CategoriesAssessment Corrective Exercise

Defending Spinal Flexion: It’s Not Always the Evil Step-Child We Make It Out to Be

No offense to my future wife (t-minus 37 days until the big day), one of the greatest days of my life was the day I got my first Atari 2600[footnote]Other days on the list: hitting my first Little League home run, earning a baseball scholarship to Mercyhurst University, getting my first article published on T-Nation, every Christmas Day for the past 38 years, and any time I see boobies.[/footnote] My game of choice: Defender.

The premise was/is simple: your planet is under invasion by waves of aliens and it’s your mission to “defend” it, as well as other astronauts.

Pew pew pew

Man, I spent hours playing that game.

I really have no other reason for leading with this story other than to say 1) it was an awesome game 2) the chick on the cover was hot and 3) the theme – defender – served as a nice segue to today’s topic……

Spinal Flexion

https://www.youtube.com/watch?v=a1Y73sPHKxw

 

Like many other fitness professionals a few years back, I jumped onto the anti-flexion bandwagon.

I mean could you blame me?

Gulfs of research – in addition to anecdotal evidence – suggest that spinal flexion has its downfalls. To be more precise, however, I should state it’s repeated spinal flexion (and extension) taken into end range that’s the real culprit. Do that on a consistent basis, let it marinate with little to no strength training, and you have the perfect recipe to herniate a disc.

And as my boy, Eric Cressey, notes:

“If you want to see a population of folks with disc herniations, just look at people who sit in flexion all day; it’s a slam dunk.”

Of course, this doesn’t automatically equate to someone being in pain or complaining of back issues. There are plenty of people walking around with not one, but maybe even two, levels of herniations or disc bulges in their spine. And they’re fine.

In fact, in a landmark study published in 1994 in the New England Journal of Medicine, researchers sent MRI’s of 98 “healthy” backs to various doctors, and asked them to diagnose them.

– 80% of the MRI interpretations came back with disc herniations and bulges. in 38% of the patients, there was involvement of more than one disc.

And these were considered “healthy” backs, and those of people walking around with no symptoms what-so-ever.

Which goes to show: I’d trust an MRI about as much as I’d trust a barber with a mullet.

NOTE: this isn’t to insinuate that MRIs are a waste of time or aren’t valuable. That’s 100% false. But I’d be remiss not to state that we, sometimes, place far too much precedence in them.

Oftentimes leading to unnecessary surgery (which should be an absolute LAST resort).

Long story short: just because someone flexes their spine – and may or may not have a disc herniation – doesn’t mean their spine is going to explode.

And least we forget the Godfather of spinal mechanics and research Dr. Stuart McGill. The man has forgotten more about the spine than any of us could ever hope to remember. I’d be lying if I said his two books – Low Back Disorders and Ultimate Back Fitness and Performance – haven’t shaped most of my thinking and approach when working with clients and athletes with low back pain.

Who the hell am I to disagree with him?!?!

That would be like me starring Yoda in the face and saying something like, “Pffft, whatever dude. Force schmorce. What do you know??”

With that commentary in mind, as a fitness professional, most of the time (but not always), I’m not going to go out of my way to include more exercises or drills that place people into spinal flexion.

Particularly with the aforementioned “people who already sit a lot and live in flexion” scenario from above.

Taking it a step further (and to help appease those people who are probably hyperventilating into a brown paper bag reading this, assuming I’m saying spinal flexion is okay):

I typically avoid the following:

1. End-range lumbar flexion

2. Lumbar flexion exercises for those who are “stuck” in flexion.

3. LOADED spinal flexion

But Just to Play Devil’s Advocate For a Second

With point #3 – loaded flexion – there are some people out there who purposely train with a rounded spine and do very well.

Lets use the deadlift as a quick example.

We could make the argument – from a bio-mechanical standpoint – that a rounded back deadlift is efficacious because it’ll allow you lift more weight.

As Greg Nuckols explains in THIS amazing article:

“Rounding your back a bit shortens the length of the torso in the sagittal plane.  In non-nerd speak, it lets you keep your hips closer to the bar front-to-back so they don’t have to work as hard to lift the same amount of weight.”

Fancy chart making skills courtesy of Greg Nuckols

The picture on the right depicts a “neutral spine.” Taking natural kyphotic/lordotic curves into account, on the right, “neutral” equates to a spine that’s 15.3 inches “long” front to back.

On the left, with some significant rounding – albeit in the THORACIC spine (more on this point in a bit) – the the length of the spine is reduced to 11.7 inches. I.e., the hips are closer to the bar.

This in mind, if you watch elite level powerlifters you’ll notice that many of them do seem to “round” their back on max effort pulls.

But lets put things into context

A). It’s important to understand that for most, the rounding is happening in the t-spine and NOT the lumbar spine. The T-spine has more “wiggle room” in terms of end-range flexion compared to the lumbar spine.

B) They’re NOT rounding their lumbar spine.

C) Pulling 600+ lbs is heavy as f***. You try pulling that much without some rounding.

