Patient Blog

Why End Range of Motion?

If you have been to therapy before you have probably gotten sick and tired of hearing your therapist say, “try to go farther, push further”, regarding low back pain and your exercises.  Why do therapists obsess so much about moving further into the end range of motion during lumbar spine exercises?

There are many theories and reasons why end range of motion is the goal.  We will discuss some main points in this article, but know there are other rationalizations/justifications of why end range of motion is targeted.

The first reason for focusing on end range of motion is the dynamic disc model.  This was a theory that was popularized by Robin McKenzie, and through decades of research has for the most part held up fairly well.  This approach is known also as MDT principals or the McKenzie Method.  The concept is simple (and one we have discussed to a certain extent), as the spine flexes forward the anterior portion of the disc is compressed and pushes the nucleus of the disc posterior.  Over a period of times the disc can begin to have structural changes on the posterior or back side of the disc and can cause either a physical or chemical irritation of the soft tissue/nerves. 

The dynamic disc model suggests that if the disc is compressed posteriorly by back bending or extending, then the disc and its contents will then shift forward and thus relieve the irritation or compression of the nerve.  The majority of the research conducted thus far, indicates end range of motion is more effective and assumes all patients reach end range of motion. 

End range of motion makes biomechanical sense to believe that the more compression achieved during end range of motion will shift the disc forward more quickly creating quicker and better outcomes.  Thus, the dynamic disc model promotes end Range of motion at the spine, and explains part if the therapist’s obsession with end range of motion.

Pain science is also a major contributing factor for the desire to reach end range of motion during exercises.  The basics concepts for pain science indicate that all sensation produced by the body is either perceived as threatening or non-threatening.  When a threatening stimulus is perceived the brain will increase muscle tone, and increase the body’s sensitivity level to that region.  IF the body continues to perceive threatening inputs then it begins to perceive pain very easily, thus provoking more hypersensitivity.  Conversely, when the brain perceives a non-threatening stimulus, the brain produces a non-threatening response by reducing pain levels, reducing muscle tone.  This creates more freedom in movement which then facilitates less threatening perception and return to prior level of function. 

What does this have to do with end range of motion.  One of the best ways to break up faulty pain pattern or pain cycles as the one listed above is to introduce a new or novel input to the brain.  End range of motion helps produce that novel input, thus breaking up the pain pattern that we get trapped into.  In fact, many have theorized (but has yet to be proven through research), that end range of motion helps to reset the nervous system.  We are not sure why, but think about end range of motion acting like pressing CONTROL ALT DELETE to nervous system, thus resetting it. 


Resetting your nervous system, decreases pain, tone, sensitivity levels while lowering anxiety associated with painful movements patterns thus promoting freedom of movement. 

The examples above illustrate the value in reaching end range of motion exercises with your back exercises.  Only one question remains, are you reaching end range of motion?  

 

 Uneven Spinal Loading

Did you know that the average person will flex or bend forward 3 thousand times per day?  In contrast to bending forward the average person will extend or bend backwards only 100 times a day.    That is a 30 to 1 ratio of forward bending to backward bending.  This creates a large discrepancy between the two motions.  The real question is, does this matter?  The short answer is yes; it does matter, but let’s look a little closer!

For simplistic purposes, let’s look at the spine as being cut in half.  The front half and the back half.  Now, we can correlate these two halves to each designated motion.  Bending forward loads the front half, and bending backwards loads the back half.
 
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As we load the front half by sitting, bending forward, or tying our shoes (think of all the ways our spine bends forward throughout the day) we are unloading the back side of the spine.  The repetitive flexion unloads the back side of the disc, over and over and over again. 
   
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Over time, when the back half of the spine is consistently unloaded, it becomes difficult or even painful to begin to load the back end of the spine. 
  
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What happens if an individual has difficulty or pain with backward bending?  That individual will typically avoid the motion all together.  Avoidance thus, creates a larger discrepancy between bending forward and backward and promotes further asymmetries.  The good news is, these asymmetries are reversible.  Asymmetries such as the one described above promotes poor spinal health.  The spine operates and is in its healthiest state when it is able to load the front half and the back half equally!

The solution to the asymmetries is extending or backwards bending more, achieving end range of motion extending and monitoring the amount of forward bending versus back bending through activity modification and posture awareness.  The goal I tell my patients is to try and lower the ratio of forward bending to back ward bending to 5:1 (versus 35:1).  This loading ratio should create better spinal biomechanics thus creating less pain.

