Rotation Stretch Increases Low Back Pain and Decreases Spine Stability

Low back pain development response to sustained trunk axial twisting. Eur Spine J. 2013 Sep;22(9):1972-8.

From the study:
Sixteen male pain-free university students volunteered for this study. The trunk axial twisting was created by a torsion moment of 50 Nm for 10-min duration. The axial rotational creep was estimated by the transverse camera view directly on the top of the head. The visual analog scale in low back area was examined both in the initial and at the end of twisting. Each performed three trials of lumbar flexion-extension with the cycle of 5 s flexion and 5 s extension in standing before and after twisting. Surface electromyography from bilateral erector spinae muscles as well as trunk flexion performance was recorded synchronously in video camera. A one-way ANOVA with repeated measures was used to evaluate the effect of twist.
The results showed that there was a significant (p < 0.001) twist creep with rotational angle 10.5° as well as VAS increase with a mean value 45 mm. The erector spinae was active in a larger angle during flexion as well as extension after trunk axial twisting.
Sustained trunk axial twisting elicits significant trunk rotational creep. It causes the visual analog scale to have a significant increase, and causes erector spinae muscles to become active longer during anterior flexion as well as extension, which may be linked to the decrease of the tension ability of passive tissues in low back area, indicating a higher risk in developing low back pain.

Chad’s comments:
This is a timely study for me as I just evaluated a new patient for low back pain with classic facet syndrome, (pain with extension, pain with side bending left, pain with rotation right, most pain with extension into the left quadrant, no pain whatsoever with flexion or slump tests). I see A LOT of people with low back pain and this is the first patient I had diagnosed with facet joint syndrome in years. Mostly facet joint irritation is secondary to a to degenerative disk disease, resultant from to too much spine flexion causing posterior disc prolapse and loss of disc height. This then brings the facet joints into close approximation with resultant arthritic changes. Only after the degenerative disc disease becomes advanced is spine extension solely provocative. This patient had none of that, and it only made sense when he later noted in passing that spends a fair amount of his work day sitting with his trunk rotated to the right, bingo.

This study relates in that researchers found trunk rotation sustained at end range just 10 minutes was enough to cause back pain in healthy subjects reaching 45 mm on a 100 mm scale (4.5/10). Trunk rotation afterwards increased a significant 10.5 degrees, which if sustained one would expect to only further increase pain. The study also noted they thought the rotation of the spinal discs increased compression and likely decreased hydration like wringing water from a wash cloth.

Also interesting from the study was they found erector spinae muscles to be active longer both during flexion and extension after the stretch than before. The researcher thought this was likely due to the rotation stretch decreasing passive structural support and putting them at a higher risk for the onset of developing low back pain. So the take home message is you really should not spend much, if any, time stretching your spine in rotation. Rather if your job or sport requires axial rotation, it’s a lot better if you pivot through your hips and your feet while you exercise to keep your spine strong and stable.

For the treatment of my patient if I were a follower of Williams I would have him stretch his knees to his chest and suggest he sit with his spine in a flexed posture regardless, unwittingly helping him herniate his lumbar discs. If I were a McKenzie practitioner I would also have him stretch away from the direction that causes pain, so in his case that would still be flexion, along with side bending right and rotation left stretches. I expect this would be entirely unnecessary as a spine does not need to be stretched in extremes of one direction to lessen stress from extremes of the other. Rather you just need to avoid the extremes. So most importantly I’m going to teach him to maintain a neutral spine during his workouts and to eliminate the prolonged spine rotation during his job through ergonomic changes. I’ll apply EMS to his abdominal and lumbar regions to eliminate pain in the short term, but also because there are no active exercises that work the abdominal muscles as well or intensely as EMS. Just as important is what I am not going to do, and that to have him lay on his back and rotate his hips from side to side and tell him it has to feel worse before it gets better.

Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember Spinal Flow Yoga for you or someone you know in the future.

Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

4 thoughts on “Rotation Stretch Increases Low Back Pain and Decreases Spine Stability”

  1. Hi Chad, I am 66 and have had chronic on again /off again lower back problems for many years. I have also been a runner for 53 years but find that running has never aggravated my back, but rather often seems to make it feel better which probably makes no sense. One thing, though, that will always lead to sharp lower back pain is when I extend and rotate my lower back, for instance, if I was lifting my back leg up by the ankle and turning to see if something was on the sole of my shoe. Is there something in particular that leads to pain with combined extension/rotation?

    By way of medical history, I have had x-rays only in the past which demonstrated a slight retrolithesis and dextroversion, and completed 4 weeks of “back school” with my hospital’s PT department. I currently do a number of prescribed back stretches daily ( no trunk rotations) which seem to help overall in lessening the number of back flares, but nothing to help the extension/rotation issue.

    Thank you.

    • Hi Tim,

      I bet you found the back school underwhelming. I hope they still aren’t having you sit on a ball, lol.

