CategoriesAssessment Corrective Exercise Program Design Rehab/Prehab

The Forgotten, Often Overlooked Cause of Low Back Pain

There are many root causes of low back pain and discomfort, and there are many people who’s day to day lives are affected by it.

In my neck of the woods – Strength & Conditioning – the culprit(s) can often be displayed on the weight room floor. Lifters who routinely default into movement patterns that place them in (end-range) LOADED spinal flexion or extension are often playing with fire when it comes to their low back health and performance.

NOTE: this isn’t to say that repeated flexion/extension is always the root cause.

1) There’s a stark contrast between flexion/extension and LOADED flexion/extension. Many people have been programmed to think that all flexion/extension of the spine is bad. It’s not. The spine is meant to move, albeit under the assumption that one can do so without significant compensation patterns (relative stiffness), limitations in mobility, and with appropriate use of both passive (ligaments, labrums, and tendons, oh my) and active (muscles) restraints.

It’s when people start placing the spine under load in ranges of motion they can’t control – often in the name of social media glory – that bad things end up happening. 

2) However, there are plenty of examples of lifters (mostly elite level, which is an important point) who have been utilizing techniques many fitness pros would deem incendiary with regards to the increased likelihood of spines all over the world resembling a game of Jenga.

A great example is a piece Greg Nuckols wrote HERE, explaining the benefits – biomechanically speaking – of a rounded back deadlift.

But back pain – specifically low back pain – can strike at any moment. I’ve heard stories of people hurting their back during training of course. But I have also, and I think many of you reading will nod your head in agreement, have heard stories of people messing up their back while bending over to pick up a pencil or to tie their shoes.

Or while fighting a pack of ninjas (hey, it can happen).

In pretty much all cases it comes down to one of two scenarios going down:

1. Ninjas attack.A one-time blunt trauma. Think: spine buckling under load, car accident, falling off a ladder.

2. A repetitive aberrant motor pattern. Think: tissue creep into sustained spinal flexion for hours on end at work.

Dr. Stuart McGill and his extensive research on spinal biomechanics has been the “go to” resource for many people – including myself – to help guide the assessment process and to attempt to figure out the root cause of most people’s low back pain.

A term he uses often is “Spinal Hygiene.”

It behooves us as health and fitness professionals to use the assessment as a window or opportunity to “audit” our client’s and athlete’s movement and to see what exacerbates their low back pain.

From McGill’s book Back Mechanic:

“Our approach in identifying the cause of pain during an assessment is to intentionally provoke it. Provocative pain testing is essential and irreplaceable when it comes to determining which postures, motions, and loads trigger and amplify pain and which ones offer pain-free movement alternatives.”

People who have more pain and discomfort in flexion (slouching, sitting, bending over to tie shoes) are often deemed as flexion intolerant. Moreover, people who have more pain and discomfort in extension (standing for long periods of time, bending backwards, excessive “arching” in training), are often deemed as extension intolerant.

Ironically, in both scenarios, people will find relief in the same postures that are “feeding” the dysfunction and their symptoms.

What’s the Fix?

Funnily enough, pretty much everything works. There are any number of methodologies and protocols in the physical therapy world that have worked and have helped get people out of low back pain.

It’s almost as if the appropriate response to “how do you fix low back pain?” is “the shit if I know? Everything has been shown to work at some point or another.”

Active Release Therapy, Graston, positional breathing, stretching, mobility work, rest, sticking needles in whereeverthefuck….it’s all been shown to work.

I’ve had numerous conversations with manual therapists on the topic and the ones who tend to “get it” and elicit the best results are the ones who take a more diverse or eclectic approach.

They’ll use a variety of modalities to best fit the needs of the individual.

That said, I’m a fan of directing people towards therapists who take a more “active” approach as opposed to a “passive” approach.

Both can work and both have a time and place. However one approach is less apt to make me want to toss my face into an ax.

Passive Approach = Ultra sound, electric stimulation, etc. This approach treats the symptoms, focuses on instant relief, and not necessarily addresses the root cause(s).

Active Approach = Is more hands on and more “stuff” is happening. Practitioners who fall on this side of the fence tend to focus more on the root cause – poor movement quality, positioning, muscle weakness, mobility restrictions – and work in concert with the patient/athlete to educate them on how to prevent future setbacks.

