By Katelyn Watson:
Lower back pain, lumbar dysfunction, lumbago, strain – whatever you want to call it!
Most of us have a generalized understanding of the importance of core strength in relation to spine stability to decrease lower back pain. We know that lower back pain can often be caused by muscle imbalances from the feet up to the glutes. In clinic, there are additional stability tests outside of our protocols that we can perform as IDMT’s to help recognize and rehabilitate these conditions in clinic.
Lower back pain is one of the biggest chief complaints that a clinician will see in their practice. With the unique occupational demands of the US Military, it comes as no surprise that our patients will have a higher rate of this diagnosis. The causes of lower back pain are complex and often unspecified, however a major cause involves weak abdominal muscles. As enlisted healthcare providers, we should be aware of the possible muscular conditions associated with lower back pain.
To review, there are anatomic features that differentiate between core stabilizers and core movers. The core stabilizers are the transversus abdominis and lumbar multifidus. The core movers are classified as rectus abdominis and the erector spine which facilitate trunk and extremity movement. There is several other muscles, such as the diaphragm, internal obliques, gluteus muscles, and pelvic floor which further contribute to the stabilization of the spinous process and provide movement.
Clinical signs of a weak core
Lordosis – Often associated with a round belly and weak core muscles. This can cause tight erector spinae, weak abdominus, weak gluteus maximus, and tight iliopsoas (hips)
Kyphosis – Hunched over, lower back will be strained in attempt to compensate for unnatural curvature
Anterior Pelvic Tilt – Overly forward arched lower back. Often caused by excessive sitting. Some studies even suggest that 85% of males and 75% of female have an anterior pelvic tilt. Pulls lumbar spine into lordosis and can alter gait.
Posterior Pelvic tilt– “Tucking in their buttocks.” Often caused by poor posture while working on computer and sedentary lifestyle. Can place excessive strain on the lower back
Rounded belly– Inability to engage core seen in patients with hyper lordosis. Obviously, there is other medical conditions associated with a “pot belly,” however this is in relation to lower back pain.
How to test in clinic:
- Leg lowering test
Have the patient bring both legs up to a 90 degree angle and have them slowly bring their feet back to baseline. This test helps assess the strength of the rectus abdominis, transversus abdominis, and obliques. If the lower back cannot maintain its natural curvature 45 degrees and above, then this is considered poor core strength. Inability to bring feet up to a 90 degree angle suggests tight hamstrings.
- The abdominal bracing (hollowing) test
A simple way to test the overall core strength. Have the patient lay on the exam table, take a deep breath, and hold for 20 seconds while slowly breathing out. They can place a finger on their abdomen to help engage the muscle. Inability to engage core for more than 20 seconds indicates weak core strength.
Thomas test
Patient maximally flexes both knees, using both arms to ensure that the lumbar spine is flexed and flat on the table and avoids an anterior tilt of the pelvis. Patient lowers the tested limb toward the table, whilst the contralateral hip and knee is still held in maximal flexion to stabilize the pelvis. Can help confirms diagnosis of anterior pelvic tilt. Pelvis should be correctly aligned with back rest on the table at all times.
- Passive Knee Extension Test
This can be done in conjunction with the straight leg raise test. This tests helps examine the degree of flexibility of the hamstring. Tight hamstrings can pull the hips back and create hip flexor imbalances. Can also be used for hamstring tendinopathy or strains.
These tests can be intertwined within our protocols to help identify potential muscles associated with lower back pain. While talking with your patient, note their posture on the exam table. Discuss their lifestyle and occupational risks (i.e. sitting at a desk). While physical therapy can be an excellent option for patients with weak core strength or pelvic tilts, give the power back to your patients by prescribing self-assessment tools and posture techniques.
If you work at a base with physical therapy capabilities, I highly recommend you shadow them to learn more about different clinical tests for your patients.
Keep on learning, IDMTs!
References:
Chang, W. D., Lin, H. Y., & Lai, P. T. (2015). Core strength training for patients with chronic low back pain. Journal of physical therapy science, 27(3), 619–622. https://doi.org/10.1589/jpts.27.619
Herrington, L. (2011, December 1). Assessment of the degree of pelvic tilt within a normal asymptomatic population. ScienceDirect. https://www.sciencedirect.com/science/article/abs/pii/S1356689X11000816
Moysey, Y., & Plail, J. (2020). The Effectiveness of Core Stability Exercise in the Management of Chronic Non-Specific Low Back Pain. Physiopedia. https://www.physio-pedia.com/The_Effectiveness_of_Core_Stability_Exercise_in_the_Management_of_Chronic_Non-Specific_Low_Back_Pain
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