through proprioception via taping or exercises remains an efficient method of neuro muscular activation rather than just increasing motor activity via strength and conditioning exercises.
Integration of techniques allows for a much more efficient treatment for clients who suffer from pain and movement dysfunction and can truly get to the core of both acute and chronic conditions. Isolated approaches yield isolated results.
To find out more about how to get out of pain and improve movement and energy please get in touch.
Frank, C Kobesova, A and Kolar, P.Dynamic Neuromuscular Stabilisation and Sports Therapy.Int J Sports Phys Ther. 2013 February; 8(1): 62–73. Myers, T. Anatomy Trains. Churchill Livingstone Elsevier. 2001. Richardson C, Hodges P and Hides, J. Therapeutic Lumbo Pelvic Stabilisation. Churchill Livingstone. 1999 Weinstock, D. Nuero Kinetic Therapy. An Innovative Approach to Muscle Testing. North Atlantic Books.
Training the classics like deadlifts and squats are an integral part of training and getting strong. More often than not we tend to sacrifice key parts of our body like a sacrificial lamb to the slaughter, inviting injury with each rep. One of the most common things that I see with clients deadlifting and injuries, is the drive with the neck in a fully extended position, which is shown above.
Using a body part to drive a movement isn't detrimental and as the motor control command is executed it has to start somehwere but extending the cervical spine shifts the emphasis on the kinetic chain. As the Cervical extensors are fully contracted, the whole extensor chain has to ensure that all the work is completed whilst a fully extended position is held. Short tight cervical extensors are a common finding in many people and their recruitment/facilitation and inhibition with many factors can be linked with issues in the calf and plantar fascia of the feet.
You will notice in the picture below as theorised by Myers and others that the superficial back line is a complete chain from head to toe. Facilitation of the cervical extensors can contribute to forward head posture and postural changes in the thoracic spine, shoulder and lower down the chain. Instead of creating injury hotspots, keeping the neck in a more aligned neutral throughout the lift and using the eyes to drive into extension can help alleviate the problems associated with facilitated neck muscles.
Medical systems can often create a vicious cycle and the Cesarean section is one such cycle. The creation of specialist departments often creates a vacuum where, what some might think as minor issues go ignored, yet affect those who have to undertake specialist procedures. In any other system say finance or banking it would be called negligence or incompetence for failing to notice where the system broke down (something not often noticed until after the debacle has occurred) but because it often involves individuals who suffer from one of the most common medical issues in the world the cause and effect often go unnoticed. It's a simple statement Cesarean sections could be one of the leading causes of back pain in females. A statement that can be validated fairly easily when you observe this phenomenon on a regular basis . I have never met a female client who had a C-section who didn't suffer from either lumbar, cervical or sacroiliac joint dysfunction. Governments who want to save hundreds of millions of unnecessary cash spent on treating back pain may want to scrutinise this point. It often serves the medical insurance system to keep this cycle system in full flow.
Females who have suffered from back pain, most likely due to failure to rehabilitate the key stabilising mechanisms of the the lumbo-pelvic complex may have avoided back pain all together. Implementing a basic program would not only help to avoid back pain but may aid women back into exercise much sooner assisting any psychological issues such as post-natal depression.
A general rule for low level exercise post C-section to begin is 6-8 weeks. The healing process starts immediately post op and the nutritional status and individuals immune system plays a significant role in healing time, decrease of infections and energetic processes.
During the surgery process. The skin, abdominal fascia, Rectus Abdominus and Transversus Abdominus (TrA) are easily severed with many nerves also being affected by the surgeons scalpel. This is where the chaos begins. Whilst the global implications of movement dysfunction are readily observed with restrictions to simple tasks such as standing, sitting and even turning over in bed. The local intrinsic nature of lumbo-pelvic stabilisation dysfunction is not observed until the women attends a specialist to deal with a particular pain syndrome. More often than not light cardiovascular exercise is recommended which serves to deepen the dysfunction not only due to the lack of appropriate muscle activation but also due to its effects on respiration.
The TrA whilst important with its synergistic role with the multifidi, diaphragm, pelvic floor muscles also has an essential function with respiration. During inspiration the primary muscle of inspiration the diaphragm contracts displacing the abdominal viscera outwards and downwards placing both the muscles of the pelvic floor and TrA in a stretched position. The natural recoil of the TrA assists in exhalation,helping to force air from the lungs. Post C-section this action can diminish placing additional stress on the excessory muscles of respiration. Additionally the flexors of the trunk, primarily the Rectus abdominis often become inhibited and other muscles can facilitate in response to altered movement dysfunction. In one case a patient with multiple C-sections presented with chronic recurrent cervical and lumbar disc issues. In particular the MRI showed a flattened cervical spine and it is worth-speculating that the anterior cervical flexors facilitated in response to a lack of trunk flexion. The patient was literally trying to flex her whole spine with her neck flexors. Use of Neuro Kinetic Therapy (TM) helped to re-establish synergistic neck and trunk flexion by restoring equilibrium.