Above all, an active approach is about finding and engraining a neutral spinal position, and finding pain-free movement.

I think by now you know my preference.

 

Tony, Shut-Up, What’s the “Forgotten” Cause of Low Back Pain?

Well, to say it’s “forgotten” is a bit sensationalistic. My bad.

We tend to solely focus on either flexion or extension intolerance…and granted those are the two biggies.

However, have you ever had someone come in and pass those “screens” with flying colors only to complain of back pain or discomfort when he or she rolls over in bed, rotates, or maybe experiences an ouchie when they sneeze?

What’s up with that? And bless you.

Spinal Instability – That’s What’s Up.

Instability can rear it’s ugly head with flexion/extension based issues too, but it becomes more prevalent when rotation is added to the mix.

The body doesn’t operate in one plane of motion, and it’s when people meander out of the sagittal plane and venture into frontal and/or transverse plane movements, when they begin to get into trouble.1

The muscles that provide intersegmental stability to the spine may be under-active and may need some extra TLC.

I’ve worked with people who could crush a set of barbell squats (they handle compression and shear loading well), but would complain of l0w-back pain whenever they did anything that required rotation.

 

The fix is still going to be helping them find and maintain spinal neutral – I don’t feel this is ever not going to be a thing. Kind of like too much money in politics or LOLcats.

In addition, gaining motion from the right areas – hips, t-spine, for example – will also bode well.

However, I’d like to offer some insight on what exercises might be part of the repertoire in terms of “pain free movement” when spine instability is a factor.2

The Stuff Most People Will Skip (It’s Okay, I Won’t Judge You)

One word: planks.

Dr. McGill has stressed time and time again that improving spinal endurance (and hence, stability) is paramount when dealing with back pain. They key, though, is performing them in ideal positions.

I chuckle whenever someone brags about holding a 5-minute plank. When in fact all they’re really doing is hanging onto their spine….literally.

This does no one any favors.3

RKC Plank.

1. It’s a bonafide way to help people gain a better understanding and appreciation for creating full-body tension.

2. I like cueing people to start in a little more (unloaded) flexion, so that by the end they’re residing  in a neutral position anyways.

3. When performed as described in the video below, 10s will make you hate life.

To up the ante you can also incorporate 3-Point Planks (where you take away a base of support, either an arm or a leg, and hold for time) or Prone Plank Arm Marches:

 

NOTE TO SELF: do more of these.4

You can also incorporate Wall (Plank) Transitions where the objective is to cue people to keep the torso locked in place. Motion shouldn’t come from the lumbar spine then mid-back. Everything should move simultaneously, as follows:

Deadbugs

I’m a huge fan of deadbugs. When performed RIGHT, they’re an amazing exercise that will undoubtedly help build core and spine strength/stability.

A key component to the effectiveness of a deadbug is the FULL-EXHALE (check out link above). However, one variation I’ve been using lately is the Wall Press Deadbug (for higher reps).

https://www.youtube.com/watch?v=gmtsGHk34C0

 

Here the objective is to engage anterior core (pressing into the wall), to breath normally, and then to perform a high(er) rep set (10-15/leg) making sure motion comes from the hips and NOT the lower back.

If you want to build stability (and endurance) this is a doozy.

Stuff People Are More Likely To Do (Because It Involves Lifting Things)

1. Offset Loaded Lifts

This is an untapped, often overlooked component to back health and performance. Offset or asymmetrical loaded exercises are a fantastic way to train spinal stability and challenge the core musculature.

By holding a dumbbell on one side, for example, you have work that much harder to maintain an upright posture and resist rotary force:

 

Likewise, with offset presses, the core must fire to prevent you from falling off the bench. Unless you fall off because you’re drunk. If that’s the case, go home.

 

And we don’t have to limit ourselves to dumbbells, either. We can use barbells too.

2. Shovel Deadlift

3. Farmer Carries

Farmer carries – especially 1-arm variations – can be seen in the same light. The offset nature is a wonderful way to challenge the body to resist rotation (rotary force) and to help build more spinal stability.

