CategoriesAssessment Corrective Exercise Exercise Technique Rehab/Prehab Strength Training

Everything and Nothing Causes Low Back Pain

The topic of low back pain (LBP) – how to assess it, diagnose it, and how to treat it – can be a controversial one. I italicized the word “can” because I don’t feel it’s all that controversial.

Cauliflower as an option for pizza crust or Zach being chosen as the bachelor on the current season of The Bachelor (when it’s 100% clear that a ham sandwich has more charisma) = controversial.

Simple stuff to consider to help with one’s LBP = not so much.

Copyright: olegdudko / 123RF Stock Photo
Copyright: olegdudko / 123RF Stock Photo

Everything and Nothing Causes Low Back Pain

The topic of low back pain and how to address it is controversial because there’s no one clear approach or answer to solve it.

(And if the last 3+ years of this pandemic dumpster fire has taught us anything it’s that we looooooove to argue over what’s best and what works).

SPOILER ALERT: Everything and nothing causes LBP.

Have ten different doctors or physical therapists work with the same patient and it’s likely you’ll get ten different opinions as to what the root cause is and what tactics need to be implemented to resolve it.

One person says it’s due to delayed firing of the Transverse Abdominus (TA), while someone else states it’s due to someone’s less than great posture or tight hamstrings.

For the record, all are weak excuses at best.

The culprit can rarely be attributed to any ONE thing.

But it’s amazing how often “tight hamstrings” is the fall guy.

  • Low back pain? Tight hamstrings.
  • Knee hurts? Tight hamstrings.
  • Have Type II Diabetes? Tight hamstrings.
  • Brown patches on your front lawn? Hamstrings.

It’s uncanny.

I mean, I could just as easily sit here and say in worse case scenarios LBP results from drinking too much coffee. I have zero evidence to back that up, but whatever.

top view of ground coffee in portafilter on coffee beans background

…neither do most of the other “culprits” people tend to use as scapegoats.

So, why not coffee?

Or Care Bears for that matter, those sadistic fucks.

What works for one person, may exacerbate symptoms for someone else. And as my good friend, Dr. John Rusin notes:

“Fact of the matter is: there is NO one right way. it’s a big mistake to lump all LBP into the same category and even a bigger mistake to assume all of it presents the same or should be treated the same.”

There’s no way for me to write a thorough blog post on such a loaded topic; especially one that will make everyone happy.

It’s impossible.

I have better odds at surviving a cage match with an Uruk-hai.

Part of me feels like the proper response to the question “what causes low back pain and what’s the best way to address it?” is this:

via GIPHY

But that would be woefully uncouth of me.1

Most people reading aren’t clinicians or physical therapists. There’s very little (if any) diagnosing going on in the hands of a personal trainer or strength coach. And, truth be told, if you are a personal trainer or strength coach and you are diagnosing, YOU……NEED…….TO…….STOP.

Just stop.

It’s imperative to defer to your network of more qualified (and vetted) fitness/health professionals whom you trust to do that.

However, it’s important to also consider we (as in personal trainers and strength coaches) are often the “first line of entry” into the medical model. We’re the first to recognize faulty movement patterns, weakness, imbalances, and bear the brunt of questioning from our clients and athletes when they come to us with low back pain.

There’s quite a bit we can do to help people.

What follows is a brief look into my mind and what has worked for me in the past with regards to LBP; a Cliff Notes “big rock” brain dump if you will.

Sorry if I offended anyone who likes Care Bears.

1) Rest Is Lame

Pretty blonde relaxing on the couch at home in the living room

My #1 pet peeve (and many agree with me) is that “rest” is the worst piece of advice ever.

“Go stick your finger in that electrical socket over there” would be better.

This isn’t to say there aren’t extenuating circumstances where taking a chill pill is absolutely the right choice; sometimes we do need to back off and allow the body a window of time to heal or reduce pain/swelling/symptoms.

That said, I think it’s lame when a medical professional tells someone to “rest,” or worse, informs them that they’ll need to learn to “live with low back pain.”

It’s a defeatist attitude and will spell game over for many people. Before you know it they’re living on a foam roller and thinking about a “neutral spine” while washing their hands.

(NOTE: I am not anti-teaching neutral spine to people. It’s a lovely starting point for most people, but at some stage people need to learn to move in (and out) of precarious positions…because that’s life).

A common theme reverberated in the S&C community is to say “strength is corrective.” I wholeheartedly agree with this sentiment. In fact, why the hell has this not been made into a t-shirt yet?

However, I think a slightly better moniker may be to say:

“Movement is corrective.“

We can use movement (and yes, strength) to help people get out of pain. Rest has its time and place, but I find stagnation to be more of a problem.

The body is meant to move and is wonderfully adaptive. And that’s the thing: adaptation and forcing the body to react to (appropriate levels of) change and stress is paramount to long-term success with LBP.

Sitting on a couch watching Divorce Court in the middle of the day isn’t going to help.

2) Move, But Move Well

I was watching Optimizing Movement with Mike Reinold recently and he noted there are three key elements to movement and why someone may not do it well:

  • Structural Issues
  • Coaching/Technique
  • Programming

It’s important to understand that, in this case, everyone is a unique snowflake.

Structure: Anatomically speaking there is huge variance amongst the population. Hip structure, for example, can have a large effect on someone’s ability to squat to a certain depth or get into certain positions. Likewise, who’s to say the hips are always the culprit? Even upper extremity considerations – like one’s ability to bring their arms overhead (lack of shoulder flexion) – can have dire consequences on back health.

The body likes to use the path of least resistance (also the most efficient) to accomplish any task. However in this case, “most efficient” doesn’t mean best. As Reinold notes:

“Efficient in this case refers to energy, not movement.”

Lack of shoulder flexion will often lead to compensation via more extension through the lumbar spine. It’s efficient movement, but it’s not better movement.

Coaching/Technique: I’m a firm believer that everyone should deadlift (it’s a hip hinge, learning to dissociate hip movement from lumbar movement, doesn’t mean we have to load it), but I don’t feel everyone should do it from the floor or with a straight bar.

Cater the exercise to the lifter, not the lifter to the exercise.

More on this below.

Programming: If someone lacks hip flexion why have them conventional deadlift? If someone lacks shoulder flexion why have them perform overhead pressing or kipping pull-ups? Some of the onus is on YOU, dear fitness professional.

via GIPHY

Hell, even something as simple as how you coach a plain ol’ vanilla Prone Bridge/Plank can shed some light here.

What’s the point if the end result looks like this?

Contemporary Woman Doing Plank Exercise

Which brings us to another golden rule.

3) Finding Spinal Neutral (Pain Free ROM) is Kinda Important

In light of a past gem by Dean Somerset on what the term “spinal neutral” even means, I realize this comes with a bit of grain of salt.

I just want to find a pain-free ROM and to help people with low back pain to own that ROM.

It’s the McGill Method 101.

Find what actions hurt or exacerbate symptoms, and stop doing it.

I know I just blew your mind right there.

For example:

1. Client says “x” hurts, and then places their body into some pretzel like contortionist position that would make a Cirque du Soliel performer give them a high-five.

Me: “Um, stop doing that.”

2. But that could also mean addressing how they walk or how they sit in a chair. Someone with flexion-based back pain, will like to be in flexion, a lot.

Maybe taking them through a slump test will offer some pertinent info.

Have them start in a “good” position:

slump-test-start

Then, have them purposely “slump” into excessive flexion:

slump-test-end

Someone who is flexion intolerant – despite preferring to be in that position – will often say this causes pain.

Ding, ding, ding.

So, the “fix” is to coach them up and try to keep them out of excessive spinal flexion. Cueing them how to sit in their chair and to get up (wider base of support, brace abs, chest up), building spinal endurance (and strength) via planks, and having them hang out in more extension may be the right path to take.

 

3. On the opposite side of the spectrum is extension, which is often a problem in more athletic populations and in those occupations requiring more standing (ahem: personal trainers/coaches).

Here you might put them into extension and see what happens.

low-back-extension

Much like people who are flexion intolerant “liking” flexion, those in excessive extension will like to live in extension.

This will likely hurt.

Finding their spinal neutral is key too.

Hammering spinal endurance/strength via planks (done well) still hits the nail on the head, as does nudging them towards exercises that emphasize posterior pelvic tilt (much of time cuing people NOT to excessively arch during their set up on squats and deadlifts), and even drills that promote spinal flexion…albeit unloaded.

 

 

Spinal flexion doesn’t always have to be avoided. In fact, it’s sometimes needed.

