Maureen Dwight Registered Physiotherapist, Clinical Musculoskeletal Specialist, Advanced Spinal Practitioner ISAEC

34943050_sOne of the most commonly accepted factors predicting recurrent low back pain is a lack of strength.  Your practitioner tells you that the reason you keep injuring is your lack of fitness or insufficient “core”[1], however the problem with this perspective is that many people find when they get more active their low back pain gets worse.

If strength is so important you would expect to see a lower rate of back injuries in athletes, but research[2] tells us that this is not the case.  Despite all those beautiful 6-packs and even an occasional 8-pack, athletes have one of the highest rates of low back pain.

This lack of correlation has been suggested by several reviews which have concluded the incidence of low back pain is a U-shaped curve.  The highest occurrence is at both the low and the high end of the activity spectrum.  Both the couch-potato and the athlete are equally at risk.  It is the moderately active person who is in the best place to avoid low back pain.

Compensatory Muscle Patterns

What often makes athletes more prone to pain is their dedication to their sport.  Many continue to compete while injured. This makes healing more challenging, as damaged tissues initially require a reduction in strain to be able to heal.

When the athlete decides to over-ride their natural inclination to reduce activity, not only do they raise their risk for further injury, they often do not perform as well.  The problem with competing injured, or when we make a decision to try to get fit while we are injured, is that the body naturally protects the injury.  Whether we want to or not, we compensate for the injury by changing the way we move.  We recruit muscles to support the injury and this means we then need to engage other muscles to produce movement.

Compensatory muscle patterns are useful as they help us to keep moving while we are healing, but they are never as efficient as healthy, normal motions.  When the athlete tries to perform at the top of their game, the high-level of demand can exceed the power and coordination available by recruiting these alternative movement patterns.  For the non-athlete these changes can often be seen in our everyday activities.   We tire more easily and can no-longer “go the distance”.  We begin to injure other joints.  Going back to sport or activity too quickly after injury may be revered by the coach and the sports press but these decisions often result in re-injury and a risk for other injuries.

Learning to be injured

Although compensation is a useful and natural process, it is also important to stop compensating once the injury has healed.  One of my coaches summarized it succinctly as “if you play injured, you are learning how to play injured.’

The problem is that during an injury our brain and central nervous system are “learning” how to move injured.  The plasticity in our brain begins to over-ride the older, more efficient movement patterns with these newer, less effective movements.  The longer you compensate the more difficult it is to return to pre-injury movements as your brain interprets the repetition as your commitment to continuing these motor patterns.  The more often you are injured the more you reinforce compensatory patterns, until finally these compensations become your new normal.

Symptoms of compensatory muscle patterning

In my practice I find that these learned inefficiencies of movement are one of the most common causes of recurrent episodes of low back pain.  They are often the reason why so many people eventually experience a similar change in their low back pain episodes.  Whereas initially the intense low back pain is followed by periods where you are pain free, suddenly you are in pain all the time.  The pain is less intense but it never goes away.

Compensatory muscle patterns are also one of the primary causes of other injuries.  After hurting your back many of my clients find that they are suddenly prone to a whole raft of other injuries.  They injure their knees or strain their hips.  Even a recurrent tennis elbow can be a symptom of the unrecognized presence of inefficient compensatory movement patterns.

The most common symptoms that prompt me to look for compensatory muscle patterns include:

  • Taking longer than 3 months to recover from an injury.
  • Hurting your back too easily i.e. picking up the bar of soap in the shower.
  • Low-grade back pain that never goes away.
  • Every time you try to get fit your back pain gets worse.
  • A sudden increase in injuries to other areas. Hip flexor pain, bursitis, recurrent knee injuries are common symptoms of compensation.
  • Your muscles remain tight no matter how often you stretch.
  • You sense you are moving differently but can’t correct it.
  • People tell you that you limp or are moving oddly but you can’t feel it.

Learning how not to be injured

When the cause of your pain is related to changes in movement, the key to getting better and for preventing future episodes lies in retraining your brain’s plasticity.  You need to re-establish pre-injury movement patterns and unlearn the compensatory movements. Fortunately the old adage of “you never forget how to ride a bike” applies here.  The healthier patterns still exist in your nervous system, you just need to remind your brain to use them.

In therapy I find that the key to getting rid of compensation is to first determine what is causing it. Once an injury resolves the compensatory patterns should naturally go away, but when they don’t there are four common reasons to consider:

  • You are still injured
  • Muscles are weak
  • Compensatory muscles are tight
  • Habit
  1. You are still injured

Prior to correcting compensatory patterns it’s important to check to see if the original injury has healed or if you now have a new injury.  Only when your tissues are robust enough to begin producing normal motion will you be able to get rid of compensatory movement. Once your therapist has determined the injury has healed, a program of strength and flexibility will help to get you on track.

  1. Muscles are weak

Although it is important to restore strength, a failure to recognize the presence of compensation can inadvertently reinforce inefficient movement patterns.  Your therapist needs to look for the specific muscles that need to be targeted before you start a general fitness program.  Moving to a general fitness program too quickly often only makes the strong muscles stronger and keeps the weaker ones weak.

  1. Muscles are tight

One of the key signs of compensation is a tight muscle(s) that never gets better no matter how much you stretch.  In compensation the tight muscle works too hard to generate the same amount of power as the more efficient primary muscle(s).

Unless you recognize that these muscles are over-worked they will continue to shorten and tighten.  No matter how much time and money you spend on massage, ART or stretching, the results will only be temporary.  Unless you retrain the primary muscle to take on its function, the compensatory muscle will fatigue, tighten and/or injure.

  1. Habit

Once I have worked through the first 3 elements in this list, the most common cause of continued compensation is that you have learned to compensate.  Repeated practice of a movement pattern causes your nervous system to commit to these movements. As anyone who has tried to correct their golf swing knows, once established these patterns of movement are hard to correct.  Not only does compensation affect how you perform in your sport, it also raises your risk of injury. As the saying goes, practice makes permanent, not perfect.

If you are having ongoing pain that never gets better and/or symptoms of compensation, it’s time to consider seeing a registered physiotherapist or kinesiologist who understands the underlying causes and how to correct them.  Developing a program which includes the repeated practice of healthy movement patterns will help your nervous system re-commit to efficiency and allow you to return to your everyday activities.  As an added bonus it also often improves sports performance as I find that the inability to correct a golf or tennis swing in adults is often a result of underlying compensatory patterns.

For more information on treatment options for prevention and alleviation of low back pain please contact us at physio@orthophysio.com or drop by our Toronto Clinic.

The advice in this article is not meant to replace advice from your health care professional.

Next topic:  How your brain prevents your low back from getting better.

 

[1] https://orthophysio.com/news/physiotherapy/low-back-pain-and-core-strength/

[2] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724651/