 

4. 1-Legged Anti-Rotation Scoop Toss

Another option is to perform anti-rotation drills such as the 1-Legged Anti-Rotation Scoop Toss. As you can see from my un-edited video below….it’s tougher than it sounds.

 

5. Anti-Rotation Press

 

A bit higher on the advanced exercise ladder, the Anti-Rotation Press is another great drill to help hone in on increased core strength and spinal stability. To make it easier, use a longer stride stance; to make it harder go narrower.

This Is Not an End-All-Be-All List

But a good conversation stimulator for many people dealing with low-back pain nonetheless. Have you got own ideas or approaches to share? Please chime in below or on Facebook!

CategoriesAssessment coaching Corrective Exercise Program Design

A Thoughtful Discussion on Low Back Sparing Strategies. Actually, Less “Thoughtful” More “Meandering”

I often joke that “lifting weights isn’t supposed to tickle.”

When you’re pushing, pulling, carrying, thrusting, and otherwise hoisting things around for the heck of it…you’re bound to end up with a few bumps and bruises along the way.1

Honestly, I can’t think of the last time my body was 100% devoid of any type of soreness or semi-nefarious “huh, well that doesn’t feel fantastic” sort of vibe.

I’m not referring to pain. Nothing that diminishes my ability to live my day-to-day life. Just, you know, sometimes my first step out of bed or sitting down to drop it like it’s hot isn’t the most enjoyable experience in the world.2

(Anyone who’s performed heavy squats the day prior can commiserate).

A lifetime of playing sports and training will do that to a body.

But that’s the point.

Lifting weights and pushing the body outside it’s comfort zone is what allows us to adapt and come back stronger and more resilient; to take on the world (or the squat rack) and tell it to GFY.

All that said: it still sucks donkey balls when the inevitable happens. We take things too far, go too heavy, or move juuuuust the right way for something wrong to happen.

Arguably, nothing stagnates or deflates progress more in the gym than a jacked up lower back.

Statistics will say that we’ve all been there. Or, alternatively, as fitness professionals, have worked with someone who’s been there.

So I figured today I’d shoot from the hip and fire back some quick-hitting suggestions/insights/alternatives to consider when working with someone dealing with low-back pain.

In No Particular Order

1) Except for this one. This is super important.

I’ll kick things off with the grandiose, off-kilter statement that if something hurts…don’t do it.

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

 

Fucking profound, right?

Dr. Stuart McGill will advocate for provocative tests/screens to be performed – slump test, toe touch, McKenzie drills, etc – in order to figure out the root cause or possible source of someone’s back pain.

The stark contrast should be done outside of that window. It’s imperative as a coach, trainer, clinician, wizard, to demonstrate pain-free movement to the client/athlete. The objective should be to mute or pump the brakes on pain and start to mold more of a “movement quality” campaign.

Dr. McGill often refers to this as “spinal hygiene.”

2) Speaking of Dr. McGill

You should read his book Ultimate Back Fitness Performance. Specifically pages 1-325.

Spoiler Alert: it’s 325 pages long.

A more “user-friendly” text would be his latest book, Back Mechanic.

3) Back to “spinal hygiene.”

The good Doc refers to this as:

“The daily upkeep of your back. It includes your recovery exercise routine as well as changes to your existing daily motions all day long. Success in removing back pain requires removal of the movement flaws that cause tissue stress.”

This could refer to something as simple and innocuous as teaching someone how to sit in a chair properly, or even how to stand up from a chair.

As counterintuitive as it seems, those who have more flexion-based back pain will feel more comfortable in flexion. Likewise, those with extension-based back pain will feel at home in extension.

It’s weird.

So, often, taking the time to clean up activities and endeavors outside of the gym will be of most benefit.

As the saying goes: “we as trainers/coaches have 1-2 hours to “fix” things, and the client/athlete has 23 hours to mess it up.”

Other things to consider:

  • Walking. This is an excellent fit for those with low-back pain. It’s just important to make sure they’re not defaulting in forward head posture and a slouched posture. McGill refers to this as the “mall strolling” pattern. One should be more upright and swing the arms from the shoulders (and not the elbows). This provokes more of a “pertubation” to the body helping to build spinal stability.
  • Grooving more remedial hip-hinge patterns like I discussed in THIS article. Getting someone to dissociate hip movement from lumbar movement is a game-changer..
  • Pigging back on the above, the hip hinge creeps its way into EVERYDAY things like brushing one’s teeth or bending over to pick something up off the ground (golfer’s lift). Anything that can be done to spare the spine (discs) and make it less sensitive to pain is a win – no matter how trivial the activity.

