PART 2 of 4: Inadequate back strength: the main reason for chronic back pain
I want to first express my appreciation for the great comments regarding the post last week. Many of you asked about where to read more about this topic. My book, which weaves my personal experiences and education about all matters spinal, is available at www.takebackcontrol.com or on Amazon (https://www.amazon.com/Take-Back-Control-Surgeons-Medications/dp/0997591803/ref=sr_1_1?ie=UTF8&qid=1517032581&sr=8-1&keywords=kamshad+raiszadeh).
Now to continue our discussion of back strength:
As we discussed, inadequate back strength is a main reason that patients develop chronic debilitating back pain. As a reminder, there are four main reasons most people have not developed an optimal amount of back strength, and we have already discussed #1: 1) the main stabilizing muscles of the spine become weakened with age—particularly in patients with chronic pain who voluntarily or involuntarily shut down their back muscles, 2) with standard core exercises it is difficult to control the resistance through the entire range of motion and to sequentially apply a measurable, heavier resistance, 3) many people lead sedentary lifestyles and/ or have spine-weakening bad posture, both of which can lead to permanent problems, and 4) it takes hard work to build muscle.
Let’s discuss the second of those four reasons:
2. The second reason most people have suboptimal back strength is that with traditional core exercises, it’s difficult to control the resistance through the entire range of motion and to sequentially apply a measurable, heavier resistance.
Doing a plank, for example, even though I like it, strengthens the back muscles at only one position. Many people think that their exercises sufficiently strengthen their core, but how can you know? I have treated professional tennis players with access to the best of standard strengthening methods who when tested, had very weak back muscles. The person who helped define normal back strength at different ranges of motion was Arthur Jones. Research funded by Arthur Jones at the University of Florida measured the isolated back strength of normal volunteers who did not have any
The shaded zone depicts the normal expected strength of the patient at different amounts of bending. This normal zone was developed by testing thousands of patients, all with similar age and gender, who did not experience back pain. The 7/25/2014 graph is the strength of a patient with chronic back pain. The 10/16/2014 graph is the same patient after three months of specialized strengthening.
As you can see from the shaded zone on the graph, we naturally have more strength in our back muscles when we are bent forward (flexion). Also, there is a smooth transition of our strength between bending forward and standing upright, then bending back (extension). With chronic back pain, the graph can become uneven and indicate significantly lower levels in a person’s strength (the 7/25/2014 graph). Doing core exercises in only one back position is just not adequate to bring this curve back to normal.
One partial solution is to do reverse sit-ups. These work well to strengthen the lower back through the entire range of motion. You can do this exercise by lying face down on a high bench and having someone hold your legs. Most large gyms have reverse sit-ups equipment, also called the Roman chair, that holds onto your lower extremities so you can do this exercise (see diagram).
Roman chair exercise: This exercise helps strengthen the multifidus and other low back muscles. First, position yourself face down by placing the pads behind your ankles and in front of your pelvis. Then do a “reverse sit-up.” To strengthen weakened spinal stabilization muscles, it is important not to use the gluteal muscles or hamstrings. (It’s also important not to overextend since this can cause increased pain and use of non-spinal muscles.) Afterward, you should feel the burn in the muscles around your spine, not in your buttock or back of thighs.
I recommend doing 10 repetitions first with no added weight. This exercise is particularly beneficial because you can increase resistance and do so throughout the range of motion. The first modification is to do the exercise with the hands overhead. A further modification would be doing the exercise with a kettlebell to increase resistance. You can even strengthen your oblique muscles by positioning yourself on your side as a further modification. This is a great exercise you can do during your workouts to start combating core muscle weakness.
Sometimes We Need Sustained, Supervised “Medical Exercise”
The Roman chair exercise is good, but difficult to perform correctly and hard to tolerate if you are having back pain. Even though some standard core exercises and the Roman chair exercise can be helpful in maintaining back strength, in back pain patients, this isolation is much better accomplished through the use of medical grade machine-based stabilization exercises. As we discussed, the Med-X medical exercise equipment isolates the back muscles, allows strengthening throughout the range of motion, and is the most scientifically studied. We have had experience using this and other machines in our SpineZone clinics for over 12 years.
At our SpineZone clinics, we start by measuring back strength at different angles of bending of the spine. Since they isolate the stabilizing spine muscles, the Med-X machines allow strengthening by safely ratcheting up the stress on the muscle. We measure the response to treatment by retesting the back strength at regular intervals to see how well the muscles are responding, and adjust strengthening protocols accordingly. I have been very pleasantly surprised at the large number of patients who have been able to avoid surgery with this process of strengthening despite suffering from severe spinal conditions.