The Oakford Group has been established with an objective to promote a healthy spine through education and innovative therapy products.  The Invertabelt was created to promote proper spinal loading strategies to improve spinal biomechanics, reduce asymmetries and promote proper spine health.

 

 

Centralization Phenomenon vs peripheralization Phenomenon


Centralization versus peripheralization of symptoms, is a concept or idea that has been used in physical therapy and rehab settings for years.  If you have been to a rehab specialist you may have heard these terms discussed before.  But what do these terms mean?

Centralization and peripheralization is a theory on pain manifestation or a pain pattern originating from the spine.  In general, when loading strategies become compromised for varies reasons, structures of the spine may become aggravated or irritated.  As the stress continues the pain may be experienced in the low back.  If the structures stay irritated and stress on the tissue increases the pain may become diffuse or larger in diameter.  Symptoms may even move into the buttocks or lower leg.  This is called peripheralization of symptoms.

Peripheralization of symptoms does not indicate that significant structural or tissue damage has occurred, rather the tissue is undergoing too much repetitive stress.  Peripheralization is the first line of defense to let our body know that a change in activity or pattern of movement is needed.  Many times, identifying contributing movement patterns that lead to deficiencies in spinal loading strategies can be affective in pain reduction.  Creating variability in the loading strategies can lead to centralization of symptoms. 

Centralization of symptoms occurs only after symptoms have begun to peripheralized.  Centralization of symptoms is the phenomenon that occurs when the spinal tissue begins to experience less stress or strain.  When tissue stress reduces, symptoms begin to “centralize” toward the low back.  Leg pain will move to the buttocks, buttocks pain to the back and diffused pain in the back will move to the center of the spine.  Centralization indicates a good prognosis!

Unfortunately, as symptoms centralize toward the low back, many times the pain intensity can slightly increase.  This can be very misleading for patients and even medical professionals.  Human nature tells us to avoid increasing pain on one’s body, so naturally patients may gravitate away from positions or activities that cause centralization as they may increase pain levels.  Remember Centralization of symptoms must occur for proper tissue stress reduction to occur, if we avoid centralization we may never began to improve spinal loading deficiencies, and thus eliminate the problem. 

The takeaway message: LOCATION, LOCATION, LOCATION!!!  Where the pain is and more specifically where the pain is moving is much more important than intensity of pain!  If a specific exercise or position moves the symptoms towards the back, that position is a positive position for spinal health even if the intensity of the pain increases slightly.  Conversely, if a position or exercises increase symptoms away from your spine for more than 10 minutes, then it is a negative spinal loading strategy.  In other words, how do your activities, spinal positions or exercises affect the location of pain.

*** Please note that intensity of symptoms should not be increasing dramatically, even if the symptoms centralize to the low back.

Many times, patients come in and note the pain is extremely variable, meaning pain moves up and down the leg frequently.  Many view this symptom variability as a negative.  Symptom variability when related to spinal loading dysfunction is a very good sign.  Using centralization versus peripheralization, spinal loading strategies can be identified. 

When treating patients, I always over simplify treatment, identify the good and bad loading strategies, avoid the bad, and do the good!  If this is performed consistently over time, symptom reduction should occur.  Ultimately, centralization gives the patient education, knowledge and direction regarding what a bad symptom is versus a good symptom!

Pain Does NOT Equal Harm

A common misconception among individuals is that if one experiences pain, harm or damage must be occurring structurally or at a tissue level.  This is simply not the case.  Pain operates as an alarm system in our body; it is not necessarily an indication that tissue damage has occurred.   Let’s look at this alarm system more closely. 
The nerves in our body always run on a low grade resting electrical system.  As tissue is stimulated and or stressed, the electrical system in the nerves may increase its electrical levels.  If the stress is alleviated, it will return to the normal resting level.  If the stress continues or is amplified, then the electrical signal continues to rise.  If the electrical signal reaches the alarm threshold, then danger signals are sent to the brain, and brain may interpret these signals as pain.  

