Treating chronic back pain holistically – The back is made for movement (part 2)

Spine – a masterpiece of stability and mobility

Our back, or spine, combines stability and mobility thanks to its ingenious structure. It consists of 24 free vertebrae, as well as the sacrum and coccyx. Intervertebral discs and small vertebral joints (facet joints) between the vertebrae ensure mobility, supported by the surrounding muscles. Stability is provided by the bony structure, intervertebral discs, tight ligaments and, above all, the deep core muscles. A distinction is made between static stability provided by bones and ligaments and dynamic stability provided by active muscle work. The spine must be flexible enough for movement and at the same time stable enough to absorb the load and protect the spinal cord – a finely tuned balance.

Sitting – the new smoking

Many people spend a large part of their day sitting down – whether in the office, in the car or on public transport, eating, relaxing on the sofa in the evening or even sleeping at night with their legs bent. This permanent sitting posture causes the muscles and fascia on the front of the body to “shorten”. The hip flexor is particularly affected (see “Shortened hip flexor”). In order to maintain body balance, the posterior muscle and fascia chain must constantly counteract this. This overload causes them to harden and tense up, which often leads to back pain, particularly in the lower back.

Core muscles

The trunk or core muscles include all the muscles that stabilise the upper body. It is crucial for posture, balance, mobility and the transfer of force between the upper and lower body – it acts like an internal support corset. A strong core stabilises the spine and pelvis with every movement and automatically tightens under load, for example when lifting. This reduces the risk of injury and pain.

The core muscles primarily include the deep abdominal and back muscles (transversus, multifidi), the hip muscles, the pelvic floor and the diaphragm. If these muscles are weakened or tense, this can lead to back pain and other complaints. If you suffer from back pain, it is important to build up strong core muscles. Training the back muscles alone, which, as already mentioned, are usually already tense, is not effective.

The important thing is that these structures work as a functional team – just like the entire body. They should therefore always be considered together and both strengthened and relaxed in a targeted manner.

Pelvic floor

The pelvic floor is a multi-layered plate of muscle and connective tissue that closes off the abdominal cavity at the bottom. The pelvic floor stretches like a trampoline between the pubic bone, ischial tuberosities and coccyx and supports the pelvic organs (bladder, uterus/prostate, rectum). It is important for bladder and bowel continence and stabilises the torso and spine, especially when coughing, laughing or lifting. At the same time, however, it must also be able to relax, e.g. during urination, defecation or sex. Incidentally, men also have a pelvic floor – but it is often hushed up. And even in women, it is usually only mentioned in connection with pregnancy, postnatal recovery or the menopause, although it is of course important throughout life and is particularly stressed during these phases.

The pelvic floor and back work closely together. If the pelvic floor is too weak, the abdominal and back muscles have to work harder – this can lead to overloading and chronic pain in the lower back. If it is tense, on the other hand, it can cause dull pain in the lower back, buttocks or pelvis. This is why pelvic floor training can be very helpful for back pain; it includes targeted strengthening and relaxation exercises. If you are unsure, it is worth consulting a specialist in pelvic floor therapy in order to practise specifically and also to recognise over- or under-tension.

Shortened hip flexor

The hip flexor – technically known as the iliopsoas muscle, often simply as the psoas – is made up of the iliacus muscle (m. iliacus) and the large and small lumbar muscles (m. psoas major/minor). It connects the upper and lower body: its fibres originate from the thoracic and lumbar vertebrae, unite with the iliacus and attach to the upper, inner thigh bone. The psoas is often one of the causes of back pain.

More than just a movement muscle

Everyday factors such as frequent sitting and lack of exercise favour a shortening of the hip flexor. This can pull the pelvis into a hollow back, unbalance the spine and cause back pain.

The psoas is the only muscle that directly connects the torso and legs. Due to its central location, it is also in close contact with the small intestine, kidneys, adrenal glands – which produce important stress hormones – and the diaphragm. It also influences digestion, stress reactions and breathing via fascial structures.

In the event of danger, the psoas tenses reflexively – the typical “fight-or-flight response”. Chronic stress can therefore lead to permanent shortening. This restricts diaphragmatic movement, promotes shallow breathing and activates the sympathetic nervous system, our stress nervous system. A relaxed psoas, on the other hand, facilitates deep breathing and activates the parasympathetic nervous system, which ensures calm and regeneration. No wonder it is often referred to as the “soul muscle”.

Training and stretching

The aim is to mobilise, stretch and strengthen the iliopsoas, but also to relax it.

• Regularity: Short sessions several times a day, especially if you are sedentary
• Posture: Gently pull in your stomach during all exercises, straighten your pelvis and activate your buttocks to avoid a hollow back

Example exercise – lunge stretch (low/high lunge stretch)

1. Variation on your knees: One leg in front, back knee on the floor.
2. Standing variation: Wide lunge backwards.
3. Gently push your pelvis forwards, upper body upright.
4. To intensify, move your arms upwards and slightly to the opposite side.
5. Duration: 30-60 seconds per side, 2-3 passes.
6. Then shake out your legs and arms, take a deep breath and relax.