D) Guys (and girls) who are strong enough to be pulling 3-4x bodyweight have assuredly trained themselves to stay out of those last 2-3 degrees of end-range flexion. Moreover, they’ve also been in compromising positions enough that they’re able to stay out of the danger zone.

E) More importantly, you’re (probably) not an elite lifter, so I wouldn’t suggest you start training with a rounded back.

In the end, we could make the case for loaded spinal flexion. Just like we could make the case for Lisa and I being introduced as husband and wife for the first time with Juvenile’s Back That Ass Up playing in the background:

 

Neither are a good idea. Except for the second one.

When Is Spinal Flexion Okay?

Let me repeat, I generally avoid:

1. End-range lumbar flexion

2. Lumbar flexion exercises for those who are “stuck” in flexion.

3. Loaded spinal flexion

I BOLDED #2 because, well, I work with a lot of athletes and people who are the opposite. They live in extension and excessive anterior pelvic tilt, which can be just as deleterious for the spine as flexion.

I BOLDED “excessive” because I want to make it clear that anterior pelvic tilt is not a bad thing (it’s normal). And because some people are morons, will miss the bolded EXCESSIVE, and will still send me a note via email or social media saying how dumb I am for saying APT is bad for the spine.

People on this side of the fence face a whole host of other scenarios like Spondylolysis (referred to as an end plate fracture, most often on the pars interarticularis), Spondylolisthesis (forward disc slippage), femoral acetabular impingement, and what I like to call fake badonkadonk-itis.

In other words: some people don’t have a big butt, they’re just rockin some serious APT.

Cough, cough Jen Selter cough, cough

Kidding aside, extension-based back pain or extension-based issues are no laughing matter, and it’s in scenarios like these where spinal flexion is warranted (and encouraged).

This is where were start to dive into the PRI (Postural Restoration Institute) philosophy and discuss breathing and how it affects pretty much everything.

Many of the (breathing) drills we use at Cressey Sports Performance place people (people who are overly extended) into spinal flexion, which is a good thing.

Watch this video below and you’ll get a sense of what I’m referring to.

Lets take the regular ol’ boring prone plank/bridge.

Learning to perform this exercise correctly (getting to and maintaining neutral spine) is a game changer for anyone experiencing low-back pain regardless of whether it’s a flexion issue or extension.

However, I rarely ever see anyone perform this exercise right. Most people start in a okay position for about five seconds, but then quickly “fall into” an excessively extended posture where their head protracts towards the floor and/or their entire spine sags, essentially doing nothing but hanging onto their passive restraints and hip flexors.

The “core” isn’t doing anything.

It kind of looks like this.

Not coincidentally these are the same people who brag about being able to perform a plank for [insert pointless amount of time here].

When done correctly – I prefer an RKC style plank: feet together, palms flat, elbows being pulled towards toes (to increase tension), and fire everything (glutes, abs, quads, nostrils, everything) – the amount of time someone can perform it is drastically different.

20 seconds and you should be hating life.

You may also notice that I’m rounding my (upper) back above. This is on purpose and goes against conventional wisdom.

Here’s the deal.

I like to start people in a bit of flexion – especially those who are overly extended – because as fatigue kicks in they’ll end up in neutral (rather than past it).

And I’m done.

CategoriesCorrective Exercise Program Design

Critical Eye for Program Design

Every Wednesday we hold a staff in-service at Cressey Sports Performance where the coaching staff along with the interns get together and talk about “stuff.”

One week Eric may break down thoracic outlet syndrome and how to go about programming around it.  Another week Greg may discuss some new sprinting drills and how we can better cue our athletes with their movement training.

Chris may take a week and touch on some elbow or shoulder anatomy.  I’ll take the reigns one week and speak to the differences between external vs. internal cueing (or just reenact a full blown assessment using nothing but shadow puppets).

And Andrew will jump in on some weeks and discuss youth training or how it is he’s able to maintain salon-quality hair at all times.

It’s fascinating.

As you can see, we hit on any number of topics and nothing is ever off the table. We even had one of our current interns discuss the merits of blood-restriction training recently and how if may have some merit with regards to training injured athletes.  The idea being that the increased hypoxia will help engage or stimulate type II muscle fibers in the absence of appreciable load.

I’m a bit skeptical, but he made some interesting points!

Nevertheless the idea behind the in-services is to promote an open platform for learning and for open dialogue and discourse.

Yesterday happened to be what we like to call the Intern Programming Challenge. The idea is simple:  We give the interns several specific scenarios with regards to injury history and musculoskeletal dysfunction of an athlete/client, and they’re expected to write a 2-day/week program for each one.

An example might be:

1. Severely sprained right ankle with secondary external impingement in left shoulder.

OR

2. Extension based back pain.

OR

3.  Grade II hamstring strain with no left eye due to a pirating accident and an explosive case of diarrhea.

We all gather together and dissect each person’s program(s). Admittedly it can be an intimidating environment because no one ever likes seeing their work held under a microscope for public scrutiny. But as Eric noted yesterday, sometimes the best way to get better is to have your stuff ripped apart.