So the above explanation concludes that when pain is experienced tissue damage occurs, right?!?!?!  Well, not exactly.  The body is a beautifully designed machine.  Take a look at the chart below.  We can see from the chart that tissue damage occurs well after pain is present.  The body is designed to experience pain prior to tissue damage.  This means that the alarmed is designed to alert the individual when potential damage is near but has not yet occurred.  Just as a car engine light will come on to warn one of potential problems with the engine, pain is designed to warn an individual that tissue is being over stressed.  

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Why are these concepts important as our bodies are recovering?  Fear and anxiety increase the resting levels of our nervous system.  When our electrical systems resting levels are elevated we have less room for movement or activity before the alarm (pain) sounds.  Individuals began to associate different movements or activities with pain.  

They also may misconstrue a pulling or stretch sensation as pain. They become fearful or anxious of these movements and when forced into them they have a much lower threshold and pain is elicited more quickly.  This can become a vicious cycle until the individual avoids the movement or activity all together. 
The two Charts below illustrate normal resting electrical signal in the nervous system, versus I heightened or sensitive level.  Notice the decrease space to trigger a pain response.  This is hypersensitivity. 

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Continual movement to a painful joint is healthy.  Only in extreme circumstances should immobilization or complete avoidance be practiced after an injury.  Pain should be respected but not feared.  A general rule is if pain is induced and lasts greater than 5-10 minutes, then you have done too much.  Some movements or motions that always elicit pain should be avoided for some time. Sometimes the tissues do need a small break, but movement should be initiated as soon as possible.

What is the take away message from this post?  Pain is an alarm and does not indicate damage.  Don’t be afraid of pain or other sensations such as stretching or pulling.  Don’t associate such sensations as stretching or pulling strictly with pain.  Movement and activity is healthy for stressed tissues unless pain persists for greater than 10 minutes after activity. 

 

PERSISTENT PAIN PARADOX (Pain Science continued)

As described in our previous post pain is an alarm system in the indicates that the body or different tissues are being over stressed.  The pain alarm system runs on a small electrical signal through the nervous system.  As stress in tissues increase the electrical signal rises until it reaches a threshold.  Once the threshold reached, a signal is sent to the brain and an output is produced by the brain, typically eliciting pain. 

In most individuals as the stress or strain of a tissue is reduces, the electrical signal slowly lowers in the nervous system.  Unfortunately, in 1 out of 4 individuals the resting electrical signal does not lower and stays at a higher level.  When we look at the chart below we see the normal resting level versus someone with persistent pain. With an amplified electrical level, the body has less tolerance to movement activity and positioning prior to pain being experienced.  So in essence individuals with an amped up electrical system cannot tolerate normal movements or activities without pain.

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When pain is induced with very little activity, increase fear and anxiety are induced prior to or during performance of said activity.  This is extremely frustrating for individuals because they feel that two things are occurring.  One the body part still has not healed, and two the activity is causing further damage to the area.  Because of these negative thought patterns, continual avoidance of the activity occurs, or continued pain is experience while perform such activity. 

So how do we fix this pain paradox, or pain cycle.  Number one is knowledge.  Educating individuals that pain does not equal harm can lower fear and anxiety.  Fear and anxiety increase the resting level of the nervous system thus creating less movement tolerance.  Number two is pain modulation.  Perform a similar activity that does not elicit the same pain response but provide similar movement patterns.  This tricks the brain in changing its output as the brain experiences similar activities without pain, it responds by turning down the alarm.  Number three is graded exposure.  Performing the activity with lower intensity or duration, and over time systematically increasing intensity and duration as the body accommodates to its new threshold. 

The take away from this post.  25% of individuals have persistent pain secondary to raised electrical signals in their nervous system, not tissue damage.  The fix for this pain paradox, education, pain modulation through similar or alternate activities and graded exercise or activity exposure. 

Patient Response Approach
Evaluation of a patient’s symptoms can be a very challenging process. One of the first goals I have during the assessment process is identifying patterns with their pain response.  In other words, when do the individuals symptoms feel better and when do they feel worse.  It is important to remember that not all pain is created equal, the centralization phenomenon (which can be reviewed here) helps us dictate what a "good symptom is versus a bad symptom".  A quick review, informs us that the location of the pain is more important than the intensity of the pain.  Any pain that is closer to the spine, versus the buttocks, leg, or foot, is a better pain or symptom.