Either way, meticulous attention to detail on finding spinal neutral – or pain from ROM – is huge. Once that is addressed, and symptoms has subsided, we can then encourage them to marinate in more amplitude of movement, taking them OUT of spine neutral (cause, it’s gonna happen in everyday life) and use the weight-room to help strengthen those new ROMs.

But I digress.

4) Don’t Treat People Like a Patient

I know this will rub some people the wrong way, but I still use the deadlift for the bulk of people I work with you have LBP.

Nothing sounds so absurd to me than when I hear someone say how the deadlift is ruining everyone’s spines.

To recap:

Deadlift = hip hinge.

Hip Hinge = learning to dissociate hip movement from lumbar movement.

Mic drop.

Resiliency is key in my book. And not many movements make the body more resilient than the deadlift or any properly progressed hip hinge exercise catered to the individual’s goals, injury history, and ability level:

 

Assuming I have coached someone up enough to understand spinal neutral and they’re able to maintain it, why not poke the bear and challenge them?

A deadlift doesn’t always mean using a straight bar and pulling heavy from the floor until someone shit’s their spleen.

I can use a kettlebell and band to groove the movement:

 

I can also use a trap bar, which is a more user-friendly way of deadlifting as it allows those with mobility restrictions to get into a better position compared to a straight bar.

https://www.youtube.com/watch?v=p-sA3PG1kGY

 

Too, I have found great success with various other exercises:

  • Farmer and Suitcase carries
  • Shovel Holds

 

  •  “Offset” loaded exercises like 1-arm DB presses or 1-arm rows, lunges or RDLs (where you hold ONE DB to the side and perform the exercise). It’s a great way to increase the challenge to the core musculature.
  • Or even outside-the-box exercises like Slideboard Miyagi’s

 

So long as we’re staying out of precarious positions or those positions which feed into the issue(s) at hand, we’re good.

Find a training effect with your clients/athletes.

Help them find their TRAINABLE MENU.

And That’s That

People have low back pain for a variety of reasons: They’re too tight, too loose, too weak, have poor kinesthetic awareness, or they’re left handed.

The umbrella theme to remember is that there is never ONE root cause or ONE definitive approach to address it across the board. However, that doesn’t mean there aren’t some “big rock” things to consider that will vastly improve your’s and their chances of success.

I hope this helped.

And, again, sorry about the Care Bear comment.

Categoriesmindset personal training

The Hard Truth About Back Pain

Happy Labor Day to my American readers.

Happy Monday to everyone else…;o)

Today’s guest post comes courtesy of TG.com regular, Shane McLean. Most will be able to commiserate because it deals with an annoying topic most of us are very familiar with: Cross-Fitters low-back pain.

We can seemingly do everything perfectly – lift with impeccable form, do our mobility work, even do an extra set or two of deadbugs & birddogs – and yet still be clotheslined by a bout of back pain.

It stinks no matter which way you look at it.

But it’s not a death sentence.

Copyright: belchonock

The Hard Truth About Back Pain

Google back pain and you come up with about 1,550,000,000 results.2  There’s no shortage of information about back pain, the symptoms, the different types, how to treat it and how to prevent it. When you’re suffering from back pain, it’s easy to be overwhelmed with all this info.

Plus, not to mention all the conflicting advice because various treatments and exercises work for different people. What worked for me might not work for you. Pain and healing are highly individual things, I think.

Back pain causes loss of income, loss of mobility, stress,  large medical bills and costs employers big money because of sick leave, health insurance etc.

Back pain is a big deal, no doubt.

You can do all the right things, diet, exercise and move right but back pain doesn’t care. It can rear its ugly head at any time you move suddenly, bend down to pick something up off the floor or when you’re wrestling with your kid.

Then you’re in a world of hurt.

There’s a school of thought that suggests back pain is preventable if you strengthen your core, have good posture, get strong and not sit or stand too much. But back pain doesn’t care. You control what you can control and let the chips fall where they may.

Truth About My Back Pain

The truth about my back pain is it was my fault.

See, I love to deadlift, but I was doing it all wrong. Rounding the lower back while pulling a barbell from the floor repeatedly is NOT a recipe for a healthy spine. Eventually something had to give. And it did.

Around nine years ago I felt a ‘snap’ in my lower back and didn’t think anything of it. Some low-grade pain around my lower back and I ignored it like any gym meathead would, hoping over time the pain would go away.

But the more I ignored it, the worse it became, to the point where lifting, playing with my kids and sleeping didn’t happen. The pain had taken over my life and it was all-consuming. To cut the world’s smallest violin story short, I had three herniated disks.

Now the disks have healed but my pain has not. More on that later.

When You’re In Pain

If you’ve ever put your back out, you’re probably thinking you’re the only one who’s suffering (because pain is all-consuming) but this is not the case. 80% of the population of the US, at some point will suffer from chronic or acute back pain.

And about 2% to 10% of people who experience low back pain develop chronic back pain.

A lot of people choose to go under the knife to fix this because of their doctor’s recommendation, but this doesn’t always work, as shown here. Plus, I’ve encountered many people who have had multiple back surgeries and they’re still in tremendous pain and their quality-of-life sucks.

Sometimes the solution causes more problems.

Get Back On The Horse

You’ve heard the saying ‘get back on the horse’ when you’ve been knocked down.

Get up, dust yourself off and go again.

You cannot change what happened. Dwell on it, yes but you cannot change it. Better to wipe the slate clean and go again.  And this is usually great advice but for back pain it’s a little different.

via GIPHY

The countless times I’ve come back to the deadlift after injury there’s a real fear, I’ll do it again. The more I focus on correct form and set up doesn’t make this fear go away. But this fear is a two-way street. It forces me to do it right, which is a good thing.

But I lose confidence in my body to perform because of this fear and this is a bad thing.  You may think this is mumbo-jumbo, but injuries have both physical and psychological consequences, and a common post injury response is elevated fear of re-injury. (1)

The loss of confidence is real and is a little talked about consequence when coming back from an injury.

Another ‘Truth’ About Back Pain

This is a case study of N=1 (me) and my experience with back pain and training clients with back pain. Barring lower back strains and waking up on the wrong side of the bed, once you’ve damaged your spine, like herniated disks the pain doesn’t magically go away.

The injury may have healed but the pain remains.

In the case of herniated disks, the fluid that leaks out between the disks which causes the nerve pain and discomfort gets dissolved by the body over time. Then there’s nothing pressing up against the nerve so the pain should all go away, correct?

I’ve suffered from low-grade (1-2 out 10 on the pain scale) and extreme lower back pain (5-7 out of 10) almost daily for the past nine years. Granted it’s not the same level of pain generated by a herniated disk and it’s not constant, but it’s still pain.

Low grade back pain doesn’t stop me from training, but it does make me more aware of my set up and form. It makes me more conscious of my posture and daily movements too and this is all positive. Extreme back pain almost puts me on the ground.

This is not.

After surgery, rehab, Physical Therapy or Chiropractic care for back aliments, the severe pain may go away but the discomfort may haunt you like Casper the friendly ghost.

Wrapping Up

Back pain, whatever form it takes, sucks.

You lose confidence in your ability to perform everyday movements and fear re-injury. But it does make you aware of taking good care of it. Because if you don’t, your back will tell you in no uncertain terms.

Note From TG: As an adjunct to Shane’s sage words, I’d highly recommend reading THIS article I wrote recently on why training with pain present is an inevitable (if not important) part of the healing process.

About the Author

Shane “Balance Guy’ McLean”  is an A.C.E Certified Personal Trainer working deep in the heart of Louisiana with the gators.

References

  1. Chao-Jung Hsu et al. Fear of Reinjury in Athletes. Sports Health Mar/Apr 2017;9(2):162-167. doi: 10.1177/1941738116666813. Epub 2016 Sep 20.
CategoriesAssessment personal training Strength Training

A Tale of Two Squat Patterns: An Assessment Case Study

I know, I know.

What a dry, bland, title for a blog post.

But if I would have titled it what I wanted to title it:

“That Time I “Fixed” Someone’s Squat In Five Minutes, BOO-YAH, God Damn I’m Good. And While I’m Here Bragging About Myself: Did I Ever Tell You About That Time I Almost Single Handedly Won the Sectional Championship For My High School Baseball Team Back in 1995? Oh, And I Made Out With a Girl Once.”

…that would have been over the top.

Kudos to you for clicking on the link anyway.

You’re cool.

Copyright: saamxvr

A Tale of Two Squat Patterns (But Seriously, Though: I Did Fix It In About Five Minutes

Last week I had a gentleman come to CORE for his initial assessment. After some initial back-and-forth and pleasantries we got into the topic of his training and injury history. He had noted that he had never really participated in strength training before and after digging a bit further he also noted that he’d had a history of chronic lower back pain (L3-L4).