4) Synchronous Movement

Learning to “lock” the ribcage to the pelvis is another key element to managing back pain. The abdominal brace is of relevance here. Basically the entire core musculature – not just any one muscle (ahem, transverse abdominus (drawing in method) – needs to work in concert and fire synchronously to spare the spine and offer more spinal stability.

One drill in particular that hammers the point home is the Wall Plank Rotation.

 

Here an abdominal brace is adopted and the objective is to “rotate” the entire body as one unit, locking the ribcage to the pelvis. Many will inevitably rotate through their lumbar spine and then the upper torso will follow suite.

5) Neutral Spine – Always (But Not Really)

The spine IS meant to move.

Neutral spine is paramount, but it benefits trainees to tinker with end-ranges of motions (in both flexion and extension) if for nothing else to “teach” the body to know how to get out of those compromising positions – especially when under load.

During our workshops together, Dean Somerset will often demonstrate to the trainees how squatting into deeper hip flexion (unloaded, and to the point where butt wink happens) can be of benefit to some people. The notion of learning where a precarious position is (and how to get out of it) is valuable.

I’ll use the simple Cat-Camel drill to teach people that it’s okay to allow the spine move.

 

Also of Note: I’d argue we’ve been so programmed into thinking that all spinal flexion is bad and that a baby seal dies every time we do it, that it’s caused a phenomenon referred to as reverse posturing.

The idea that more and more people are now “stuck” in extension, and thus at the mercy of a whole spectrum of other back issues (spondy, etc).

You can read more about that HERE.

Suffice it to say: we can’t discount Rule #1…helping to build improved spinal endurance/stability.

Plain ol’ vanilla planks come into the picture here.

This:

Not This:

This:

  • Keeping people honest and accountable on proper position (not “hanging” on passive restraints and dipping into excessive lumbar extension) is kinda of important.
  • Rule of thumb is to be able to hold a prone plank 120s, side plank (per side) for 90s. McGill will note it’s a RED FLAG if there’s a huge discrepancy between right/left sides.
  • I prefer more of an RKC style once someone is ready. This helps to build more bodily tension, to the point where everything – quads, abs, glutes, eye lids, everything – are firing. Ten seconds is torture when done right.

However, we can always graduate to less vomit in my mouthish exercises. As much as planks are baller and part of the equation to helping solve someone’s back pain, they’re about as exciting as watching a NASCAR race.

6) A few favs include:

Elbow Touches

https://www.youtube.com/watch?v=AUgz2U65KPc

 

Progressing lower and lower towards the ground.

Farmer Carries – all of them

 

Offset Loaded Exercises

 

I love offset loaded exercises for a variety of reasons. But most germane to this conversation is the fact that there’s a heavy rotary stability component when performing them.

Getting people moving and performing more traditional strength & conditioning drills – assuming they’re pain free and of high movement quality – will help to get them out of “patient mode,” and more excited to stick to the plan.

7) A Few Other Ideas to Consider

Don’t be an a-hole and marry yourself to the idea that everyone HAS to deadlift from the floor and that everyone HAS to pull conventionally.

The only thing people HAVE to do is sign up for my newsletter. (wink, wink, nudge, nudge)

Sometimes we have to set our egos aside and do what’s best for the client/athlete and what’s the best fit for them. I think the trap bar deadlift is a wonderful tool for people with a history of low back pain.

To steal a quote from Dr. John Rusin:

“Without sending you back to Physics 101, the forward position of the barbell causes a less than optimal moment arm to stabilize the core position in neutral while moving some serious loads off the floor.

During the traditional deadlift, the center of mass (barbell) falls in front of your body, therefore causing the axis of rotation of the movement to be farther away from the load itself.  This all translates into increased shearing forces at the joints of the lumbar spine, putting all the structures, including intervertebral discs and ligaments at increased risk of injury with faulty mechanics of movement.”

