Lumbar Aftercare

As you may have come to discover by this part of the book, the tips that have been offered to you are based on my experiences of being a physical therapist and massage therapist for many years, working with the general population and those clients suffering in general with musculoskeletal conditions. One of the conclusions I have come to is that pain and stiffness in the lumbar region (but also in the neck and thorax) are exacerbated and may be caused by the retention of static postures for long periods of time. Therefore, the flavor of this aftercare chapter for the self-management of clients with low back complaints focuses on encouraging movement of the lumber spine. Five of the tips are devoted to this topic alone and should provide you with enough ideas to be able to encourage any client with low back pain to move their back more often, in a variety of different positions, safely. Research supports and encourages self-management of symptoms for people with low back pain. This will never replace the soothing effects we can deliver with massage, nor the comfort of explaining a particular set of stretches, and there will always be a place for hands-on therapy in the treatment of patients with back pain. The aftercare tips provided here are designed to complement any existing treatments you have found to be effective and to provide you with another skill—that of being able to provide sound, supporting advice for the management of pain in the lumbar spine—to your clients.

Many people with back pain find relief from resting in a warm bath. Most are likely to lie still, fatigued from a day of lumbar pain and pleased to get some relief at last. You could use the information in this tip to educate such clients, explaining how simple movements, performed regularly, may be beneficial in reducing pain. The seven exercises described in this tip are designed to be performed in the bath and are indicated in the following situations:

• When it is not possible to treat a client because their low back condition is too acute.

• When your client is recovering from a period of immobility and their back feels stiff or where you have observed a reduced range of movement.

• When there is no further treatment, you can provide that will alleviate pain.

• In the early stages of rehabilitation following injury, providing the subject has medical approval.

The purpose of the exercises are to gently mobilize the lumbar spine, making use of the heated bath water for pain relief and the dimensions of the bath which purposefully limit the degree of movement that is possible.

Mobilization is likely to occur as a result of the following:

• A reduction in muscle spasm (if present) brought about by the water temperature.

• Gentle lengthening of lumbar muscles.

• Gentle movement of lumbar spine segments.

The exercises described here will have little effect on an asymptomatic subject but will enable a symptomatic subject to mobilize their lumbar spine safely, something they may be unable to do when not in the bath. All exercises are performed in the recumbent position and may be performed in any order. They are not intended to be performed vigorously, nor with any effort, and should be manageable. You could begin by suggesting that your client perform each one just a couple of times, for example.

Place the hands in the water, palms touching the base of the bath. Keeping the legs outstretched, the buoyancy provided by the water enables a subject to lift their buttocks from the bath while still remaining submerged. Note that the object of this exercise is not to lift the hips out of the water, which could be potentially harmful, but only to lift the buttocks from the base of the bath, keeping the heels pressed to the base of the bath in order to bring this about. Very little effort is required from the hip extensors to perform this movement.

Effect: Partial lumbar extension produces very slight lumbar extension and may be useful for clients with a decreased lumbar curve. When combined with the posterior pelvic tilt, the effect is a gentle mobilization of the lumbar spine in an anterior–posterior direction.

Exercise 2: Posterior Pelvic Tilt

With the hands either in the water, palms touching the base of the bath, or resting comfortably on the sides of the bath, the client relaxes and, with the hips and knees comfortably flexed, uses their abdominals to bring about a posterior pelvic tilt.

With the hands either in the water, palms touching the base of the bath, or resting comfortably on the sides of the bath, the client simply flexes one hip and knee at a time, sliding the heel of one foot to the buttock on that side, and then slowly returns it to neutral.

Effect: Unilateral hip flexion produces a mild posterior pelvic tilt, decreasing lumbar lordosis and lengthening lumbar extensors on the side of hip flexion.

This is usually easier with the hands in the water, palms touching the base of the bath but could be performed with the arms resting on the sides of the bath. Your client gently flexes both hips at the same time, sliding the heels toward the buttock, before returning them to neutral.

Effect: Bilateral hip flexion produces a mild posterior pelvic tilt, decreasing lumbar lordosis and lengthening lumbar extensors.

Exercise 5: Hip Hitching

Place the arms on the sides of the bath. The client “hitches” their right hip up, contracting quadratus lumborum (QL) by moving their right foot away from the end of the bath while keeping their leg straight. The client then attempts to “drop” the hip, attempting to touch the end of the bath with their toe, and does this several times before repeating on the left side.

Effect: Hip hitching strengthens QL; hip “dropping” lengthens it; and it mobilizes the spine into lateral flexion.

Place the arms on the sides of the bath. Keeping the legs outstretched and together, the client attempts to sway these from side to side, touching the lateral side of their right ankle to the right side of the bath, then swaying the legs together so that the lateral side of their left ankle touches the left side of the bath.

Effect: Leg swaying strengthens the muscles of lateral flexion both posteriorly and anteriorly and mobilizes the spine into lateral flexion.

Exercise 7: Partial Lumbar Rotation

Place the arms on the sides of the bath. One of the easiest exercises to perform in the bath, the client keeps their ankles together, hips and knees flexed, and simply lets their knees fall to the right and then to the left. The sides of the bath prevent full rotation. However, clients with shorter legs, or when the exercise is performed with the knee less flexed, achieve fuller rotation to each side.

Effect: This exercise provides slight lengthening of lumbar muscles and mobilization of the lumbar spine into rotation.

Traction has been used for centuries as a treatment for back pain. Here are four safe and simple positions your client could use to self-traction their lumbar spine. Practice these yourself and decide whether one or more might be suitable for your client. Use the table (“My findings”) provided at the end of this tip to make notes and to document any ideas you have for alternative items that could facilitate the position, plus any tips you want to be sure to give to your clients when attempting these positions.