Most people can commiserate.

A vast majority reading these words right now have likely experienced some form of low-back pain in their lifetime.

(raises hand)

It’s never fun and can leave most people in a seemingly never-ending state of frustration and despair. In dealing with many people in the same predicament throughout my career as a coach & personal trainer my goal during their initial session isn’t to spend it telling them how much of a walking ball of dysfunction they are.

via GIPHY

Rather, my objective is to take them through a few rudimentary screens, watch them move, see if anything exacerbates their symptoms, and if so, modify things to see if we can reduce them.

Low back pain is very common and has myriad of root causes:

✅ Tight this
✅ Overactive that
✅ Inactivity
✅ Aberrant movement patterns
✅ Losing a street fight to Jason Bourne
✅ It’s Tuesday

Whatever.

It’s rarely ONE thing, which makes it altogether impossible to look someone in the eyes and say, definitively, “x is why your back hurts.”3

Which is why I prefer to get people moving during their assessment.

It’s easier for me to ascertain and glean a larger picture of things when I can watch someone show me their movement strategies through a variety of tasks.

Don’t get me wrong: I’ll perform several screens on an assessment table: Thomas Test, Craig’s Test, Slump Test, active vs. passive ROM, etc.

However, I also believe it’s important (if not crucial) to get them off the table and have them demonstrate to me how they choose to move.

It’s simply more information.

Without any prompting from me (I didn’t want to coach him on how to perform the “test”) here’s what my client’s squat pattern looked like:

Before

 

Notice how he immediately “falls” into an aggressive anterior pelvic tilt as a descends toward the floor? Likewise, notice the speed or lack of control as he lowers to the ground?

Furthermore, notice anything as he finishes at the top and “locks out” his hips?

He hyperextends his lower back.

I.e., he finishes with LUMBAR extension rather than HIP extension.

I had him watch the same video above and then broke down in more detail everything I explained here (and that my suspicions were that those may be the culprit of his low-back woes).

I then spent a few minutes breaking down some simple “squat technique tenets” I like to pass along when breaking down the movement with clients.

✅ We talked about foot pressure and corkscrewing his feet into the ground (to help ramp up torque in the hips).
✅ We also discussed the abdominal brace.
✅ I broke down the canister position and how that’s ideal (rib cage down and stacked over the hips)
✅ I reiterated that the squat is equal parts breaking with the hips & knees simultaneously so the net result is squatting DOWN, not BACK.4
✅  I wanted him to think about “pulling” himself down toward the floor rather than falling.
✅  Lastly, I encouraged him to “finish tall” at top; to squeeze his glutes (lightly) rather than ramming his hips forward.

Five minutes later this happened:

After

By no means was it a perfect squat (does that even exist?), but that wasn’t what I was after.

I was seeking PROGRESS.

And I think we achieved that.

Here’s a top (before)/down (after) comparison:

 

The bigger indicator, though, was that he had zero pain while squatting after these minor tweaks to his technique were made. And it didn’t take me giving him a laundry list of “corrective exercises”  in order to “fix” it.

Sure, I could have told him to foam roll for 37 minutes and stretch his hip flexors, followed by an abyss of varying glute medius exercises…

…and he likely would have felt better as well.

However, we wouldn’t have really addressed anything.

In short: Help people find their trainable menu. COACH them. Show them what they CAN do, rather than barking at them what they can’t.

CategoriesProgram Design Rehab/Prehab

Why You Can and Should Lift Weights With a Herniated Disc

You all know the stat: upwards of 80% of the population will experience some form of debilitating back pain – often times a disc herniation – in his or her’s lifetime.

It can strike with one dubious rep on a set of deadlifts, bending over to pick up a child, or, I don’t know, during a random after hours office Fight Club.

However (0r whenever) it happens, it sucks. But what also sucks is the often archaic advice many receive with regards to what to do when a disc herniation happens.

In today’s guest post by UK based physical therapist and strength coach Alex Kraszewski, he helps to set the record straight.

Enjoy.

Copyright: teeradej / 123RF Stock Photo

Why You Can and Should Lift Weights With a Herniated Disc

Just like Crossfitters, Vegans and Anti-Vaxxers5, if someone has back pain and they think it’s a disc herniation, it’s probably the first thing they’ll tell you.

There’s not many days that go by where I don’t see someone with back pain, and in more cases than I’d like – the opening conversation tends to go like this;

Me: “So what brings you in today and how can I help you?”

Client: “My doctor/chiro/shamanic healer said I’ve got a disc out, a trapped nerve and my MRI proves it. It hurts and I need you to put it back in.”

Me:

The intervertebral disc has become the scapegoat for a lot of back pain and disability. When the word ‘disc’ is used, it tends to create a cascade of fear, anxiety and worry for the future.

Do I need surgery? Am I going to have problems later in life? Can I still lift and get jacked? Will Dr. Dre ever release Detox?

I don’t know if we’ll ever hear Detox, but the answer to the other stuff is more promising.

I had a great follow-up question from my webinar on Flexion & Extension based back pain as part of The Complete Trainer’s Toolbox, and it gives us a great opportunity to discuss this and think critically about this topic:

“Do you consider exercises with reasonably high compressive and shear load to be risky for someone with disc herniations?”

Short Answer: No.

Long(er) Answer: It depends. We know that only Sith’s deal in absolutes – particularly on Tony’s site, because six other articles have made this gag. Lucky number seven for me.

Let’s break this question down into two smaller questions:

1) Are disc herniations always bad or problematic?

2) Will exercising under high levels of shear or compression increase the risk of pain, injury or further problems?

Are Disc Herniations Always Bad or Problematic?

No.

Many of us jump to the conclusion that when told we have a bulging or herniated disc, we’re doomed.

It’s normal to worry – our back hurts and we’re told there might be a problem with it that could threaten what we enjoy doing and how we earn money.

Whilst disc herniations can contribute to back pain, it doesn’t mean they absolutely will contribute to back pain.

One of the best things here is to look at research investigating the low back in pain-free populations. This study from 2015 pooled over three thousand pain-free people, and at least 30% of people had either a disc bulge or protrusion with no pain.

Nada.

Zilch.

The other biggie here is a steady increase in pain-free findings as we age.

The older we get – the more likely it is to find ‘stuff’ on MRI, that doesn’t have to be a straight up cause of a client’s back pain.

So again, no, disc herniations are not a death sentence for your quest for jacktitude.

But

Pathology can still contribute to pain.

This research is great, but sometimes the pendulum swings a little too far, and these findings can be dismissed without proper assessment. Want to piss off your client who believes their back is due to a disc problem? Tell them outright it’s not a problem with no real justification other than ‘the research says MRI findings don’t matter’.

Rapport = gone.

But how do we know when to take notice of an MRI report or not?

Consider the concept of an active wound or healed scar to weigh up how relevant pathology is to pain. I picked these terms up from Dr. Stuart McGill, who knows a thing or two about spines.

He also knows a thing or two about awesome mustaches.

An active wound is where symptoms, assessment findings, and imaging reports all match up enough to connect the dots.

A healed scar is the presence of pathology on imaging, but without clear correlation to assessment findings. The dots are there, but not clearly connected at this point time.

Remember that an MRI is a single snapshot in time of your client laying on their back, doing nothing. It might look ‘bad’, but they might also be in no pain and crushing their training without fear or worrying about it.

How do you figure out whether you’re dealing with a wound or a scar?

Work with a healthcare professional who knows how to lift and help come to a clear understanding of your client’s back pain. Trainers are one million percent qualified to work with clients with back pain and disc herniations, when they have been screened and assessed properly.

Will Exercising Under High Levels of Shear or Compression Increase the Risk of Pain, Injury or Further Problems?

Short Answer: No.

Longer Answer: You need to ‘dose’ things appropriately.

As a quick refresher, spinal compression is the force that approximates each vertebrae. Spinal shear is the force that tries to pull one vertebrae forwards or backwards on another (at least in the sagittal plane).

Compression (image via Stronger by Science)

Shear (image via Stronger by Science)

The spine is designed to bear load, and the interactions of motions, loads and postures will load the spine in different ways.

What counts as ‘high’ levels of shear and compression?

If you’re a Sith dealing in absolutes:

  • High shear loads come from a more horizontal torso angle and increased spine flexion
  • High compressive loads come from greater loads lifted, more intense bracing strategies and a more extended spine position

If you’re a Jedi and want to consider context:

  • ‘High’ for a super heavy powerlifter will be different to ‘high’ for a yoga instructor
  • ‘High’ for your client who has never lifted a weight is different to ‘high’ for your seasoned lifter who has accumulated decades of time under the bar.
  • ‘High’ for someone in pain is different to ‘high’ for someone who is pain-free.
  • ‘High’ is the upper end of an individual’s tipping point to tolerate load at that moment in time

This is where the science & art of training and rehab meet.