The trap bar deadlift results in a better torso position for most people and less shear load in the spine. For anyone with a history of low back pain this is a no-brainer.

Use an incline bench rather than a flat bench when programming pressing movements. It’s just an easier scenario for most people and less “wonky” of a position to get in and out of.

Too, program more standing exercise variations – standing 1-arm cable rows, pull-throughs, landmine presses, Sparta kicks to the chest.

CategoriesUncategorized

Shatterproof Your Spine

In an industry that’s inundated with movers and shakers promoting their watered down products, it’s always refreshing to have the opportunity to promote something I feel will help a lot of people. Back in 2009 (maybe it was 2010), fellow colleague John Izzo asked if I’d be willing to watch his DVD, Shatterproof Spine.

As the name suggests, it covers the spine (more specifically, lower back pain) and highlights a workshop that John did with a number of trainers at the facility he used to manage back in the day.

Note:  he now OWNS his own facility.

What I liked best was that John mixed the perfect formula of science/research and combined it with the perfect blend of practical knowledge into an easy to follow, easy to assimilate format.  Truth be told, he left no stone unturned covering topics such as assessment, corrective exercise for for low back health, proper posture positioning, understanding the role of fatigue as it relates to core strengthening, and much much more.

All told, I loved it, and it’s consistently one of the more popular DVDs that’s “borrowed” out of our Cressey Performance Resource Library.

Thing is, you can’t purchase the DVD anymore – it’s sold out (which should tell you something).  As such, John has decided to re-release Shatterproof Spine as an instant download, so you can watch it anywhere at any time.

Reciprocally, while the product alone is outstanding, John has “sweetened” the pot by also including a couple of  incentives:

5 Practical Drills to Identify Low Back Pain Sufferers – The book is complete with some applicable drills that John uses with his general population clients to help better understand which direction to take his programming, and also serves as a nice adjunct to his screening process.

Eye of the Trainer – Video download along the same lines of using certain exercises as observational assessments and helping trainers plan accordingly with their exercise programs.

Combined, this is a fantastic resource for any personal trainer out there looking to take his or her craft to the next level, and separate themselves from the masses.

To that end, I wanted to share an interview I did with John highlighting the release of Shatterproof Spine. In an industry that is notorious for less than exemplary practices, John is one of the rare few who “gets it,” and is recognized as one of the leaders in personal training standards.

Enjoy!

TG: John, lets get the particulars out of the way.  For those who may not be familiar with you or your work, can you give my readers the Cliff Notes version?  Where are you located? What’s your background? What’s the main demographic that you work with?  Do you like walks on the beach?

John Izzo:  Thanks for having me Tony. Here is the gist of Izzo…I am a personal trainer located in Manchester, CT about 15 minutes away from Hartford. Years ago, I thought I wanted to be a strength coach….so I focused my attention on young athletes in a commerical gym setting. Didn’t work out. Being inside a commerical gym, every kid that called himself an “Athlete” wanted to train like a bodybuilder.

Sooner than later, I was getting more and more general population clients walking up to me looking for directions to their goals: better health, losing fat, and getting stronger. They were seeing what I was doing with many of the younger guys and thought that I can help them out. Well….I was able to and soon over  90% of my clientele were “normal” Joe’s and Jane’s looking for better function. Training younger athletes started to dwindle down and I turned my attention to helping people improve everyday performance. This was back around 2002. Around 2007, I came to the realization that I was a personal trainer–not a strength coach

Through the years, I found myself in management running the day to day operations; outfitting facilities, and balancing budgets. Thinking I can turn my back on personal training and make more money in management, I found out that I was wrong. Managing others is a bitch. You try to get everyone on  the same page–same thought process as yours–but its never easy. As a gym manger, you are listening to people bitch and moan about changing channels on the TVs; music volume, someones hygiene on the treadmill, or trainers having sex outside. (Yes, that is a true story and guess who was the one that had to knock on the car window?)

TG:  Ohhhhhhhhhhhhhhhhhhhhhh snap. BOM CHICKA BOM BOM.  Okay, sorry.  You were saying……

JI: Anyways….my love to train others soon won. I returned back to full-time training in 2008. I opened my own facility in 2010 and it is mainly a one-on-one private training studio. I do teach group strength classes, but my love shines in one on one. That is where I feel I am a coach.