Not that we’re purposely ripping programs apart to make our interns feel bad. Rather, we’re using this as an opportunity to refine their programming skills and to think more objectively and “outside the box.”

Take secondary external impingement for example.  The word impingement is a garbage term as it is, because it speaks nothing to what’s actually causing the impingement (or pain) in the first place.

In watered down terms all “secondary impingement” means is that we know it’s not caused from a bony growth or deformation like a bone spur (this would be referred to as primary impingement, where the boney growth affects the acromion space and makes it narrower).

Instead we can chalk secondary impingement towards things like poor t-spine mobility, anteriorly tilted scapulae (poor scapular stability), poor tissue quality in the pec, pec minor, and/or lats, downwardly rotated scapulae or “depressed” shoulders, so on and so forth.

Conventional wisdom may dictate that the prone plank is an innocuous enough of an exercise where it would be a nice fit for most people, even in this example.

Mmmmm, maybe.  Maybe not. It depends.

The plank position will cause a lot more approximation in the shoulder joint (jamming the humeral head into the shoulder socket itself) which may be problematic for someone with external impingement.

It’s this kind of critical thinking – and the type of feedback we give back to our interns – which helps them become better and programming.

Lets dive into another common scenario……

Extension Based Back Pain

While flexion tends to get all the attention and love, extension-based back pain is something that’s grown in prevalence in recent years – especially in more athletic populations which involve a lot of extension and rotation.  Think:  baseball, golf, etc.

Too, extension-based back pain is very common in the more “meatheaded” population in addition to the personal training and coaching fields (where we tend to stand on our feet all day).

I’m not going to re-invent the wheel and elaborate on the specifics since I already wrote on this topic extensively HERE.

Needless to say, since we’re on the topic of programming I wanted to highlight some ways and ideas we could work around the issue when working with a client or athlete who exhibits this condition.

 

Seriously, read my post HERE if you’re curious how to assess for extension-based back pain as well as some thoughts on how to address it (rib cage position, how to cue certain lifts differently, and how to address proper breathing mechanics).

Do it!!!!!!

The most severe cases will typically manifest as Spondylolysis.  “Spondy” refers to a fracture of the pars interarticularis portion of a vertebra (95% of the time, it’s L5). The pars essentially connects the vertebral body in front with the vertebral joints behind.

Presence of spondylolysis runs the gauntlet in terms of who it effects, but its highest prevalence is among weightlifters. That said we’ve seen a huge influx amongst young athletes as well, especially those who participate (and specialize too early) in sports that require excessive extension and rotation (ie:  baseball).

I wrote a post on Spondy HERE if you’re interested.

1.  First and foremost the name of the game when dealing with ANY injury is to ensure you’re eliciting a training effect.

No one wants to feel like a patient when they’re training.  I mean, what fun is it to head to the gym only to perform a litany of ankle mobility and breathing drills?

Booooooorrrrrrrrriiiiiiinnnnnnggggggg.

This isn’t to say that those things won’t need to be addressed, but it’s important to understand that your job as a trainer or coach is to garner a training effect for your clients.

2. Whenever we have an client or athlete with a legit case of Spondy start at the facility our general rule of thumb is no back squatting for TWO YEARS – and that’s even if they’ve gone through an entire “treatment” with a back brace.

Placing a bar on the back means you’re moving it further away from the axis of rotation which increases shear forces on the spine ten-fold.

In this case things like Goblet Squats may be a better fit.  But even then, you may need to hold off for a few months before you implement them into a program.

3.  Single-leg work will almost always enter the equation, but you need to be very cognizant of back positioning.

If someone lives in extension and has extension-based back pain, they’re going to want to go into extension.  I  know, it’s confusing.

It’s important to engrain proper rib positioning, core bracing, and pelvic positioning when doing any single leg work.

4.  To that end, variations like slideboard reverse lunges are an awesome fit because they inherently make people use less weight, which in turn will result in less axial loading on the spine.

But even if we’re not dealing with a severe case like Spondy, it’s crucial to stress “neutral spine” throughout.

Start with dumbbells and progress to barbell variations.

5.  Glute bridging is fantastic provided the back stays in a posteriorly tilted (flatter) position throughout the entire set.

6.  Anything which promotes posterior pelvic tilt with someone with extension-based back pain is going to be money.

To that end, ensuring they’re squeezing their glutes during things like chops and lifts will be paramount.

I’ve often incorporated Posterior Pelvic Tilt Hip Thrusts (via Bret Contreras) into the mix:

I’ll be your BFF for life if you do these in a public park or something. I dare you to perform them in the waiting area at your doctor’s office!!!!

That’s just some food for thought. It’s important to embrace a more critical mindset when writing programs – especially when writing them for people with specific issues or dysfunction(s).

Hope that helps.

Now excuse me as I go practice my shadow puppets…..;o)