Lumbar Extension Exercises and Chronic Low Back Pain

Understanding and Applying Isolated Lumbar Extension Resistance Training

There have been several cases when I've applied resisted lumbar extension to modulate pain during lumbar extension in standing. In the cases where the patient had chronic pain, I noticed they were barely able to resist extension. They tested EXTREMELY weak. Part of their program then was doing isometric prone extension from the floor and then supermans with hips stabilized in the gym or by someone at home off of a bed. This got me into looking at lumbar extension and low back pain, something that isn't very popular, but I think could be utilized in patients who aren't responding to your typical repeated loading program or stabilization programs.

Isolated lumbar extension (ILEX) resistance training is a therapeutic exercise approach that focuses on strengthening the lumbar extensor muscles while minimizing the involvement of other muscle groups. The lumbar extensors, including the erector spinae, multifidus, and quadratus lumborum, play a critical role in supporting the spine and controlling movement in the lumbar region.

Chronic low back pain (CLBP) is a highly prevalent condition, with significant economic and personal impacts. Deconditioning of the lumbar extensor muscles is often observed in individuals with CLBP, and is considered a contributing factor to pain and disability. ILEX resistance training has emerged as a potential treatment strategy for CLBP, aiming to improve lumbar extensor function and reduce pain.

Key Considerations for Physical Therapists

Specificity of Exercise:

People with CLBP often exhibit deconditioning of the lumbar extensor muscles, characterized by reduced strength, endurance, atrophy, and increased fatigability.

This deconditioning suggests that not all exercise programs are equally effective in addressing CLBP.

Specific exercises that target the lumbar extensors, such as ILEX resistance training, are likely to yield better outcomes compared to general exercise programs.

Pelvic Stabilization:

• Stabilizing the pelvis during lumbar extension exercises is crucial for effectively isolating and strengthening the lumbar extensor muscles.

• Specialized equipment, such as the MedX Lumbar Extension Machine, is designed to restrict pelvic movement and ensure that the targeted muscles are appropriately engaged.

• A study comparing lumbar extension training with and without pelvic stabilization found that only the group with pelvic stabilization experienced significant improvements in lumbar strength and reductions in pain and disability.

Intensity and Frequency:

High-intensity ILEX resistance training, performed to momentary muscular failure, appears to be most effective for achieving clinically meaningful results..

Surprisingly, a low frequency of once per week has been shown to be sufficient for eliciting improvements. This finding may be encouraging for patients who have difficulty adhering to more frequent exercise regimens.

Range of Motion:

Both full and limited range-of-motion ILEX resistance training have demonstrated effectiveness in improving pain and disability in individuals with CLBP..

The choice between these approaches may depend on individual patient factors, such as pain levels, movement limitations, and exercise tolerance.

Assessment and Evaluation:

Reliable tools and methods are available for assessing lumbar range of motion and maximal isometric strength..

These assessments allow physical therapists to evaluate a patient's baseline function, track progress over time, and make informed decisions regarding exercise prescription and progression.

For instance, isometric strength testing can be conducted at various degrees of lumbar flexion to determine the optimal starting point for resistance training.

Beyond Lumbar Extensor Strengthening

Multifactorial Nature of CLBP:

CLBP is a complex condition with multiple contributing factors, including physical, psychological, and social aspects.

While ILEX resistance training can address lumbar extensor deconditioning, it is essential to consider other potential sources of pain and dysfunction.

A comprehensive treatment plan should encompass a variety of interventions, such as manual therapy, pain management strategies, education, and ergonomic modifications.

Lumbar Extensor Strength and Balance:

• Emerging evidence suggests that lumbar extensor strength may contribute to balance performance, particularly in individuals with CLBP..

• This finding has important implications for fall prevention and overall functional capacity.

• Strengthening the lumbar extensors may improve balance and reduce the risk of falls in this population.

Neuromuscular Imbalances:

Research has shown a significant association between neuromuscular imbalances of the erector spinae muscles and the occurrence of LBP, particularly in athletes..

These imbalances may persist even after a back exercise program, particularly in those whose pain does not fully resolve.

Addressing neuromuscular imbalances through targeted exercises and other interventions may be an important aspect of CLBP management.

Clinical Testing Considerations:

Common clinical tests for spinal mobility and muscular flexibility may have limited correlation with LBP and neuromuscular imbalances..

Relying solely on these tests may not provide a complete understanding of the underlying factors contributing to a patient's pain.

More comprehensive assessments, including measures of muscle strength, endurance, and activation patterns, are crucial for developing effective treatment plans.

Further Research

While existing research supports the use of ILEX resistance training for CLBP, more research is needed to:

• Compare ILEX resistance training with other specific exercise approaches.

• Determine the optimal parameters for ILEX resistance training, such as the ideal combination of intensity, frequency, and range of motion.

• Further investigate the relationship between improvements in pain and disability and changes in lumbar extensor function.

Conclusion

ILEX resistance training is a promising treatment option for CLBP, offering potential benefits in terms of pain reduction, improved function, and enhanced motor control. Physical therapists can integrate ILEX resistance training into a comprehensive treatment plan, considering individual patient needs and the multifactorial nature of CLBP.

References

1. Steele J, Bruce-Low S, Smith D. A review of the clinical value of isolated lumbar extension resistance training for chronic low back pain. PM R. 2015 Feb;7(2):169-87.

2. Lee KW, Hwang JH, Bang HJ. Isometric evaluation of the lumbar extensors in chronic low back pain. J Korean Acad Rehabil Med. 1997;21(1):1-7.

3. Roussel NA, Truijen S, De Kerf I, Lambeets D, Nijs J, Stassijns G. Reliability of the assessment of lumbar range of motion and maximal isometric strength in patients with chronic low back pain. Arch Phys Med Rehabil. 2008 Apr;89(4):788-91.

4. Renkawitz T, Boluki D, Grifka J. The association of low back pain, neuromuscular imbalance, and trunk extension strength in athletes. Spine J. 2006 Nov-Dec;6(6):673-83.

5. Smith D, Bissell G, Bruce-Low S, Wakefield C. The effect of lumbar extension training with and without pelvic stabilization on lumbar strength and low back pain. J Back Musculoskelet Rehabil. 2011;24(4):241-9.

6. O'Sullivan K, Smith A, Beales DJ, Straker L. The relationship between balance performance, lumbar extension strength, trunk extension endurance, and pain in participants with chronic low back pain, and those without. Clin Biomech. 2018 Mar;53:22-30.

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