Science tells us that a conventional deadlift and back squat can probably allow us to lift the most load, but knowing your client would benefit more from front squats and trap bar deadlifts whilst their back hurts or if they are learning the ropes of lifting, is the art.

Don’t be this guy.

So what happens if we apply the appropriate ‘high’ level of stress with a disc herniation?

Just like everything else – discs will adapt

The body is a wonderfully adaptive organism that will react to the stresses placed upon it. If you get the dose of ‘high’ in the right ball-park, you will create positive adaptation. We’ve known about this the 80’s, where this study found the intervertebral disc positively adapts compressive load, yet it’s often viewed as a fragile structure that, when injured, spells game over.

Seems not.

This can be incredibly empowering for the clients suffering from back pain, whether it’s a diagnosed disc pathology or otherwise, that things can get better. This case study showed a huge improvement in a patient with an L4/5 herniation in just 5 months:

Credit – New England Journal of Medicine

Not sure if this applies to lifters?

Check out Brian Carroll’s MRI before and after working with Stuart McGill.

He started being disabled by pain with a broken sacrum and pretty banged up lumbar spine, but returned to the Powerlifting platform to set new world records at a lower bodyweight.

Credit – Brian Carroll

For me – this is where we need load within a low back rehab program.

If back pain stops us exercising, we will lose some level of fitness and adaptation as a result, which means we need to find a way back to exercising, based on what we can currently manage. I think this is why a lot of rehab programs don’t do well – it’s either too much load too soon which lead to flare ups and setbacks, or not enough load over time which means symptoms linger for longer than necessary.

So if we can say with confidence that disc herniations are not permanent, can get better and need load to return to our meaningful activities, how do we decide how to push it, when to push it, and how far?

Let’s answer these too.

How Do We Push It?

If you’re working with someone with back pain (or any pain really), your assessment should tell you this by answering this question;

“How much load can this client currently tolerate right now, and how can I best safely apply this?”

Don’t be afraid to use load in your assessments.

In fact, USE LOAD IN YOUR ASSESSMENTS.

A table and movement assessment is the starting point to see what the foundation is like, but how does what you see ‘at rest’ compare to when you’re at working weights?

Your client might have a perfect air squat, but if it resembles a melting handle at their working weight, you probably want to find that point where it looks good enough. Not perfect, not scratch-my-eyes-out terrible, just good enough.

Your 3/3 on the Overhead Squat won’t save you if you look like this under load.

If you start running into pain or problems under load, be comfortable enough to tweak the load, change the exercise variation, or coach it further. It’s OK if your assessment starts to resemble a training session, because it will give you way more information for your initial program with that client than relying on unloaded tests alone.

This is where you need the nuts and bolts of exercise progressions/regressions, coaching cues, and loading/tempo schemes to find the sweet spot for your client at that moment in time.

When Do We Push It?

Adaptation takes time, but it shouldn’t take forever. Your assessment gives you your starting point and how you feel during and after your lifting should guide how you progress. You don’t have to be pain-free, but you shouldn’t be pushing yourself through agony either. Here’s how I tend to work;

  • Pain settled within 2 days and below a 3-4/10? Carry on wayward son.
  • Pain longer than 2 days and/or above 5/10? Slow your roll.

Previous injury, pain, surgery or a lot of concern from your client will influence how quickly you choose to reapply the ‘stress’.

It’s ok to give it a little longer if needed, so know you can be flexible.

If things do go beyond what’s deemed acceptable, it doesn’t put us back to square one, but it might just require a little course-correction from time to time. No return from pain or injury ever moves in a nice linear, expected direction.

Credit – Sports Physio

As long as the loads, intensity and your client’s confidence and pain are steadily improving over time, you’re on the right track. Where ‘how’ is the science, ‘when’ is the art – know when to hit the gas, and when to pump the brakes, because it’s rarely a straightforward process.

How Far Do We Need to Push It?

What’s your client’s endgame?

The greater the demand of what your client is asking their body to deal with, the more time you’ll probably need. The new parent with a month or two of back pain wanting to pick up their kids without hurting and get 2-3 workouts in a week, will have a vastly different course to the powerlifter who’s been beaten up for years and wants to be out of pain and setting new world records.

Not everyone needs to hit soul-crushing, nose-bleeding levels of intensity, but if a client wants to work on their true maximum strength, you better be ready to take them back to working to 90% and above.

The goal of any rehab plan should be to build both physical and mental robustness that allows us to remain resilient to the stresses we want to place on ourselves, and still have enough in the tank to deal with the stresses we have to put on ourselves. As much as we want ourselves and our clients to crush their training sessions, it shouldn’t come at the expense of living the rest of their life the way they want to.

Remember – Disc Diagnoses Aren’t Death Sentences

The biggest challenge when someone is in the depths of an episode of back pain that may or may not have involved the ‘D’ word, is that they have the opportunity to get better and it’s not game over.

If we can get past this barrier, it becomes a matter of ‘when’ will they get better, not ‘if’. The intricacies of getting can be incredibly individual, but with the right approach, there’s no reason why you and your clients can’t get back to crushing it.

If you want to take a deeper dive on this – check out the Complete Trainer’s Toolbox, where I spend nearly three hours talking through what influences spinal loading during exercise, and how to plan a way back to beast-mode if back pain is a problem.

Ps – disc’s don’t ‘slip’ (courtesy of The Honest Physio).

About the Author

Alex works as a Physiotherapist in Essex, United Kingdom, with a special interest in working with those involved in strength and barbell sports.

Alex holds a triple bodyweight deadlift, and regularly publishes content through Rehab to Robust on Facebook & Instagram.

CategoriesCorrective Exercise Program Design

4 Exercises to Strengthen Your Core and How to Program Them For Lower Back Pain

Raise your hand if you watched The Royal Wedding this weekend.

*raises hand*

But I only tuned in because Julian was up so early Saturday morning and there was nothing else to watch.

Yeah, yeah….that’s it.

Anyway, I’ve got an excellent guest post for you today from Florida based trainer William Richards covering a topic pretty much everyone can get on board with…..

…..low back pain and how to choose or modify the best bang-for-your-buck exercises to help nip it in the bud.

Copyright: lightwise / 123RF Stock Photo

4 Exercises to Strengthen Your Core and How to Program Them For Back Pain

When it comes to core training and sensitive lower backs I have been through the gauntlet.

I have experimented on myself and have worked with so many frustrated clients who want to train their core but always seem to re-injure their backs or stay on what I call their own pain cycle.

They go to the gym with minor inflammation thinking a good workout is what they need. They knock out what they think is a “safe” workout and spend the last 20-30 minutes hitting some hanging leg raises, decline sit-ups and maybe even some weighted jumping ball slams (because they heard a stronger core will beat their back pain). The intention behind this workout was good and hopeful but they go home and slowly start to experience this gradual increase in pain and tightness in their lower back.

Fast forward 24 hours and mornings feel like you have a tree branch wedged between two vertebrae.

Forget bending over to tie your shoes let alone put pants on. You feel 80 years old until the Extra Strength Tylenol and Ibuprofen concoction kicks in and you get a small glimpse of what it feels like to be pain-free and healthy. For most this is the only sense of relief they will ever experience.

We all know lower back pain can be complex. There could be a lot of different factors at play here but one of the key topics I want to shed light on is the core training approach.

How Should I Approach Core Training With Lower Back Pain?

In my experience with coaching corrective core training for sensitive backs, there are three key points I find myself covering over and over again.

(1) Safe modified approaches to “modern” exercises that have the sensitive back in mind.

When you here modification you immediately think “an easier version of what your showing me.” Which is true in most cases, but when dealing with a sensitive back your not looking for “easy” you’re looking for a certain pain threshold that the individual/you can control.

This threshold is extremely important to coaching sensitive backs because that very threshold can put someone on the couch for a week popping pain meds or training and moving towards freedom and a faster recovery.

So when picking and executing your core exercises think more about how the variation is affecting the way your lower back feels in the moment AND 24 hours after doing it.

Nothing you should be doing will consists of training through pain. Often times any irritation or discomfort from an exercise will kick in the next day once all the feel good chemicals have worn off.

(2) The correct coaching through these modifications to safely progress to the level of difficulty that is safe for you.

Once you have dialed in on your own safe threshold it’s time to start modifying the exercise to fit your needs. There are tons of ways to do this so I will highlight a few of my top cues here.

If you’re experiencing pain:

-1- Check the position of your pelvis.

Is it neutral?

