McTimoney Chiropractor Andrew Hunter writes:
Along with Chiropractic adjustment for alignment and Soft-Tissue Release for treating facilitated, tight, fibrotic muscles, Corrective Exercise is the third contributor to musculoskeletal health. Normally for patients with back problems, corrective (rehabilitative) exercises will start on the floor.
Floor Work – First Reason
There is a good reason why Chiropractors who give their patients Corrective Exercises often start with floor work. This is because spinal loadings (the forces going through the spine) are much lower when a patient is lying on the ground than when they are standing up. In a nutshell, the patient’s weight is in the floor rather than being self supported by the spine and so exercise on the floor is generally both safer and less painful. So, for a disc patient, the safest place to exercise is lying on the floor. And, after the initial inflammatory stage has subsided, even a disc patient should be exercising. This should start very gently and be initially under close supervision by the Chiropractor.
Floor Work – Second Reason
If you think of a young child standing for the first time. The child is able to stand erect but has never previously used its muscles standing up. The muscles it uses to stand up were developed on the floor by rolling over and crawling on the floor. So, it makes sense when a patient’s back has gone wrong for the Chiropractor to put the patient back on the floor so the back muscles can redevelop again. So, essentially, the fancy exercises a rehabilitation specialist teaches are really a systematised and safe way to repeat the journey of the infant from rolling over to crawling to standing and walking.
Floor Work – Starting Position
Let’s imagine a patient in considerable back pain who wishes to start exercising on the floor. What position should the Chiropractor put the patient in to start exercising on the floor? The Chiropractor should ask the patient to lie on their front (prone) for up to ten minutes. And on their back (supine) for ten minutes. This could be with the patient’s knees up and feet flat. The Chiropractor needs to ask the question “Was there any difference in low back pain, lying on the front to lying on the back? Which was more comfortable in the low back? If the patient has the same pain in both positions, it doesn’t matter which position the patient starts out exercising in. But if the patient is considerably more comfortable in their low back when lying on their back, they should start exercising on their back and as they get better progress to exercise on their side and then on their front. If they are more comfortable in their low back when face down, they should start face down, progress to exercises on their side and then on their back.
What can be learned from this preference for front or back?
Generally patient’s who are more comfortable on their back are more likely to have sacroiliac problems. This is because lying supine tends to put slack into (i.e.) takes the tension off the sacroiliac ligaments. Being prone puts the sacroiliac ligaments into stretch which is generally more painful for these patients. On the other hand patients with lumbar spine problems (including disc problems) tend to be more comfortable face down. This is because lying face down tends to restore the lumbar curve. Now pain when lying on the front or back is only one indicator, so it is not a sure sign. An X-ray or an MRI scan, for example, would give much more information. Also, it is not the case that every patient who is more comfortable in their lower back is a lumbar spine patient. There are many exceptions. Also, an unlucky patient may have both a sacroiliac problem and a lumbar spine problem. It should never be assumed that the patient has just one thing wrong with her. However, the patient is usually able to adapt to exercise quickest in the most comfortable position and then they can build out from that position as normal function is restored and pain reduces.
Should a Patient Exercise in Pain?
The answer is “yes”. The patient who us in permanent pain can exercise in pain. The patient should score their pain out of ten. They can continue exercising so long as their pain does not rise above that score. Obviously they should start out with something they are pretty sure they can safely do and then build out from their.
“Draw Navel to Spine” or “Brace”?
A controversy in exercise recently has been whether the patient should support their spine by “drawing the navel to the spine” as is seen in some physio exercises or in Pilates. Or, whether the patient should “brace the spine”. With this instruction, the patient holds their abdominal muscles as if they are about to be punched. The advantage of this method is that it activates more of the core muscles. The advantage of the “draw the navel to the spine” method is that it follows the neurological muscle firing sequence. That is to say, this method activates first the muscle that should fire up first. Chiropractor Andrew Hunter favours using the “navel to the spine” method first with patients so as to get the muscle firing sequence established. He then progresses patients to the “brace” method which actually gives more support and is better for heavy lifting.
For floor exercises, there is an excellent series in Janda trained US Chiropractor Donald Murphy’s two booklets “Lumbar Spinal Stabilisation – Floor Exercises” and “Cervical Spinal Stabilisation Exercises”. For disc patients, some version of New Zealand Physio Robin McKenzie’s lumbar extension exercises will probably be appropriate at some stage. After, recovery has been well established, movement teacher Eric Franklin has some interesting ideas. His exercise for eccentric strengthening (i.e.lengthening contraction) of the psoas (primary hip flexor) has proved useful for patients over the years.
Progression to Real Exercise.
At some stage the patient will be ready for “real” exercise. This is exercise where the spine is not deliberately braced before moving. Bracing is necessary as part of the process of getting better but the goal is to go beyond bracing. To demonstrate this to yourself, screw up a piece of paper and throw it hard against a wall. Now brace your tummy muscles as hard as you can and try to repeat the throw. You’ll find it is impossible to throw the ball of paper well when the abdominal muscles are braced – the rigidity and tension in the muscles which protects the back also makes free movement impossible. So to be able to do ” real things” like throwing a ball, the patient has to progress beyond bracing.
The end point of exercise is to be able to do unbraced exercise, safely, standing upright. For some very injured patients, this can be a long journey. When the patient is ready, Chiropractor Andrew Hunter advises his patients to work through the Anatomy in Motion (AiM) system. These exercises are based around the gait cycle – that is trying to enhance our capacity for walking. In particular, the AiM system features a series of “eccentric” (that is lengthening) contraction of the gluteus maximus (the “glutes”). The glutes are by far the biggest and thickest muscles in the body. They should bear most load. The glutes are a far more important muscle than the (relatively insignificant) inner layer of tummy muscles, the TVA (transversus abdominus). Getting the “glutes” to do the work of posture and movement should be a primary goal of any corrective exercise program.
If you would like to learn more about Corrective Exercise, please contact Chiropractor Andrew Hunter at one of his London Clinics (Canary Wharf, Moorgate in the City of London, or Blackheath) on 07855 916 602.
Lumbar Spinal Stabilisation Exercises – Floor Exercises by Donald Murphy, 2001. Available from www.OPTP.com
Cervical Spinal Stabilisation Exercises by Donald Murphy, 2003. Available form www.OPTP.com
The Psoas. Integrating your Inner Core by Eric Franklin 2011 Available form www.OPTP.com
Anatomy in Motion (AiM): http://www.anatomyinmotion.co.uk.