Author's note: This article is the first in a series on which exercises and rehab strategies are best for particular spinal conditions. A patient-directed companion article appears in To Your Health, which is poly-bagged with this issue. Each article includes links to YouTube videos demonstrating the exercises.
How many of your patients come in with a recurrence of their typical pain? I am always asking these patients, "What do you do when you are in pain? What exercises help your pain?" I am continually surprised that very few patients know what self-care to do when they have an acute painful episode. This includes the motivated patients and the patients I have seen before and carefully shown the right exercises. Maybe it is because their brains quit working when they hurt severely, maybe it is a deer-in-the-headlights phenomena, and maybe it is fear.
Most of them just rest, ice, and use NSAIDs (and don't know that NSAIDs block healing).Many of them say, "I hurt too much to exercise." I suspect this means that they cannot do their usual walking, running, stretching, etc.
When I examine these patients, I can almost always identify some movement that would help them. It could be a fixated joint where self-mobilization would be useful after I have adjusted them. It could be a pain generator, such as an irritated disc, that unloading in some fashion would be helpful.
Specific Reset Strategies
The McKenzie model1 is very interesting in this regard. If I understand it correctly, the doctor attempts to identify a direction of movement that creates relief, and then instructs the patient to use this movement to help correct their own condition. In the classic McKenzie model, especially on the first office visit, there is little to no hands-on therapy. The reset button is usually lumbar extension, often combined with a side-bending that reduces the antalgia. The McKenzie model, in my experience, works best when the pain generator is the lumbar disc.
I have some issues with this model, however. I don't think it is complete, in that it tends to miss the profound effect that stuck joints have on pain generators. The McKenzie model does a great job of educating and motivating the patient to do what they need to do. The patient knows what exercises to do, both intellectually, and experientially. They perform an exercise or self-correction, and they can immediately feel that they are better, less bent, less stuck forward, and/or have less sciatica.
That said, McKenzie is a little tricky for the patient the first time. Backward bending does not necessarily feel good to the local tissues. When you bend backward, the lumbar muscles, the lumbar facets, may hurt. The patient needs to be able to put up with this increase in pain during the exercise, and see how they feel after they have done the exercise. If McKenzie is effective, they will have less pain, or at least a more centralized pain, after the exercise. If they come to your office bent, into flexion or side-bending, they will be straighter after doing the right McKenzie exercise.
Other disc patients do better with decompression. I always prefer home decompression, done as close to hourly as possible (or even more often). I wrote a previous article2 on decompression exercises, and will explore further ideas on decompression, and some of the recent research behind this, in another article in this series.
There are other patients who do better with flexion. This does not necessarily mean they feel better when they bend forward. It does mean that a controlled form of hip flexion seems to help them. I've written previously about Richard Don Tigny's model of the SI.3 I think Tigny oversimplifies the lower back and the SI, but despite this oversimplification, his basic idea - treating the SI and having the patient self-treat the SI as if it is stuck in an anteriorly rotated position - seems to work a high percentage of the time.
The SI joint is less stable and more loosely packed when the ilium rotates forward. When the ilium is sagittally rotated backward, it creates stability. Tigny's simple unilateral leg-flexion exercises take the ilium into this posterior rotation pattern and give relief to many SI patients.
The Power of Movement
Let's not forget movement. The body is designed to move. Once you are in pain, the severity can be increased by stasis, by congestion. This becomes a vicious cycle. The area hurts, the muscles tighten up to protect and splint, and circulation is limited by the tightness. Too many of our patients stop moving when they hurt. They may get temporary relief from lying down, but then are even more stiff and sore when they get up. Motion often helps break this cycle. Whether it is walking, swimming, or just doing little pelvic tilts, getting some kind of motion into the back often acts to reset or decrease the pain levels.
Find the little motions that are pain-free; feather toward the pain-free limits of flexion, extension, rotation, and/or side-bending. Movement that doesn't hurt empowers the patient and mitigates their feeling of helplessness.
I don't have the space here to go into details, but Brian Mulligan, a New Zealand physical therapist, has spent his whole career finding patterns of mobilization with movement and self-movement that act as reset buttons. I suggest you review an introduction to these exercises online.4 The basic principle: Exercises should be pain-free and should increase range of motion.
The main point I am making here is simple. You, the doctor, need to take the time to find a reset exercise for your low back pain patients on their first or second visit. The exercise should be relatively pain-free (see McKenzie comments above) and should improve their function immediately. I prefer to show the patient the exercise before I adjust them, as it makes it clear to them that they can help themselves.
If you can find the right exercise and teach it to your patient, and they can feel an immediate improvement, they will be motivated to do the exercises. They might even remember to do them the next time they have a flare-up.
References
- McKenzie RA, The Lumbar Spine: Mechanical Diagnosis and Therapy. New Zealand; Spinal Publications, Inc., 1981.
- Heller M. "Decompression, Myths and Models." Dynamic Chiropractic, Jan. 1, 2007.
- Heller M. "Sacroiliac Joint Correction - A Different Model." Dynamic Chiropractic, Dec. 17, 2005.
- Mulligan Home Exercise Introduction. Available on YouTube. www.youtube.com/watch?v=SussB3V5jD4&feature=related
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