TG: Even though you and I have never met, we’ve exchanged several emails throughout the years, and I’m always amazed at just how “real” you are, never hesitating to call BS on anyone or anything. This is your chance to sound off.  You and I both know that the fitness industry can be a circus – at best.  What are some of the things, as of late, that really get your goat?

JI:  Oh boy…are trying to get me in trouble…? The truth is, its not that I enjoy calling BS on anyone, I just feel that any good, honest adult should. I truly have a love for what I do, what you do, and what many fit pro’s do. I feel sometimes the industry is tainted with people that don’t belong here.  I ‘ll put it to you this way…I know you are a big movie buff. Remember that scene in “Behind Enemy Lines” with Owen Wilson? That is one of my Top 10 best movies, BTW.

Anyway, remember the scene when the evil admiral was dead-against the US Marines going in to save Owen Wilson? Remember when the Marine captain was going over the Intel with his team on the deck and then the admiral showed up with some “French troops”? The admiral stated that the French troops “would be going in for the extraction”. Those guys didn’t belong there! Those guys had ZERO attachment to our guy down behind enemy lines! They didn’t care about our man. They were not going to give 110% effort, because there was no passion for Owen Wilson!

Well, that’s how I feel about alot of the guys that turn personal trainers’ attention away from serving the client and make them focus on making money. They don’t belong in our industry. They know what they are doing. They are feeding on a fear or scarcity that young, under-developed trainers have. And to me, they continue to hurt the industry—not help it.

TG: Okay, lets talk Shatterproof Spine. What was the impetus behind making this product?

JI: Around 2008, I was working with alot of golfers (still do). Alot of these guys were working at the investment firms, private business, or playing bridge all day and then wanted to hit the course. Well, many of them were having major back pain and it was affecting their swing.

If you can’t swing, you can’t play golf. If you suck at golf, no one is going to ask you to meet them for 8:30am tee off.

So, I went to work researching Dr. Stuart McGill and Shirley Sahrmann’s books. The info I found was fascinating and once I put it to practice with my golfers, they began to tell me how their backs felt better. As a trainer, you have to realize that everyone knows someone that has some sort of low back pain. Some people hide it, some people disregard it, and some people take medicine or have surgery for it.

The job of the trainer is to help people alleviate the symptoms of low back pain and restore optimal function. When it came time for me to teach a workshop for new trainers, I put together a slide-show that would encompass everything I had learned from the authors, along with my own findings–including videos with my golfers. The participants in the workshop were amazed at how much help they can provide (as trainers) to their clients simply by designing exercise programs more carefully and utilizing the drills in the video.

TG: On that front,  what do you feel are the biggest mistakes trainers and coaches make with regards to working with clients who suffer from acute or chronic lower back pain?

JI: Mistake #1: Trainers ignore client’s complaints of low back pain. Personal trainers tend to ignore the small, subtle comments people make about low back pain and continue on with a strength training program. Or they tend to think a plank will fix everything. These trainers need to research more about mechanical low back pain and possibly learn the benefits of massage therapy, ART, and corrective exercise.

Mistake #2: Trainers shy away from giving clients challenging workouts because of low back issues. It is a double edged sword. New trainers–especially–tend to give clients very subtle, boring isometric exercises or tubing exercise that really make a client want to gag and leave

 

Truth is, most people that suffer from low back pain are probably overweight, sedentary, and lack adequate core strength. Trainers tend to be “too careful” because they don’t know how to approach and design an exercise program that can include drills to strengthen the core and relieve low back tightness, improve hip mobility, and add flexibility. Hence, they do nothing and the client gets nothing.

TG:  Great points on both fronts John.  Elevator Pitch:  who will benefit most from this product?

JI: Shatterproof Spine, Eye of the Trainer, and 5 Practical Drills eBook are really designed with the personal trainer or strength coach in mind. That’s not to say that your average exerciser can’t benefit from the drills demonstrated in the hands-on portion of the workshop.

TG:  Thanks John.  For those interested in more information on John (and his products), visit his site HERE. In addition, for those interested in Shatterproof Spine, what are you waiting for GO!!!

—-> Shatterproof Spine <—-