Especially with exercises like the ones you will see below it’s paramount that you take unwanted stress OFF the lumbar spine. Some of this stress is commonly caused by an overextended or flexed lumbar spine. If you’re experiencing pain, simply being overextended or over flexed will only get worse when you add compression or a form of challenge to the position.

Note From TG: Here’s a great way to teach/cue people how to (safely) move their spine into flexion and extension IN CONTROL. Sometimes back pain is the result of being “stuck” in an over extended or flexed position. Allowing people “access” to range of motion can be a game changer.

 

-2- Bring the loads or limbs closer to your body.

Wait, what?

Try this out: If you have back pain, take a 10 lb plate and hold it straight out in front with your arms stretched out. How does that feel on your lower back?

Now bring the weight closer to your chest. Did that bring relief?

The majority of instability issues will produce pain with the outstretched arm. The closer the load or limbs are to your body the less your body (in this case your lumbar spine) has to work to keep you upright.

You can apply this cue to exercises such as the plank (side and front) or a Pallof press. The more fully weight bearing you are with the plank the more stress it will put on the irritated lower back. The same goes for the Pallof Press.

 

The further outstretched your arms are the more demand it will place on the lower back.

The more sensitive the lower back the more pronounced this will be.

(3) A Mindset Change

When training your core for back pain relief you have to adopt this way of thinking.

It’s not about the exercise you’re doing but the position of your painful points when doing the exercise. I did a quick 1-minute explanation of what I mean below:

Where Should I Start With Core Training?

Now that we have covered how you should be approaching core training, let’s get into applying what we learned. Below I want to show you four of my favorite exercises to use and modify for various levels of clients.

Let’s dive in.

1. Banded Quarter Crunch

 

One of the biggest reasons I love this exercise so much is because of the full upper body muscle recruitment it requires. Sometimes as new lifters or even those who are more seasoned we forget that bracing the trunk and engaging our body with a certain movement requires a lot of interaction between joints and muscle fibers.

To save on energy we subconsciously do the bare minimum to get the exercise done.

This is where weak links in our chain are created.

When doing these banded crunches I want you to think about bringing your arms down and out and engaging your lats before you begin moving anything. When in position be sure your spine is neutral, shoulder blades are tucked down and back and your chin is pulled in towards your neck.

When you go for lift-off, the goal is to move everything together and using the trunk as your primary mover while everything else upstream stays rigid and stiff. One way I like to cue this exercise so that the person isn’t trying to do too much of a sit up is to think about pushing your for-head up towards the ceiling. This will actually make the exercise seem a bit harder and trigger an even more intense muscle fiber recruitment.

You can get creative with this when it comes to the sets and reps scheme. You can do just reps or holds for a number of breath cycles. One rep would be a lift-off followed by a full cycle of breathing (inhale and exhale). For holds, after lift off, you can cycle 3-4 breaths before returning to the starting position.

2. Banded ISO-Deadbug

 

The dead bug can be a major let down for someone with a sensitive back. Most articles you find on the internet for lower back pain and core training you will find the dead bug. Unfortunately, those who take the dead bug at face value and don’t know how to tailor it to fit them are the ones who quit on the exercise before any benefit is seen.

In this video, I show you four variations that you can work from easy to more difficult with this exercise. We are going to use a similar band like the exercise above to help with upper body engagement.

3. Banded Sit Backs With ISO Hold

 

One thing I am a huge fan of other than hole-in-the-wall (probably should get shut down) Mexican restaurants are exercises that are designed or coached not only to make the individual stronger but to teach and groove healthy movement patterns.

One of these movements I see butchered is the hip hinge.

We do tons of exercises that include the hip hinge but with every rep and set we are putting ourselves in more danger than anything else. It’s hard to find an extra 30 minutes a day to practice proper bracing, coordination or healthy movement patterns separately. Which is why I will always work them into my workout like you see in this video.

Key points to remember with this exercise.

The most import thing is what I said HERE

I care more about the integrity of your body position then I do how many sets reps or weight you can do. You have to earn those gradual increments.

You want to stay within your pain threshold. No pushing through the pain to get a better burn. Leave that to the people who enjoy soaking in salt baths every night and are popping muscle relaxers and Percocet just to sleep at night.

4. Banded Birddog

This is another one of those exercises that can lead to frustration and more pain if not taken in small increments depending on how sensitive your back is to this type of movement.

I didn’t respect this exercise when I first introduced it into my personal rehab program. Instead, I just did what it LOOKED like I should be doing and went from there.

I want to help break this habit of the copycat approach. The more you know WHY you’re doing the variation of the exercise the better you will understand what you’re doing.

When doing this exercise, I want you to focus on the different modifications that are available with this move. We talked earlier about your specific pain threshold. These modifications should help keep in the safe zone.

Key things to remember:

Don’t rush the exercise. Start by breaking it down into segments and make sure there are no gaps or missing factors that are causing your pain.

You can attach the band to both the wrist or ankle to add difficulty to that individual limb either in the full Bird Dog or broken segments.

I Know What You’re Probably Thinking

Well, what exercise should I start with or which one is best for _________.

Don’t fall into this trap.

Remember, It’s not about what exercise you’re doing that will unlock your potential for long-term relief. It’s how you approach the exercise that you’re using. Focus on the position of your body BEFORE you even start the exercise then use the exercise to challenge that healthy position.

If you apply this to every core exercise, or any exercise for that matter, your ability to train towards lasting relief will significantly improve.

About the Author

After rupturing my L5-S1 disk over 7 years ago I was told that surgery and pain meds were my only option for a “pain-free” life.

I made a choice as a fitness professional to relentlessly pursue the truth to whether or not exercise could truly be the secret to getting relief.

After 10+ years coaching in the fitness industry I now focus the majority of my time teaching people how to pursue their own drug and surgery free path to back pain relief.

Aside from coaching you can find me on the Gulf Coast of Florida, surf fishing with my two kids and wife or eating my weight in Mexican food. For more info on me and what we have going on you can check out my website HERE.

CategoriesAssessment coaching Corrective Exercise

Low Back Pain: Habitual Movement Can Have Greater Influence Over Intentional Exercise

We’ve all seen the statistic: 80% of the population will experience low back pain in their lifetime.6

Back pain is the single leading cause of disability worldwide. Americans spend upwards of $50 billion per year on back pain. Back pain is the nemesis of all ninjas.

The struggle is real folks.

Given how pandemic the issue is and the sheer number of resources there are on the topic, why is LBP still such a nuisance and the Bane of many people’s existence?7

Copyright: kudoh / 123RF Stock Photo

 

When it comes to low back pain there is no one clear cut answer or way to explain things. As my good friend David Dellanave would say “different shit is different.”

It’s impossible to definitively point the finger at one or two things and say “there, that’s it. THAT’s why everyone’s back feels like a bag of dicks.”

Certainly we can proselytize, but at the end of the day we’re mostly just guessing at what may be causing someone’s low back pain. We’re using an amalgamation of relevant anecdotes, experiences, expertise, and evidence based research to make those educated guesses.

But it’s guessing nonetheless.

[BEFORE WE MOVE ON: Another good friend, physical therapist Zak Gabor, sent me THIS rather thorough paper on management of low back pain. To quote Zak…”Movement is key, but EDUCATION on false beliefs about the body is arguably most important.”]

A week or so ago as I was watching an episode of VICE News on HBO and one of the main stories that night was on opioid addiction and of a former drug representative who, sadly, because of debilitating low back pain, had become addicted to the very pain killers that had made him so successful years prior.

In the story he described a seemingly endless barrage of treatments ranging from massage therapy and acupuncture to ultrasound treatments, physical therapy, and traction.

It was a hefty list and I can’t remember all of it.

In the end he ended up having back surgery, yet unfortunately was still reliant on pain killers to help with his chronic low back pain.

As the story unfolded they panned to the same individual miniature golfing with his family and I ended up taking a screenshot of him bending over to pick up the ball after sinking a shot.

If I could add sound it would be accompanied with a cacophony of painful grunting akin to a rhinoceros passing a kidney stone.

Now, what follows is not an attempt at me diminishing his experiences, and I’m fully cognizant my only source of info regarding his “treatment” was/is the five minute snap shot I was given from the story.

That said, I wonder how much agony and frustration might have been prevented in his lifetime if someone took the time to show him some basic “spinal hygiene” (to steal a phrase from Dr. Stuart McGill and his book Back Mechanic) tactics to clean up his daily movement?

What might have happened (what can happen?) if, instead of acupuncture, he was shown how to hip hinge well or given a healthy dose of Deadbugs, Birddogs, and Breathing Side Planks?

