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The missing link in spinal pain management

Have you been prescribed a spinal conditioning program but never improved? Are you perplexed by your pain that wont go away? Have you been told you have “non specific” pain? If so, this is a must read.

I get so excited by biomechanics and physics of the human body. Why might you ask? Because I have patients come to me with pain that is “untreatable” in their words, and within a few sessions they are already improving. How, might you ask?

It all starts with the now well known word “core”. I'm sure almost all of you have heard of this.

"Core stability" is often referred to as strengthening muscles of the abdomen. The term has become a trendsetter in the physiotherapy world when managing back pain but I it can become a very broad “band aid approach” for therapists when not individualised/ prescribed poorly with often minimal focus on quality of the technique. I especially see this in the “chronic lower back pain” population where a general exercise plan is prescribed or the patient is told to just do Pilates. As therapists I feel we too often fall into the trap of grouping people into this category, and not fully exploring the biomechanical factors contributing to pain and perhaps asking ourselves why previous treatment has not been successful. It could be load related, technique related or the type of exercise they were prescribed in the past, in addition to psychological factors.

Why is "core"?

I’m referring here to the deepest layer of muscles including the diaphragm, transverse abdomens, pelvic floor, perineum, and deep paraspinals. There are recently several studies that look at the effect of strengthening the abdominal region and back muscles and this has long term been seen as essential for those with lower back pain. BUT, studies have very much polarised each other and there is no conclusive evidence that stability type exercise is superior to usual exercise in terms of lessening pain. This is however due to the fact studies group together people with back pain into control groups "general exercise" versus treatment group with the same blanket "core/stability" exercise for the group - BUT, in doing this they fail to individualise the exercise plans to each individual. This does not mean it is not effective, but is because the treatment was not specific to the patients pain, pathology, posture, load/movement aggravators or weaknesses/dysfunctional movement patterns.

The main missing piece to the puzzle is understanding the persons load/movement aggravators and offloading the structures that are painful with specific exercise prescription that lessens pain and allows the patient to active muscles, build muscle (especially in atrophied muscles) and integrate this into improving stabilisation in a corrected posture with the addition of movement and load. The ribcage and spine are supported by postural muscles that maintain erect posture throughout the day, often overlooked, the diaphragm works to provide support for the spine, and the importance of addressing it when treating poor posture, cervical, thoracic and lumbar pain and even incontinence is vital.

What is “good” technique?

At rest, there is minimal difference between the diaphragm of someone with back pain versus someone without. The diaphragm can be actively moved without breathing, and can move up to 4.5cm during active motion without breathing, and 3.5cm on breath holding. When breathing technique is good, the diaphragm pushes down into the abdominal cavity and with the resistance in an upward direction provided by the pelvic floor, it expands the lower ribcage in a “bucket handle movement” (out and up action). There is usually a simultaneous eccentric contraction of the tranverse abdominus (muscles in front of the spine) with the diaphragm, and the pressure created in front creates a co-contraction of the paraspinals (muscles at the back of the spine). As the musclces work together, they assist in controlling intraabdomial pressure, and fully supporting the spine.

Improving ribcage expansion and spinal elongation creates:

- Improved stiffness of the lumbar spine when under load

- Increased tension on the muscles of the abdomen which assist with rotational control

- Better length/tension relationship of muscles in the abdominal wall and those at the back of the spine, lessening the load on passive structures

- Prevents arching or flattening of the lumabr spine under load

- Elongation of the spine reducing intervertebral compression

What is “poor” technique?

The problem in those with poor diaphragm control/ poor breathing patterns or poor posture, is that the diaphragm moves up the abdominal concavity rather than expanding the lower ribcage. This means the intra-abdominal pressure does not reach all the way down in the lumbar spine where loading is most prominent, and often causes the patients' spine to be pulled forward /backward at the lower back, subsequently increasing load, and often causing pain. This is typical of people who really struggle to keep their lumbar neutral. They often arch or round their lower back under even the slightest load.

Key tell tell signs they have a weak diaphram or poor co-ordination/control:

- Belly breathing, or breahing into the abdomen with no outward movement of ribs creating abdominal distention/ lax abdominals

- Poor posture is a tell tell sign; often “hanging in the lower back” with abdominals lax, or loss of lordosis in lumbar spine

- Restricted in lumbar flexion

- A rise of the shoulders on inhalation

- Overactive/ increased tone in the neck muscles (often neck pain)

- Breath holding is a big one

- Rapid breathing

When should I be looking at the diaphragm and breathing?

If you have:

- “Non-specific” back pain with no pathological cause

- Pain while exercising

- Pain that has not been addressed by other therapists or has not improved as expected

- Observation of poor posture

- Observation of poor breathing pattern or rapid breathing ie: upper chest breathing

- If you report stress or anxiety

- If you report neck pain in conjunction with lower back pain

- Observation of a hyper-kyphotic type posture/ or loss of the inwardness at lower back

How do I improve my breathing?

As you inhale, take the breath low into the lungs all the way around the abdomen, evenly all sides, while maintaining head over a neutral pelvis, feel the ribs create space and stretch of the tissues, then maintain this space on exhale.

Feel how there is a flattening of the abdomen and lengthening in the lumbar spine with a softening of the pelvis down at the back.

Can you re-create this posture without using a breath in, but just using muscle memory.

I hope this has been helpful for those still exploring treatments for better management of spinal pain. In addition, breathing has been shown to reduce pain through focused attention, mindfulness and through reducing stress and anxiety which may be contributing factors to pain. SO...INHALE, EXHALE!


1. Chaitow L. Breathing pattern disorders, motor control and low back pain. Journal of Osteopathic Medicine. 2004, 7 (1) 33-40

2. Flanagan et al. Activation of core musculature during exercise with stable and unstable loads and surfaces. J of Strength & Conditioning. 2010, 24

3. Hodges et al. Activation of the diaphragm during repetitive postural task. Journal of Physiology 1999, 522, 165-175

4. Kolar et al. Postural function of the diaphragm in persons with and without chronic low back pain. Jounral of Orthopaedic and Sports Physical Therapy. 2012, 42, 4

5. Ledermen E. The myth of core stability. Journal of Bodywork & Movement Therapies. 2010, 14, 84-96

6. Okada et al. Relationship between core stability, functional movement and performance. Journal of Strength & Conditioning Research. 2010

7. Stokes et al. intra-abdominal pressure and abdominal wall muscular function: spinal unloading mechanism. Clin Biomech.2010 dii:10.1016

8. Vostatek et al. Diaphragm postural function analaysis using MRI, 2010, doi: 10.1371/journal.pone.0056724

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