Knowing what a "good versus bad symptom" is vital in the recovery process.  Many patients come into therapy extremelydepressed as they tell me, “there is no pattern, sometime my butt hurts, sometimes, my thigh and even sometimes my calf!”.  If this sounds like you, then I will tell you exactly what I tell my patients – GREAT!!!! 
If the symptoms vary, then in almost every instance there is a distinguishable pattern.  You just haven’t noticed, because you don’t know how to, YET!  Your job, along with your therapists help, is to identify the pattern. 

When treating patients, I often tell them, “if you aren’t sure what a “good” symptom versus a “bad” symptom, then trying to treat yourself is like playing darts with a blind fold”.  This means that without having the proper knowledge to treat yourself your more than likely going to fail or miss the board.  Having the right knowledge gives you a point of reference, just like taking the blind fold off when playing darts.  With the proper knowledge and direction, now it’s your time to execute.  Having a point of reference regarding good and bad symptoms gives you a chance to self-treat and hit your target of reducing symptoms!  

This is where the Patient Response Approach comes in.  With the help of your therapists, you can now evaluate and assess your symptom response during specific exercises, during a treatment session, and in between treatment sessions.   

Conceptually, the process is actually quite simple; exercises and spinal positioning are assessed individually by you and your therapist during a treatment session.  Activities that produce positive symptoms are noted.  Activities that produce a negative symptom response are discarded.  As more positive exercises are noted, they are continued to be grouped together to be performed during treatment sessions and possibly as a home exercise program.  Each treatment session is continued to be evaluated so that each patient has the right exercise grouping. 

Individual exercises and activities are given for patients to continue to be performed as a home exercise program.  Home exercise programs are continually evaluated for effectiveness in pain management and positive symptom response.  Your therapist should continually be assessing your pain response in between session. 

The Patient response approach can be extremely effective in treating low back pain and promoting self-efficacy.  Patients become engaged in their treatment because it makes sense and ultimately their treatments make them feels good.  The most important reason why the Patient Response Approach is so successful because it is predicated on complete customization of exercises that work specifically to your body.  You just have to learn what a good and bad symptom is first!

Exercise indications and progressions
 Please refer to exercise section for further home exercise explanation

Pure Extension responders

 -Individuals who symptoms centralize with pure extension exercises
 -Patients may experience low back pain or pain that is in buttocks or leg

Progression:
 Unloaded and Static positioning:

- stomach lying with foot anchor

Prone lying invertabelt andy champion oakford group self treatment of low back pain, back pain product
- Stomach lying with resistive bands placed at chest level
- Stomach on elbows without resistive bands
- Stomach lying on elbows with resistive bands
*** positions should be maintained for 4-5 minutes at time 3-5 x a day

Unloaded and dynamic movement

- Press up with foot strap
- Press up the foot strap and resistive bands
Invertabelt oakford group andy champion physical therapy back treament product

Loaded (standing) and dynamic

- Standing back with foot anchor

INvertabelt back bend mckenzie method MDT back pain product

*** 10-20 repetitions every 1-3 hours
***Maintain good posture between exercise sessions

Lateral responders

 -Individuals who do not centralize with pure extension exercise
-Individuals may have a lateral shift present, where a patient’s shoulders/ribcage are shifted laterally from the pelvis.  Shoulders will typically shift away from the painful side
-Majority of lateral responders will need to side bend the spine towards the painful side
 
Unloaded static

- Lie on stomach, use foot anchor, offset hip to one side 
***Lumbar spine should be compressed on the painful side – hips shifted to opposite side of pain
- Lie on stomach, use foot anchor, offset hips to one side, use resistive bands and place hands at chest level
- Lie on stomach, use foot anchor, offset hips to one side, use resistive bands and prop oneself up on to elbows
Road Kill positions

- Lie on stomach, use foot anchor, raise leg on the painful side up and out so that the inside of the knee is lying flush with the bed
 ***Looks as if the leg is performing a breast stroke swimming kick
- Lie on stomach, use foot anchor, raise leg on the painful side up, hold resistive bands to chest level
- Lie on stomach, use foot anchor, raise leg on the painful side up, move to elbows positioning
***All unloaded static positioning should be performed 3-5 minutes 3-5 x a day
Unloaded and dynamic

- Lie on stomach, use foot anchor, offset hip to one side, perform press up
- Lie on stomach, use foot anchor, offset hip to one side, with resistive bands perform press up
Unloaded dynamic road kill positioning