 

Repetitive (aberrant) flexion, as shown in the still shot I took, certainly isn’t doing his back any favors. And, I have to assume this type of thing is happening dozens (if not hundreds) of times per day, whether he’s picking up a golf ball or getting out of a chair.

It glaringly demonstrates how we often neglect to address the obvious and simple everyday “hammers” in our lives that can (not always <— this is important) lead to back pain.

Nope, not those hammers.8

I’m talking about the kind of hammers – repetitive movement (repeated spinal flexion, and extension for that matter) – that start off as innocuous nothings (the twist there, the bending over there), yet manifest into something far more nefarious once one’s tissue tolerance is surpassed.9

As my friend and strength coach, Joy Victoria, notes:

“Habitual daily postures and movement strategies have a greater influence, than intentional exercise.”

Massage, ultrasound, etc, while likely part of the puzzle (and can provide immediate, albeit temporary relief), are just band-aids.

I think exercise, and to be more specific, strength, can play an integral role in the grand scheme of things.

However, as fitness professionals it’s imperative we keep a keener eye. Deadlifts don’t cure everything. Recognizing run-of-the-mill wonky movement and attacking that, as trivial as it may seem, can make all the difference in the world for those who suffer with low back pain.

CategoriesExercise Technique Exercises You Should Be Doing

Exercises You Should Be Doing: HBT Front Squat March

In my career as a strength coach I’ve worked with numerous athletes and non-athletes alike dealing with back pain. And while much of the time my initial “go to” exercises are things like the McGill curl-up, birddogs, deadbugs, and various planks I also recognize that, after awhile, some people would rather wash their face with broken glass than perform another rep of any of those exercises.

Copyright: stylephotographs / 123RF Stock Photo

 

Curl-ups, birddogs, and planks work. There’s no denying that. Coaching people up on those three movements alone and having them perform them on a consistent basis will clean up a lot of aberrant movement reduce pain in a symptomatic back.

However, it’s just, you know, they get boring after a while. As much as I’m a fan of those movements (and could care less how bored someone gets if it’s what they need to be doing to get better), part of my job as a coach is to help people not feel like a patient and to find other means to elicit a training effect.

I mean, raise your hand if this sounds familiar:

Athlete/Client: “Ready to train coach. What are we doing today?”

Coach: “You’re in for a treat. We’re getting after it with birddogs today. Holla!”

Athlete/Client:

via GIPHY

Like I said, it’s not to bemoan the birddog – it’s lovely exercise – but it’s not to say we can’t toss in alternative exercises that are just as conducive to working through low back pain AND more palatable for those looking to actually train.

HBT Front Squat March

 

Who Did I Steal It From? – a combination of Dr. Joel Seedman and MA based strength coach, Ryan Wood.

What Does It Do? – I’ve discussed the concept of HBT before in THIS article, but to reiterate:

“HBT = Hanging Band Training.

It’s exactly what is sounds like. You take some bands, hang some stuff off them, and do stuff. Because, science.

While at first glance it comes across as a bit gimmicky, HBT training does have a fair amount of efficacy. As Dr. Seedman explains in the article linked to above, the oscillatory characteristics of this brand of training provides a unique training stimulus that challenges stabilization, increases core demand, helps “excite” the CNS, and also has a bit of carryover to muscle gain due to the increase in time under tension.”

Germane to this exercise, the oscillatory effect of the kettlebells (or plates if you don’t have access to KBs) works wonders with regards to challenging the core musculature to stabilize and in helping to build a more resilient back.

The exercise itself can work in one of two ways:

1) If you have the space to do so, you can have someone unload a barbell from a rack and have him of her walk a specific distance.

2) Or, if you’re like me, and have a smaller studio, you can just as effectively have someone stand in place and march it out, like my client Dima is doing in the video above. Like a boss.

Key Coaching Cues: This is a fairly intuitive exercise. The KBs hanging from the bands is going to jostle the individual every which way if they’re too lazy and not CONTROLLING the barbell. The objective is to resist the movement of the KBs.

I like to tell my clients to “keep the KBs quiet.”

Some other things you want to be on the lookout for is too much leaning back and/or any excessive lateral flexion (side bending). The idea is to “stay tall” as one alternates back and forth from foot to foot.

You can either shoot for a specific time (say, 30-40seconds) or a specific number of steps. Give it a try and let me know what you think.

CategoriesAssessment coaching Corrective Exercise Exercise Technique

Porcelain Post: The Birddog Exercise: Please, Start Coaching It Right

NOTE: the term “Porcelain Post” first came to fruition last year between Brian Patrick Murphy and Pete Dupuis. Without getting into the specifics, it describes a post that can be read in the same time it takes you to go #2.

Huh, I guess that was more specific than I thought.

Enjoy.

Copyright: fizkes / 123RF Stock Photo

 

The Birddog Exercise: Please, Start Coaching It Right

The birddog exercise is a common drill used in many components of health/fitness. It’s most commonly utilized within yoga/pilates circles and referred to as either the donkey kick or chakaravakasana. Which, as we all know, is Elvish for, “doing something poorly and making my corneas jump out of their sockets into a fiery volcano.”

Okay, that’s not true.

But we all know that the bulk of people performing this exercise, whether they’re in a yoga class, performing it on their own, or following the tutelage of a strength coach or personal trainer, end up looking like this (not always, but enough to warrant an intervention in the form of this brief post):

Copyright: fizkes / 123RF Stock Photo

The birddog exercise not only targets the back, but also the hip extensors. It also, and more importantly, teaches the discipline of using proper hip and shoulder motion while maintaining a stable spine.

The picture shown above is the complete opposite of that. What we see instead is a gross exaggeration of lumbar (lower back) extension and a lengthening of the rectus abdominus compounded with excessive rib flare and cervical extension.

Essentially this person is tossing up a ginormous middle finger to any semblance of spinal stability.

Now, in fairness, maybe the woman pictured above was coached into that position for a specific reason:

  • Prepping for the World “How to Eff Up Your Back” Championships?
  • Because it’s Wednesday?

I don’t know the true details. Maybe I should lighten up.10 But what I do know is that I find little benefit in performing the birddog, and it’s likely doing more harm than good.

And when I see it performed this way it makes me do this:

via GIPHY

 

Lets Clean Things Up, Shall We?

What’s most frustrating is the reactions I get from some people when I ask them to perform the birddog. I’ll get someone coming in with a history of low-back pain, and after taking them through a series of screens to see what exacerbates their symptoms I’ll then have them demonstrate this exercise.

What follows is typically a few eye-rolls and a seemingly crescendo of “come on Tony, really? I’ve been doing this exercise all along, can we please turn the page?” 

Low and behold 9/10 (if not 10/10), the same person who has been complaining of weeks/months/years of low back pain in addition to a bevy of other fitness professionals espousing the merits of the birddog, when asked to demonstrate it, ends up looking exactly like the second picture above.

Case in point. I had an eval with a new female client last week. She was a referral from another trainer located here in the Boston area and she informed me that this client had been battling some chronic low-back shenanigans for the past few years. To the other trainer’s credit: much of what she had been doing with this client was spot on (and I have zero doubts this client was coached very well). However, the birddog lends itself to be one of those “hum-drum, don’t worry, I got this” exercises where people (I.e., the client), when left to their own devices, becomes complacent and lackadaisical in its execution.

Play close attention to the before and after videos below:

The birddog exercise is a well known exercise to help build core strength/endurance and spinal integrity, and many people do it very poorly. It’s one of those exercises that gets the “yeah, yeah, I already know how to do that one” treatment because it looks so simple and easy. Here’s a new client that came in yesterday for an eval and described a long history of chronic back pain. She actually presented with both flexion & extension intolerance. Sucks. I asked her to show me her birddog because she mentioned she had been performing it all along (top video). I wanted to swallow a live grenade. It wasn’t a great looking exercise. She’d fall into an excessive arch on every rep more or less “feeding” her symptoms. So I took a few minutes and coached her up to clean up the pattern. I got her to find “spine neutral” and cued her to instead of thinking about raising her back (moving) leg UP, to move it BACK instead. To help with this I also had her place her foot on a ValSlide so as she extended her leg back she couldn’t arch through her lower back (sorry my video taking skills sucked here and I didn’t show the ValSlide. I promise it’s there though). Once there, and her leg was fully extended, I had her ever so slightly lift her foot off the slide an inch or two (not much) and then “own” the position for a few seconds. As you can see a HUGE improvement. Talking the time to coach your clients up, even on the seemingly “easy” exercises can make all the difference. I suspect we’ll be able to accomplish a lot in the near future.

A post shared by Tony Gentilcore (@tonygentilcore) on

 

Before = her execution of the exercise was “feeding” into her symptoms and most likely resulted in a kitten dying.

After = ticker tape parade for coaching!