How to Use Self-Tractioning Positions

• You might suggest that your client practice a different position for a few days and decide whether it reduces their symptoms. Clients are likely to have their own preferences. For example, a hanging traction may be more suitable to someone who lifts weights and wants to “decompress” their spine afterward.

• The most effective stretches are adopted for a period of about 30 seconds, and performed regularly. Whether your client can rest in any of the positions shown here for that length of time is likely to be variable.

• Position “A” may be used in an acute stage, providing it does not exacerbate symptoms.

• Each could be performed twice daily: once in the morning and once in the evening.

• The more relaxed your client feels, the more beneficial the traction is likely to be; therefore, traction positions “A” and “B,” discussed in the following sections, are likely to be the most effective.

Position A

Experimentation is needed to get the height of the chair correct for this position, which should elevate the legs so that the hips “hang,” thus tractioning the lumbar spine. Symptomatic subjects are likely to need assistance in positioning the chair or cushion to the correct height. A sofa, a bed, or a bench could be used equally well.

This subject is resting over a gym ball, but a small stool or pouffe could be used. In this example, the subject’s knees are touching the floor. Ideally, the knees should not touch the floor at all because it is counterproductive to use the knees for support. The hips should “hang.”

Position C

Here your client simply hangs, letting the weight of the hips and lower limb produce the traction. It requires good upper limb strength. Anything can be used from which to hang, providing it is strong and immovable, such as a tree branch, pull-up bar, or the horizontal bar of a goal frame. This tractions the upper limb and should not be used if your client has a history of subluxation or dislocation of the shoulders or elbows.

This is a similar but slightly different to position C. In position D, a strap is used to hang from and you can see that, because the body is not directly beneath the arms, the lower limb supports more of the weight and therefore tractions the lumbar spine less. (Practice positions C and D for yourself and you will see the difference.) However, another difference is that in position D, the hips are flexed to a greater extent, so the lumbar curve is reduced more than in position C as hip flexion produces a posterior pelvic tilt. As with position C, this tractions the upper limb and should not be used if your client has a history of subluxation or dislocation of shoulders or elbows.

People with pain in the lumbar region of the spine often seek help from people other than their doctor. This may be because they have been prescribed medication that no longer seems to be effective or because they do not wish to take analgesics. If you are reading this as a massage therapist, you may have been approached many times by clients hoping that massage will alleviate their symptoms. While massage can ease pain, musculoskeletal pain is often aggravated by the retention of a static posture—whether such posture is lying, sitting, or standing—and encouraging movement is a good thing. Part of our work as a therapist is to help clients find ways to self-manage symptoms on a daily basis. Not surprisingly, however, people with back pain avoid movement, having found that initially this aggravated their symptoms or because they are scared, believing that moving might damage themselves further. As a consequence, people with low back pain often find themselves trapped in a cycle that perpetuates their pain:

1. They have back pain.

2. They avoid movement.

3. With inactivity, muscles weaken and joints stiffen, and sometimes muscles spasm. This leads to more pain (1). So the client avoids movement (2). And so it continues.

In the majority of cases, with reduced movement pain is worsened over time, whereas with gentle movement pain is eased over time. We can play an important role in educating clients about this, offering them gentle encouragement and reassurance as they cautiously begin to move their backs. You do not need to be a fitness expert or an exercise specialist to encourage clients with back pain to move more. The exercises shown here are safe and gentle. There are, of course, some clients for whom these would be contraindicated, and you can find information about those in the question box.

• It does not matter which exercise your client selects. They should start with the one they find easiest to perform.

• A good starting point is for the subject to perform each movement about three to five times.

• Performing the exercises daily is likely to bring about the most relief. These are mobilization exercises and are not the same as the kinds of exercises you might do in a gymnasium, where you need to give your muscles a day or two of rest in between.

• Movement could be uncomfortable but should not worsen pain or other symptoms such as sciatica.

• If symptoms do worsen, the exercise should be stopped.

• Performed daily, clients will often report an improvement in symptoms within 3 to 5 days. They should therefore be encouraged to persevere with the exercises unless these worsen symptoms.

• Keeping a diary is a useful way of recording which exercises have been performed, any improvements the client notices, as well as any challenges.

In the pages that follow, you will find a wide range of simple, safe exercises that may be performed in the side-lying, supine, kneeling, sitting, and standing positions. These have been separated into different tips because it is likely that your client may only be comfortable with one set of exercises and so you should focus on that group first. There is no ideal starting point: some clients find standing easier than lying, but you are equally likely to find clients for whom standing—or sitting—is intolerable. It is therefore important to enquire as to the kinds of positions your client prefers to rest in, in order to achieve a degree of relief, and to select exercises from the group that most closely matches that position.

Question: Are there any clients for whom these sorts of exercises are contraindicated?

The movements shown in this tip encourage flexion of the spine. Flexion of the spine may be brought about by actively curling the spine but also occurs when the hips are flexed. When performing the exercises, your client need not flex both hips/knees simultaneously.

An alternative is for the client to use their hands to gently draw the knees toward the chest, encouraging lumbar flexion (a). (Or the client could ease their torso toward the knees.) The aim is to bring about greater hip flexion and therefore an induction in the lumbar curve (b). In either case, the client returns to the starting position (c) following gentle flexion of the spine.

Exercise 3

In the supine position, the lumbar spine changes from a position of flexion to extension depending on the position of the pelvis. As the hip is flexed, the spine flexes; as the hip is returned to neutral, the lumbar spine extends slightly as it regains its normal lordosis. Straightening the legs in the supine position can be extremely uncomfortable for some clients; therefore, it is best to attempt to straighten only one leg at a time.