Some individuals with lower back pain tend to have over activation of their lumbar extensors with excessive lumbar extension and lack proper activation of the hip extensor muscles; such as the gluteus maximus and hamstrings.  Usually this discrepancy is most prominent during hip extension motions.

I wanted to find information that will help modify this motor pattern during dynamic exercises and eventually functional tasks.  I came across an article that focused on an abdominal drawing-in maneuver (ADIM).  The idea is that while performing an ADIM when completing a hip extension exercise the lumbar extensors will not be as active and the hip extensor muscles will complete most of the task.

There are a couple theories to the cause of this adjustment in muscle activation with abdominal hollowing.  One is less anterior pelvic tilt causes a poor length tension relationship for the lumbar extensors and a more optimal one for the hip extensors.  Another theory is due to reciprocal inhibition, which means that when the agonist muscles (e.g. abdominal muscles) are activated the antagonist muscles (e.g. lumbar extensors) naturally become less active, so the hip extensor muscles must take over to complete the task.

(Click the link below for access to the article)

Effects of Performing an Abdominal Drawing-in Maneuver During Prone Hip Extension Exercises on Hip and Back Extensor Muscle Activity and Amount of Anterior Pelvic Tilt

Purpose: To measure the electromyographic (EMG) signal amplitude of the hip extensors and erector spinae and the angle of the anterior pelvic tilt during hip extension in the prone position.

Methods: The researchers examined two groups of subjects completing a prone hip extension with the knee extended with an ADIM or without an ADIM.  They measured the muscle activation of the erector spinae and the gluteus maximus and medial hamstring on the dominant side.  They had the subjects sustain the hip extension for 5 seconds.  They placed a pressure cuff underneath the abdomen inflated to 70 mmHg and instructed the subjects to maintain the pressure at about 60 mmHg during the movement.

Results:  The researchers compared the outcome measures of hip extension without an ADIM to hip extension with an ADIM and found a significant decrease in erector spinae activation (49% to 17% MVIC), significant increase in gluteus maximus (24% to 52% MVIC) and medial hamstring activation (47% to 58% MVIC), and a decrease in anterior pelvic tilt (10 degrees to 3 degrees).     *MVIC = maximal voluntary isometric contraction

Limitations: The data cannot be generalized because the subjects were only healthy and no unhealthy subjects were studied.  There is a potential for the EMG to pick up signals from adjacent muscles.  The researchers did not differentiate muscle activation between abdominal muscles, the diaphragm, and the pelvic floor with the abdominal drawing-in maneuver.  Finally, the lumbopelvic hip movement patterns were not measured to see how much movement at those segments were occurring.

There are many treatments that can be used to help treat low back pain. Two treatments that physical therapists use are spinal posterior to anterior (P-A) mobilizations and prone press-ups. I was curious about the effectiveness of both of these treatments and which one has the better outcome. I came across this article that helped to answer this question.

(Click the link below for assess)

Effects of a single session of PA spinal mobilization and press-up exercise on pain response and lumbar spine extension

The researchers compared a single session of P-A segmental mobilization to press-ups and measured pain with a visual analog scale and lumbar extension range of motion with an MRI on individuals with nonspecific low back pain.  They found significant improvement in pain and lumbar extension range of motion but no difference between the two treatment options.  Even though there was no significant difference between the two treatment options the participants treated with P-A mobilizations had an average reduction of pain by 41% and an average increase in lumbar extension motion of 17.8% and the press-up group reduced pain by 30% and increased motion by 11.7%.

Purpose: To examine the immediate effects of P-A mobilization and a press-up exercise on pain with standing extension and lumbar extension in people with nonspecific low back pain.

Methods: The participants consisted of 30 individuals between the ages of 18 and 45 years old.  Inclusion criteria consisted of a recent onset of back pain (<3 months), localized low back pain at or above the waist level, decreased lumbar extension during standing, and increased low back pain with standing lumbar extension.  Participants were excluded if they had spinal malignancy, cardiovascular disease, evidence of cord compression, aortic aneurysm, hiatal hernia, uncontrolled hypertension, spinal infection, severe respiratory disease, pregnancy, abdominal hernia, prior low back surgery, gross spinal deformity, spondylolisthesis, rheumatic joint disease, and implanted devices that may be affected by MRI.  Other exclusion criteria consisted of radiating pain below the buttocks, sensation changes in the lower extremities, diminished reflexes, low extremity weakness, neurological signs, urinary or fecal incontinence, or increased pain with repetitive lumbar extension.