      Actually I think it makes sense that running doesn’t hurt your back. Running is an upright neutral spine activity, and while there is some oscillating compression with each step, the spine generally handles those kinds of forces very well. It’s bending, twisting, slouching (which is just prolonged bending) that damage it. So yeah, those stretches your PT gave you, I would probably stop. If you have tight hamstrings, and I would not be surprised if you do, it’s cool to stretch the hamstrings. But if you are stretching your back, or laying down and stretching your knees to your chest, that’s just glorified slouching.

      A reasonable guess as to why you are having the extension/rotation issue is that you have some disc degeneration at some level in the lumbar spine, per the usual causes. And because at least one of the discs is thinner (again more likely from slouching in a chair than from running) your facet joints approximate and give you pain quicker when you move into extension, made worse when leaning to that side. Discs to weird things, so even though extension is thought to immediately lessen disc bulges, I remember at least one instance in a study where they did the opposite.

      I don’t think the exact cause is so important. Certainly try and avoid the twist that’s aggravating you, but I would think the trick to getting better is to improve spine posture in general. As a a runner you probably have considerable muscle endurance, but global strength would probably, help. I would think F5 would stabilize everything and build power, perhaps after a bit of C5 to make sure spine/hip coordination is adequate. Actually I’d be curious if your back school taught anything different from C5. Except with C5 being a lot less expensive, and a LOT faster.

  2. Chad, I definitely try and avoid the movements that incite trouble, but sometimes life just happens and sudden torsional movements in response to unforeseen danger occur without time to think about them.

    I do a pretty fair amount of time in the gym doing weight training and core exercises, a typical session lasting at least an hour and performed 3x/week along with an additional 35-45 minutes of aerobic conditioning on the elliptical trainer or stairmaster. On the other 3 days per week I run outdoors and do my stretching routine. One day per week is for rest, where I may walk easily for 3-5 miles.

    And yes, my hamstrings are notoriously tight, despite years of trying to lessen it with various forms of passive stretching. I suppose 50+ years of running will do that. As well, my theory as to why I typically run without back pain is that it is probably the one time when my posture is actually pretty decent, which agrees with your take as well. My work days are typically spent being up and down quite a bit so sitting for extended periods is not usually a problem, although as I near retirement, that may become a larger issue I will need to address.

    I am not familiar with C5 or F5 by name, so I cannot tell you if what I currently do for my daily back maintenance involves either. Can you explain them a bit further. I read the descriptions but without visuals was unable to completely grasp whether it is some form of yoga – which I have never done – specific exercises, or both.

    Thank you again for your time – I realize it is everyone’s most precious commodity and I genuinely appreciate you offering up some of yours to try and help me. I’ve been pondering making an appointment with the orthopedic docs at the hospital where I work just to see if someone can possibly pin down the actual root of my problem – retrolisthesis, spondylolisthesis, facet problem, degenerative disc, etc. – so that I might hopefully address it accurately, but worry that without sciatica or other ominous symptoms, scanning is probably not in the cards and I’ll be left with an educated guess and a return ticket to the PT department. I am certainly not opposed to additional PT, on the contrary, I am one of those folks who if told something will help me, I will be compliant to the nth degree, but it would be nice to know that what I’m doing is working towards making things better rather than worse.

    • Tim, sorry for getting back to you late. I’m sure you can imagine, it’s been a weird couple weeks.

      Regarding torsional movements of everyday life, they’re never something you can fully eliminate, nor would you even want to. The spine is meant to allow movement in all directions. However, pain and DDD is indicative that it’s had too much in some or all of those directions and they need less going forward. They’re almost never something you need to “work on” with formal stretching.

      It sounds like you exercise about 10x as much as I do. C5 and F5 are described here.

      Up and down a lot at work is generally good. Provided when you are down you have good lumbar support. If you are down in a flexed posture only 20 minutes at a time, but you are down there 10x in a day, that’s still bad for the spine. Up and down could be bad, however, if when you are in the process of changing position you are flexing through your spine, rather than through your hips. Given you have back pain, that is probable. It can only be one of so many things. That’s part of what C5 teaches explicitly, to bend though the hips keeping the spine neutral.

      I need to come up with a visual “commercial” of how C5 and F5 are taught and go together. Unfortunately, I just haven’t got there yet. The exercises are taught via video and take 5 minutes per program, per day, to complete once you know them.

      Almost certainly getting further diagnostic tests are not going to help you. The fix is the same regardless. The fix being to allow your spine to heal by keeping it more neutral, more often, during your day. Easy to say, harder to do, but not really that hard once you have developed good strength and habits. Lol, probably if you go back to PT they’ll just stretch you again, in a way that’s bad for your spine, again. If it were me I would just do Spinal Flow Yoga, you learn the system for less than the copay for one PT visit. It’s just better, a LOT better.


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