With a just a few subtle cues and a “molding” of the exercise to better fit her current ability level, we were able to significantly clean up her technique and the exercise not only felt more challenging, but she felt better.

  • The difference maker was placing a ValSlide underneath her moving leg so that she’d be less likely to fall into extension.
  • From there, with the leg fully straight, I then had her lift her foot off the ground an inch or two and then “OWN” the movement/position.
  • She then held for a 3-5s count, performed 3-5 repetitions per side, and we then fist pumped to some Tiesto.

Coaching oftentimes involves paying closer attention to the details, even with the more mundane exercise that we often take for granted. With the birddog it often behooves us to slow people down, get a little more hands on with them (provide more kinesthetic awareness), and hold then accountable to be SPOT ON with their technique each and every rep.

This is what separates correctives and programs that work (and serve a purpose) and those that lead to less than exemplary results due to haphazard execution.

CategoriesAssessment coaching Exercise Technique Rehab/Prehab

The Post Where I Tell You It’s Okay to Move Your Spine

Back pain can be tricky. First off, anyone who’s ever dealt with it (pretty much everyone) knows it’s no fun. Second, there’s no overwhelming agreement as to what actually causes it. One person says weak glutes, another says tight hip flexors or hamstrings, and yet another may point to a bad hair day (NOTE: read this footnote, it’s a doozy —>).11

Third, if the stock photo I chose below is any indication, back pain can also put a real damper on what can only be described as an Old Spice or Abercrombie & Fitch ad shoot.

Copyright: olegdudko / 123RF Stock Photo

 

In my career as a personal trainer and strength coach I’ve worked with dozens and dozens of athletes and clients battling low back pain. It comes with a territory as a fitness professional. I’ve tried my best to arm myself with the best skill-sets possible (within my scope of practice) to help my clients work through their low back shenanigans. I can assess – not diagnose – and try to come up with the best game plan possible to address things.

And, to be honest, addressing one’s lower back issues can be mind-numbingly simple.

In short:

“Find what movements hurt or exacerbate symptoms, don’t do those movements, and then find movements that allow for a degree of success or pain free training.”

I’d be remiss not to mention Dr. Stuart McGill’s work here. Not only is he one of the world’s Godfathers of spine research, but he’s also one of the world’s best mustache havers.

He’s co-authored hundreds of studies and written several books on the topic of low-back pain – with Ultimate Back Fitness & Performance (now in it’s 6th Edition) and Low Back Disorders being his flagship pieces of work.

Speaking of Ultimate Back Fitness & Performance, look who makes a cameo appearance on pg. 289 in the latest edition:

BOOM

For the Record: TG Life Bucket List

  1. Get to a point in my career where Dr. Stuart McGill not only knows who I am, but emails me out of the blue and asks permission to use a picture of me in his latest book update.
  2. Appear in a Star Wars movie.
  3. Become BFFs with Matt Damon
  4. Own a cat.

I’d have to say, however, that his most “user friendly” book is Back Mechanic. In it, he breaks down his entire method for “fixing” low back pain covering everything from spinal hygiene, assessment, corrective exercise, and strength training.

I’m not going to belabor anything, you can purchase the book and peel back the onion on his protocols (seriously, the assessment portion is gold).

I’ve noticed a trend in recent years, though. Dr. McGill has done so much for the industry and his work is so ingrained in our thoughts as fitness professionals that I feel the whole idea of “avoiding spinal flexion (sometimes at all costs)” has bitten us in the ass.

Yes, avoiding spinal flexion is a thing, especially if someone is symptomatic and flexion intolerant.12. It’s that point, though, “avoiding spinal flexion” that has gotten the best of us for the past decade or so.

We’ve done such an immaculate job at coaching people to know what “spinal neutral is” via prone planks, side planks, and birddogs, and then used strength training to engrain that motor pattern, that (some, not all) people transitioned into more extension-based back pain because they lost their ability to move their spine into (pain free) flexion.

Dr. Ryan DeBell discussed this phenomenon recently where he discussed his own back pain history. He started as flexion intolerant, trained himself into “spinal neutral,” (which is what you should do), started to avoid all flexion like the plague, and after awhile, extension-based movements & positions started to hurt…because he was locked into extension.

As a corollary, I see this quite often myself: someone comes in to see me and both flexion and extension based movements hurt. It’s so frustrating for the person and I can understand why.

My job, then, as the coach is to garner confidence and self-efficacy with my client/athlete and work with him/her on what I know tends to work….find movements that do not hurt and work from there.

Dr. McGill has his own version of the “Big 3,” or his go to exercises when first starting with a low-back person:

  • The Curl-Up (I.e., not a sit-up)
  • Side Bridge or Plank
  • Birddog

Even when we master those movements, which are often very challenging for people when performed right, I’ll stick with them for a couple of months and just up the ante with appropriate progressions. Lets take the birddog for example.

Birddog w/ RNT

 

The band adds an additional kinesthetic component where increased stiffness or engagement occurs in the anterior core and glutes. Truthfully, it’s not uncommon for me to START with this variation so the person can feel what their limbs are doing in space.

Birddog – Off Bench

 

I “stole” this one from Dr. Joel Seedman and feel it’s an ingenious progression. Doing the birddog off the bench takes away a component of stability (feet off the floor) and forces people to slow the eff down and learn to control the movement. If they don’t, they fall of the bench. And I laugh.

Your Spine, Move It!

Going back to the assessment for a quick second, it’s not uncommon for me to assess someone and to find that their spine doesn’t move. Whether it’s because of a faulty pattern or they were coached to avoid flexion at all costs (even when asymptomatic) it’s as if their spine is Han Solo frozen in carbonite.

One screen I like to use is a the toe touch drill. When someone bends over to touch their toes there should be a consistent curvature/roundness of the spine. Often, what I’ll see is more of a “V” pattern where they’ll bend over, but instead of seeing a nice curve I’ll see their lower back stay flat throughout the movement; as in zero movement.

This can be just as detrimental as anything else. It may or may not be a root cause of their low-back pain, but I know it’s a red flag I’d like to address.

Segmental Cat-Cow

Below is a drill I’ve been using more and more with my low-back clients. We’re all familiar with the Cat-Cow exercise, where you round and arch your spine moving through a full-ROM.

Cool, great. The human body is great a compensating, and unless you have a keen eye for detail it’s easy to assume that if someone can round and arch their back they’re good to go. But

But are they? Often, if you SLOW PEOPLE DOWN it’ll become abundantly clear that they may move well in certain areas of their spine (thoracic), but not in others (often lumbar).

Coaching them through the movement – point by point, segmentally – is a fantastic way to hammer this point home and to help nudge them to move their spine in a slow and controlled fashion.

 

Give this one a try with some of your clients. COACH THEM. This drill doesn’t require more than two passes (up and down) per set, for a total of 3-4 sets. Helping them understand that they are allowed to move their spine – assuming it’s pain free – is a sure fire way to set them up for long-term healthy spine success.

CategoriesAssessment Corrective Exercise mobility Program Design

4 Ways to Fire Up Your Belly

Today’s guest post comes courtesy of Gavin McHale, a Certified Exercise Physiologist from Winnipeg, Canada (in his words, straight north of Fargo). Gavin attended a workshop I did with Dean Somerset in Minneapolis a few weeks ago and he wanted to write up some of the things he picked up from it.

Read on to find a breakdown of how you can clean up your shoulders and hips, lift more weight and allow yourself to relax, just by changing the way you breathe.

Copyright: sunlight19 / 123RF Stock Photo

 

4 Ways to Fire Up Your Belly

Let me paint you a picture.

A client or physical therapist refers someone to me and they walk in ready to get their ass handed to them. After our initial conversation, I tell them we’re going to start the session with some breathing drills.

They often glaze over and assume it means something else, until I tell them to lie down and take a deep breath.

“Wait, you just want me to breathe?”

“That is correct.”

Almost every time, I can provide a new client a take-home benefit with a couple of breathing cues, all inside the first 2 minutes on the gym floor.

Image courtesy of Crossfit Southbay, via A.D.A.M

Why, you ask? Well there are lots of reasons why breathing is a good practice to get into, and I’m not talking about the breathing we do mindlessly, day-in day-out. I’m talking about mindful “diaphragmatic” or “belly” breathing.

We live in what I’d call a very sympathetic world. Our sympathetic nervous system, also known as fight-or-flight, is cranked up all the time. We have to drive to work in traffic, get a project done, feed the kids, manage the mortgage… you get the point.

All this stress kind of shuts down our parasympathetic nervous system, also known as rest-and-digest. You know, the one that fixes all our shit? Ya, that one.