• P-A Spinal Mobilization – The mobility of the lumbar spinal segments were assessed and the segments with hypomobility and a reproduction of symptoms were the target areas.  The subject was placed in prone with a pillow under the stomach.  Each segment was assessed with 1-2 Grade I mobilizations.  If there were no reproduction in symptoms then mobilizations increased to Grade III and IV.  If there was no reproduction in symptoms then the next segment was assessed until a painful segment was found.  Once a painful segment was found the examiner completed 3 sets of 40 second oscillations to a Grade IV intensity or just shy of pain reproduction.
• Press-ups – A press-up was completed as far as possible without a reproduction of symptoms.  The subject was prone on a table and extends the arms to lift the chest.  The hips and pelvis may lift from the table and sag due to gravity.  The subject was instructed to hold for 5 seconds and repeat 10 times.  The subject was encouraged to go higher each time.  If the symptoms reduced or were unchanged then 2 more sets were completed.

Limitations: The study had 5 reported limitations.  They stated that the participants were relatively young which allowed for greater absolute lumbar extension range of motion which would not be possible with more elderly individuals.  The inclusion criteria was quite selective making the results difficult to generalize to other people with low back pain.  The examiners only assessed the immediate effects of the treatments and not the long term effects.  The study did not have a sham group to assess the placebo effect of treatment.  Finally, they mentioned that they were not able to exactly reproduce the pretreatment resting position during the post-treatment MRI assessment.

I came across this article that I thought might be beneficial to help with treating patients with low back pain.  The idea is that people who suffer from low back pain have range of motion abnormalities elsewhere.  These abnormalities place stress on the lumbar spine.  I plan to use this article to help me understand that more common hip rotation range of motion abnormalities in individuals with lower back pain and assessing patients that I work with to see if they have similar findings.  Then trying to improve upon these deficits to speed up the recovery process.

Hip Rotation Patterns:

Pattern I: Total medial hip rotation equals total lateral hip rotation of both lower extremities and is broken down into two subcategories.

• Pattern Ia: Left medial, left lateral, right medial, and right lateral hip rotations were all equal
• Pattern Ib: Total medial hip rotation equals total lateral hip rotation but one or more of the ranges were unequal (e.g. left lateral, left medial, right lateral, right medial hip rotations)

Pattern II: Total medial hip rotation is greater than total lateral hip rotation

Pattern III: Total lateral hip rotation is greater than total medial hip rotation

Ellison JB, Rose SJ, Sahrmann SA. Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain. Phys Ther. 1990; 70:537-541.

Purpose: 1. to describe the amount of hip rotation range of motion in healthy subjects and in patients with low back pain; 2. to categorize these individuals based on different patterns of hip rotation range of motion; and to compare the distribution of healthy subjects and patients with low back dysfunction in the range of motion pattern categories.

The authors discus the fact that low back discomfort doesn’t just come from dysfunction of the back but also can translate from adjacent areas such as the hip.  They focus on the idea of limited or excessive hip range of motion.  These abnormalities at the hip can cause cumulative stress and strain on soft tissue and bone.

The researchers measured the hip rotation ranges of motion of a little over 20 subjects in prone with the knee flexed to 90 degrees and while seated with a goniometer and an inclinometer.  They found that there was not significant difference between testing position or the use of a measuring device.  The researchers decided to use the prone position with an inclinometer to measure the subjects for the study.

They measured 150 subjects (100 healthy and 50 patients with low back pain).  They decided that equal ranges in motion would measure within 10 degrees of each other.  The percentages of subjects for each pattern were presented.

Pattern Ia: 27% of healthy subjects and 14% of patients with low back pain

Pattern Ib: 5% of healthy subjects and 8% of patients with low back pain

Pattern II: 41% of healthy subjects and 30% of patients with low back pain (most prevalent pattern for healthy individuals)

Pattern III: 27% of healthy subjects and 48% of patients with low back pain (most prevalent pattern for patients with low back pain)

They also found that the total left hip rotation (medial + lateral hip rotation) and the total right hip rotation (medial + lateral hip rotation) was equal in 78% of patients with low back pain and 94% of healthy subjects.

This research article shows that there is a significantly greater proportion of individuals suffering from lower back pain with greater total lateral hip rotation when compared to medial hip rotation.  They also showed that healthy individuals had a greater prevalence of equal hip rotation ranges of motion than did individuals with low back pain.

My recommendation for future research is to differentiate between low back pain diagnoses (e.g. stenosis, disc herniations, etc.), reduce the range for equal hip range of motion to <5 degrees which is the standard error for goniometric measuring, and to differentiate between female and male patients with and without low back pain (due to gender differences in normal hip ranges of motion).  The researchers had difficulty understanding if the abnormalities in hip rotation range of motion was due to low back pain or predisposes an individual to low back pain.