With the hip flexor, it is also important to keep an eye on the psychological situation (soul muscle) and to ensure good stress management (more on this in Part 3).

Adhesive fasciae

Fasciae are fine but extremely resistant connective tissue sheaths that surround and connect muscles, organs, bones and nerves. They run through the entire body like a three-dimensional net and give it stability and shape. They consist primarily of collagen and elastin fibres, which makes them both tear-resistant and elastic. Fasciae allow muscles and organs to glide smoothly past each other. They constantly adapt to our movements by producing new fibres, known as fibroblasts. Fasciae also play an important role in force transmission and body perception, as they contain many nerve endings. The interstitial fluid in the fascial network ensures the supply of nutrients and the removal of waste products.

Fasciae can “stick together” due to a lack of movement or one-sided strain. A vivid image of this is a woollen jumper that has been washed too hot; the previously elastic fabric is now matted and rigid. When fasciae stick together and harden, this can lead to pain, tension or restricted movement. The large thoracolumbar fascia is located in the lower back, which is often thickened in cases of chronic back pain and can be responsible for pain.

Regular, targeted fascia training can help to restore elasticity and suppleness to the fascia and relieve pain.

Elements of fascia training are

• Special stretching exercises to promote elasticity
• Self-massage with fascia rollers and balls to loosen adhesions and get the interstitial fluid moving; degradation products are removed, nutrients can flow in
• Long-chain stretching movements that address entire muscle-fascia chains
• Controlled, slow, flowing movements that promote body awareness and coordination, release tension and strengthen the fascial network

Suitable exercises include Pilates, functional training or Liebscher & Bracht stretching and strengthening exercises. Don’t forget to drink enough, as fasciae need a lot of water to remain supple.

Fascia distortion model (FDM)

The fascial distortion model assumes that many acute and chronic pains originate from deformations (distortions) of the fascia. The FDM describes six typical distortion patterns, which are characterised by the patient’s “pain gestures” and descriptions. Trained therapists feel the affected pattern and treat it with targeted manual techniques in order to loosen adhesions and improve the circulation and gliding ability of the connective tissue.
Fascia distortion model offer in Winterthur

Useful things for an active everyday life

Ergonomic (office) chairs are another valuable and helpful way to support the back in everyday (working) life, especially if you sit a lot. For example, there are chairs that allow controlled pelvic movements with a stable spine, which specifically stimulates the back muscles. Ideally, move and stretch for a few minutes every hour. You may also have a standing desk at your disposal so that you can change your position regularly. Back-friendly shoes are also important; hard, constricting shoes or those with heels are not suitable. Specially developed soft, elasticated, slightly rounded soles, on the other hand, activate the small support and stability muscles in the legs when standing and walking and cushion impacts on hard surfaces.

Recommended movement approaches and therapies

Physicians usually prescribe physiotherapy for back pain, which is often a good (first) port of call and can be helpful. When choosing a physiotherapist, make sure that the person has additional training that offers a wider and more holistic range of options for pain therapy (e.g. osteopathy or fascial distortion model, etc.).

(Parietal) osteopathy is a holistic approach in which therapists use gentle manual techniques to treat muscles, joints and connective tissue in order to improve their mobility and promote physical balance. They focus on the whole body and the connections between organs and body parts, as well as the psyche, and also support the body’s self-healing powers.

Exercise concepts that are holistic, i.e. combine strength, coordination, balance, flexibility, relaxation and body awareness as far as possible, are preferable to one-sided ones. Ideally, different training programmes should be combined. Not every workout is suitable for every person; find out for yourself what works best for your individual situation. It is important that a professional shows you how to do the training correctly and corrects you if necessary.

Some possibilities:

• Pilates training
• Foundation training
• Liebscher & Bracht stretching exercises
• Functional training (functional training)
• Pelvic floor training
• Fascia distortion model

Continuity instead of quantity and individualised training

Caution: Many people start out full of motivation, they want to get rid of the pain immediately and start training like a fire engine. But they often become disillusioned after a short time: the pain hasn’t gone away. Motivation wanes – and many people stop again. Please note: back pain often develops over years – sometimes even decades. No wonder that relief and healing also take time. Muscles, nerve pathways and other structures often need 6-8 weeks of regular training before the first noticeable adjustments occur. The key is not quantity, but continuity. It is better to take small, consistent steps instead of overstraining the body.

The attitude “I just have to train more and the pain will go away” is also deceptive. On the contrary, the wrong training or increasing it too quickly can actually make your back pain worse. Training only works if it is individually tailored to you – to your problems but also to your resources. There is no “one-size-fits-all training”, only the right training for you.

• 10 – 15 minutes a day of targeted, correctly performed exercises
• Small corrections in everyday life (e.g. when sitting or lifting)
• Conscious breaks and relaxation

This is part 2 of the series “Treating chronic back pain holistically”
Part 1 – Nutrition and supplements for a strong back
Part 3 – Influence of the gut, liver, psyche, sleep and stress