The diaphragm is actually intended to be our body’s primary breathing muscle, but as a consequence of modern life, it’s been shunned like Tony and I are by all those cat haters (I see you). Instead, the much less efficient breathing muscles of the upper chest and neck then must take over, creating all sorts of issues.

Although it doesn’t look very sexy, diaphragamatic breathing allows us to create a better balance between fight-or-flight and rest-and-digest, and could be the key to fixing a lot of movement issues as well.

When we breathe, this dome-shaped muscle contracts, allowing the lungs to take in air. What we should see is the stomach rising as the dome compresses the abdominal cavity. This is why I tell my clients to try and “get fat” if they’re having trouble figuring it out. I often see the exact opposite, and while it may present a more pleasing side profile, it only allows the lungs to partially expand and results in weaker core stabilization.

 

So why do we do it?

Not only is it a good idea to get back to the muscles we should be using for an activity like breathing, but an under-active or dysfunctional diaphragm is going to lead to movement issues as well. Neck and shoulder issues are the bulk of what I see, but back and hip irritation have also been linked to breathing concerns.

Proximal stability leads to distal mobility.

If we can create more stability in the core and centre of the body, the limbs and other areas where we need to be more mobile are free to do their job as well.

Test/Re-Test

Below, I’m going to give you several tests to try based on areas that you may have trouble with or issues you want to clean up. The protocol here is to test the movement, correct with a breathing drill, the re-test to see if it got better.

If it did, great! If not, we may have to do some more digging. The breathing correctives are outlined at the end of the article.

1. Shoulder Issues

I found it very interesting how many people had shoulder pain and dysfunction when I first started training. I cleaned up their technique, had them pull way more than they pushed and focused on opening up their thoracic spine. Things got better, but never really got better, ya know?

Then I went further down the rabbit hole and recognized there was more to it. I realized that almost all shoulder problems are somehow tied to breathing mechanics, and a couple of simple drills can make a world of difference, especially when done consistently. Here are two (related) tests to see where problems may lie and outline the path to correcting them.

Shoulder Test/Re-Test #1: Active and Passive Shoulder Flexion

*Ideally, the shirt is off for all tests of shoulder function. Although it can be awkward, this allows someone to see exactly what the scapulae are doing during these movements.

You may have to stand against a wall to do this properly, but stand tall and proud and slowly brings your hands up over your head in front of you. Your ribcage should stay down (the back should stay against the wall) and the head should stay in a packed position (no poke-necks).

How high did your arms get? Was there any pain?

Here is Tony showing an example of a bad active shoulder flexion (left) and a good active shoulder flexion (right). If you’re not careful, you may think the “bad” test is better than the good one. A closer looks reveals that Tony is flaring his ribcage, overextending his lower back and poking his head forward. The test on the right is a true test of his active shoulder flexion. Not bad T, but why is your shirt still on?

The passive test is the same as the active test, only lying down on your back. The knees should be bent and feet flat on the floor or table. The ribcage should stay down and lower back flush to ensure a true test.

We will review correctives later in the article.

Shoulder Test/Re-Test #2: Scapulo-Humeral Rhythm (probably need a friend for this one)

Stand in the same position as your active shoulder flexion test, but this time we’re going to bring the arms overhead by your sides, trying to touch the backs of your hands together above your head.

As the arms move overhead, the scapula should rotate ½ as much as the humerus does. So, to get overhead (180 degrees total), the humerus should rotate upward 120 degrees and the scapula should rotate the remaining 60 degrees.

Image courtesy of BEST Performance Group

If there is any pain with this movement, you should see a registered healthcare professional (or refer to one, if you’re a trainer).

However, if you’re a trainer and you notice the scapula isn’t moving as it should (i.e. the medial border isn’t at 60 degrees) see if you just help it along by manually moving it to the desired position.

Better? Great, let’s get to breathing and fix that shit. Still painful? Refer.

2. Back Issues

Everyone who’s ever had or worked with people with back issues raise their hand! Ya, a lot of us have, myself included and it’s no fun. Whether it’s chronic back pain or a little tweak here and there, worrying about blowing your back out is a real concern for many people.

They’re scared to lift things around the house, scared to bend over the wrong way and especially scared to lift a shit-ton of weight off the floor in the gym (covered later). We can’t be having that… let’s fix it.

I said that lower back and shoulder issues can be related because their main structures are intimately connected via the thoracolumbar fascia. You can see the lats (major players in the shoulder) and the glutes (major players in the lower back) in the image below. If you have issues getting your arms overhead, you may very well have lower back problems as well, and vice versa.

Image courtesy of Neil Asher Healthcare

Back Test/Re-Test #1: Active Straight Leg Raise

This one is nice and simple. Lie on your back, legs straight. Lift one leg as high as you can before you stop or you feel pain. The knee should stay straight. Note how high you got. A good score is 90 degrees with no movement in the opposite leg.

Image courtesy of www.FunctionalMovement.com

Back Test-Re-Test #2: Passive Hip Rotation (bring that friend back, you’ll need em)

Lie flat on your back with legs straight and lift one leg. Bend the leg at the knee, coming up to 90 degrees hip flexion. Move the hip into external rotation (foot to opposite hip) and internal rotation (foot outside hip) while supporting the knee. Note the angle achieved with each movement. A good score is 90 degrees from midline for external rotation and 45 degrees for internal.

Photo courtesy of geekymedics.com.

LIFTING HEAVY A.F.

(if you have to ask what it means, you’re not ready for it)

There’s no question that if you’ve ever done a heavy squat or deadlift and not wrecked your back, you know that you need to be able to create massive amounts of tension through your core. If you can’t, you get hurt, pretty simple.

The diaphragm plays a massive role in stabilizing the core. It forms the lid on the “core box”, working with the obliques, QL, pelvic floor and transverse abdominus. Being able to take in air and maintain a high-pressure area in the abdominal cavity is crucial for lifting heavy (another reason I start with breathing drills).

RELAXATION

Remember that sympathetic world I spoke about earlier where most of us live that wreaks havoc on our breathing patterns? Needless to say, it can also create difficulty with relaxation and sleep.

I’m pretty sure most of us (and our clients) can agree we’d like to sleep better.

So, when you watch the videos below, don’t just put them in the “workout” box, but remember they can also have a positive impact on your ability to relax and even fall asleep.

Not only will these breathing drills assist in improving movement patterns, they’ll set up the context for creating tension before and during a heavy lift.

THE BREATHING CORRECTIVES

Prone Crocodile Breathing

If you’re new to the diaphragmatic breathing game, this is your place to start. Maybe you scored poorly on one of the above tests or you have an itch to throw more weight on the bar but aren’t yet comfortable doing so.

Either way, give this drill a shot before moving on.

 

Prone Lengthening

This one is particularly useful if you have trouble with your shoulder and/or struggled with the shoulder flexion and scapulo-humeral tests. Many people’s shoulder dysfunction comes from a number of factors, one of those being tight/ropey serratus anterior. This drill will help to release that muscle, allowing it to do it’s part in moving the scapula to get that arm overhead.

The serratus anterior (SA) works in concert with the upper traps (UT) and lower traps (LT) to allow the scapula to upwardly rotate.

Note From TG: props to Dr. Evan Osar for introducing me to this exercise a few years ago.

 

Crook Lying Belly Breathing

This is another great beginner drill as the lower back is supported and the table or floor can provide external feedback. This is also the best position for belly breathing, allowing the belly to fully expand. Along with the others, this one is great for those with back or hip issues.

 

Quadruped Breathing

This is another great drill for those with issues rotating that scap when going overhead. The serratus anterior is a massive player and if we can get it rotating properly (or at least better than it was), we may be able to provide relief and learn what it is we need to focus on moving forward.

So there you have it, a good, hard look at what we should be looking for and how to make it better, just by changing the way we breathe.

One final note for trainers, make sure you try these yourself as you may find that different cues work better. If you do, please tell me. I want to know all your secrets!

OBLIGATORY PROMOTIONAL PLUG FROM TG (sorry not sorry)

Pretty much everything discussed above is covered in more detail in mine and Dean Somerset’s Complete Shoulder & Hip Blueprint which is being released this week (Nov. 1st).

hipandshoulderfb-banner

In fact the site goes LIVE tonight. You can check back HERE at midnight to get in on the action. It’s totally going to be like a Harry Potter book release! Except, you know, without wizards and Sorting Hats and shit.

Author’s Bio

gavinGavin McHale is a Certified Exercise Physiologist from Winnipeg, Manitoba, Canada (straight North of Fargo).

He loves getting people to lift things they never imagined they would both in-person and online.

He also likes to lift said heavy things and, much like Tony, loves cats.

Check him out at www.gavinmchale.com.