In this and 100% of all clients who have had a C-section the TrA can either be facilitated or inhibited. strategies to stabilise compromised structures and dysfunctional movement can be local or global. How Muscular dysfunction occurs
Strategies can include:
Breath holding via facilitation and compromised diaphragmatic action Facilitation of the pelvic floor Clenching of the masticatory muscles of the TMJ/Jaw Local compensation such as Quadratus Lumborum facilitation Cervical muscle facilitation and inhibition Altered lower limb mechanics including plantar fascia and disruption of dorsi flexion and toe mechanics.
Scar tissue formation can be problematic due to adhesions of healing tissue in particular to fascial continuation, function and adhesion of tissue to internal organs. Addressing these adhesions and restoring optimal function of the TrA and its dual facilitory or inhibitory effect on both local and global structures can be achieved with therapies such as NKT and appropriate corrective exercises. Even without a Cesarean section, you can apply the same rationale to tears or episiotomy procedures and the same fuzziness that the nervous system experiences when trying to provide stability to the body.
References: Chek, P. Posture and Craniofacial Pain. A Chiropractic Approach to Head Pain. Williams and Wilkins 1994
Weinstock, D. Neuro Kinetic Therapy. North Atlantic Books. Berkeley, California.
There are many reasons why we get back pain. In fact the points raised above are merely what occurs when the musculo-skeletal system is out of alignment, I repeat, what occurs when the musculo-skeletal system is out of alignment. What does that mean? Well if you work on balancing structures then all of the above points can be managed and in many cases eradicated. When we breathe, sit, think and complete exercise inefficiently we start to compensate with a variety of muscles. So getting movement and structure analysed can help to determine mobility and motor control issues that need to be addressed.
If you are ever diagnosed with any of the factors above and are told that you should avoid exercise then ignore that specialists advice. One of the most important things in anything spine related that you can do is to exercise but you need to exercise correctly, understand what has caused these conditions and use a variety of therapy and exercise to rectify the faults. Here is a brief summmary of the points suggested above.
1. Sacro-iliac joint dysfunction- is one of the most common forms of back pain and one of the most commonly mis-diagnosed conditions, often mistaken for a disc herniation. Females are often more exposed to SIJ dysfunction and can often be resolved with mobilisation and exercise to support the extra width of the pelvic basin.
2. Facet (zygapophysial) Joint- is the main articulation of the vertebra and can often become dysfunctional due to the position of the spine as most of these conditions can. Mobilisation and improving recruitment of spinal muscles can help to improve the movement of the facet joints.
3. Disc Herniation- a common problem in those over 30 mostly in the lumbar spine (can occur in cervical/neck too) with pain often felt either locally or referring commonly along the distribution of the sciatic nerve into the back, glute, legs and feet. The nucleus of the disc, the hardened jelly like material between the disc can rupture causing compression of the spinal nerves and pain ensues. Flatter back people are more predisposed to herniations but rotational and lateral movements also contribute to herniations. Strengthening of the core muscles, particularly the multifidus muscles can help alleviate and remove pain. Sometimes restoring the natural lumbo-pelvic rythm can be effective in this condition too.
4. Stenosis- the hole created by the lateral structures of the spine, is the space where the spinal nerves exit. Often when there is instability, osteophytes, small growths of bone can occur to stabilise segments of the spine. A side flexion of the trunk can close down the space of the nerves exiting that vertebral segment too. This can cause irritation of that particular nerve. Once again understanding what structures are over and underworking can provide relief to this problem.
5. Spondylolisthesis- is a fracture of the pars articularis a part of the vertebra which causes a rotation (if one sided) and forward slippage of the vetebral body, which can create torsion of the disc, also placing pressure on the spinal cord itself. Some people are born with this fracture but rotational sports such as golf contribute to this condition. Rotation and flexion at high speeds can create the sheer responsible for this fracture but can easily be avoided with the right stretch, mobilisation and exercise program,.
There are many other causes of back pain all of which can be rectified or avoided with the right program. One thing to take away from this blog is that if you are experiencing pain then you need to change what you are doing. Don't worry pain is a communication from your body to change but find someone who can deal with structural issues decribed above. You may often find that the solution is with doing less but more intelligently.
1. Bogduk, N. Clinical Anatomy of the Lumbar Spine. Churchill Livingstone. 2003
2. Porterfield, J.A., DeRosa, C. Mechanical Lower Back Pain. W.B. Saunders Company 1991.