- Perform Road kill positioning on elbows, using your elbow move your lumbar spine further into a side bent position towards the leg that is propped up
- Perform press up in road kill position without resistive bands
- Perform road kill position with resistive bands
Loaded (standing) dynamic

- Use foot anchor, place strap anchor on the opposite hip of pain location, shift hips (side glide) away from the pain

- Use foot anchor, place strap anchor on the opposite hip of pain location, shift hips (side glide) away from the pain, while shifted away bend backwards
***All dynamic exercises should be performed 10-20 repetitions every 1-3 hours
***Maintain good posture in between exercise sessions

Flexion Responder Treatment Indications


Treatment Indications:
- Pain will typically abolish or greatly diminish with sitting or sustained bending forward
- Pain typically builds in standing and peripheralizes (gets larger or moves down legs)
- Patients symptoms may include: Back pain, buttocks pain, leg pain that is bilateral or unilateral

Exercises:
Supine

- Single knee to chest: With waist strap secured at waist just above back pain, lie on back, hold onto resistance bands and pull one knee to the chest
- Double knee to chest: With waist strap secured at waist just above back pain, lie on back, hold onto resistance bands and pull both knees to the chest
Seated
- Seated knee to chest:  Sit with waist strap secured at waist just above back pain, hold onto resistance bands and pull one knee to chest
- Seated piriformis stretch: Sit with waist strap secured at waist just above back pain, cross knee over leg, hold onto resistance bands and pull knee to across body to opposite chest
- Seated Flexion:  Sit with waist strap secured just above back pain, hold onto resistance bands, flex forward and grab knees with hands


Standing

- Standing flexion:  Stand with waist strap secured just above back pain, hold onto resistance bands, flex forward and reach for the floor

*** All exercises should be performed 1-3 sets with 3-5 repetitions 15-20 second holds
Core Strengthening/Stabilization: What am I doing?

Core strengthening is a vital part of spine recovery and spine maintenance.  Many times, when I work with patients regarding therapy, I emphasis the importance of the core musculature.  Patients often get excited about being able to become an active participant in therapy and taking control and taking control of their symptoms.  Unfortunately, that excitement leads to disappointment once the strengthening exercises are revealed.

Many times, I hear patients say my initial core strengthening exercises are considered “easy” or “not hard enough”, or they will ask “what else”.  I then go into my long explanation of “what we are really trying to achieve with core strengthening”.  This explanation begins with what core strength is.

Strength is defined as a muscle that has the ability exert or withstand a force.  Regarding the spine, strength is the active control of the spine stability which is achieved through the control of the forces in surrounding muscles. 

Wow, what a mouth full!!! 

When the spine is unstable, the musculature does not have the ability to apply enough force to stabilize the spine during normal movements.  Conversely, a stable spine has core musculature that can support the spine during normal activity. 

This helps us conclude, we perform core strengthening to achieve core stabilization. 

So why are patients not excited about the core strengthening/stabilization exercises? 

The muscles can be categorized as local systems or global systems.  The local muscles is where most strengthen protocols begin.  These muscles are deep, specifically weakened, endurance based and require 30-40% maximum contraction.  In other words, they take very little movements to activate them and they must be performed over a period of time to improve endurance……BORING!!!

The muscles targeted early are the transverse abdominal and the multifidus.  Stabilization begins with these muscles.  Movements are basic and simple.  Patients want to move, they want to sweet! 

Unfortunately, many patients are unimpressed with introduction of these exercises.  The spine must be able to maintain rigidity during static positioning and during dynamic activities and local muscle are the foundation for spinal rigidity. 

Global muscles are the opposite of local muscles.  Global muscle are fast twitch, superficial and used for power, and involve over 40% of maximal voluntary contraction.  These muscles involve big movements and are typically the exercises patients look forward to.  They are functional exercises that and make the patient sweet!

Unfortunately for the patient functional (global muscles) exercises need to be implemented after foundation (local muscles).   So to conclude, the most important thing to remember is

FOUNDATION BEFORE FUNCTION!!!!

For additional strengthening exercises for the local muscle groups check out our exercises page here!

If you would like additional more advanced information regarding please check out our more advance breakdown of core and stabilization exercises located here!!!

Source:
Core Strength: Stabilization the Confusion
Strength and Conditioning Journal April 2007
Mark D. Faries and Mike Greenwood