Here is Part Two of Dr. Michael Stare’s guest post on spinal health from yesterday.

Enjoy the weekend!

In part one I focused on discussing the debate about bracing or hollowing the spine for optimal stability, and revealed evidence suggesting that focusing on just on muscle is a flawed method of improving stability and treating low back pain.Rather, I suggested that the focus should be geared towards improving position sense, or lumbopelvic proprioception.

Then I discussed why imagining has a very limited and potentially negative role in helping diagnose and treat low back pain.

In part 2 I’ll offer insights about whether spinal flexion and rotation is really bad for the back, then provide suggestions for preventing and treating low back pain.

Are spinal flexion and rotation bad or not – What gives?

This issue seems to confuse many, mostly because like most things it can’t be discussed in absolutes. Plenty have offered their opinions, but few of those opinions are from those who treat back conditions for a living.

So here’s my take:

Flexion and rotation of the spine is just fine. But when you do it repetitiously without breaks, with high speeds, and heavy loads or light loads held away from your body, or sustain these positions for long durations you are asking for trouble. Still, under these circumstances, healthy spines won’t have many problems.

Now this is the key point that I believe gets lost on most: very few people have healthy spines!!

The fact is, many of us have abused the bajeesus out of our spines. In this context, rotation and flexion become even more risky, especially under the conditions described above. Then, let’s consider the state that many people are in – acute pain. Under these circumstances, rotation and flexion are like chewing on a steak with an abscessed tooth.

Now there are some back issues (extension sensitive spondylolisthesis and stenosis) where flexion might be just fine, but for most with disc issues, the above statement applies.

Like most things, the appropriateness of flexion and rotation applies to context.

So the follow-up to this, then, is what about athletes or fitness folks with little to no low back pain that want to keep it that way? Should they avoid exercise that involves flexion and rotation?

The best way to answer that is: what are the benefits of these movements compared to the risks?

A simple way to look at this is to view the programming of those who treat high level athletes. Several have taken a cue from McGill and greatly reduced the amount of flexion and rotation based exercises in favor of anti-flexion and anti-rotation exercise, or emphasizing full body rotation (emphasizing the hip and thoracic spine versus lumbar spine). This approach has a strong biomechanical rational, considering the high failure rate lumbar tissues experience during flexion and rotational based motions, as well as data suggesting that many sports motions involve limited segmental rotation or flexion of the spine. It’s hard to argue the success with such an approach.

Just ask Tony and Eric about the mph they add on pitchers doing mostly heavy compound lifts.

Here’s some more interesting biomechanical data about the lumbar intervertebral disc as it relates to rotation. Studies show that the lumbar annular fibers can lengthen to about 4% of their resting length, after which point annular fibers tear. After these fibers fail, the next constraint to rotation is the facet joints.

And yes, as you can imagine, repeatedly smacking facets together can lead to joint damage and fracture, giving rise for spondylolysis and spondylolisthesis.  This maximal lengthening tolerance of the annular fibers occurs at about 3 degrees of segmental spinal rotation. Given 5 segments of the lumbar spine, we are looking at 15 degrees rotation total. That’s not much.

Accordingly, it seems to behoove us to focus on getting more motion from other areas best suited for rotation. Yes, that means hips and thoracic spine.

So, considering that most of us beat up our spine enough by sitting at computers and doing stupid things throughout our twenties rendering these tissues less capable of withstanding abuse, I’m going with the approach that minimizes flexion and rotation during training. Many herniated L5-S1 disc and other happy backs I treat agree.

Note from TG:  Granted the guy in the video isn’t in his 20s, but this is the kind of batshit craziness the good Doc is referring to (I think.  Well, I’m pretty sure it is.  Wait, what are we talking about again?):

So what should you do to prevent back issues?

Prevent is the buzz word, but I think what we really mean is reduce likelihood of back problems while being very active and doing what we want. If you really wanted to “prevent” back issues, don’t use a computer, play golf, row a boat, or have kids. With that out of the way, try the following:

1. Don’t sit without changing positions longer than 15 minutes. Don’t sit longer than 30 minutes without getting up. Don’t sit longer that 7 hrs total a day, including driving.

2. When lifting heavy things, focus on keeping the object close to you. Good spine position is important, but not helpful if the object is at a great perpendicular distance from your spine.

3. Don’t be in any position without moving every few minutes, especially if it is away from neutral spine.

4. Learn to distinguish the warning signs of back issues. Forget distinguishing muscle from joint issues. Few can do it. Nothing good happens after the back fatigues, so that counts. Don’t freak out, keep moving, but reduce intensity and frequency, and start thinking about what might have caused it. Find it and change it.

5. Learn to improve proprioception of your spine. You should be able to easily anteriorly and posteriorly tilt your spine from any position to find neutral spine. Start by practicing in easy positions, like hooklying, and palpate your spine to verify. Challenge it with arm and leg movement. Progress to quadruped and standing. People usually skip this part, especially those who are very strong but have chronic pain. It requires a skilled coach to help you develop and recognize better motor patterns. Here’s a video of me teaching a basic means of using pressure biofeedback to teach proprioception.

6. Have a qualified strength coach develop a conditioning program for you – there’s too much to give it justice in this article. Key points would be trunk endurance, producing power with the hips, learning how to pull with your scapula versus arms, avoiding stupid high risk stuff, etc.

What should you do to treat back issues?

I’m sure you appreciate that no good clinician will tell you in an article exactly what you need to do to fix your back. The process involves too much human interaction to articulate a comprehensive solution for your specific scenario. However, there are a few generalities that should help clinicians, coaches, athletes, and patients move towards an effective treatment solution.

Consider the 3 points below:

1. Of course the best option is to see someone who evaluates and treats backs for a living. As a PT I have to say that. I really do believe it, as it will save you a boat load of time and frustration.

And see one quickly.

I unfortunately get disaster cases that come far and wide after two or more failed episodes of “care”. Studies clearly show that the quicker you see a PT, the quicker you get better and the less health care dollars we spend (by the way, I’m sure good chiros would see the same – just reporting on what the research said).

The main reason you want to see a spine specialist for your back issue is to rule out red flag issues that require immediate non-conservative care (requiring a referral to a surgeon or PCP to address non-musculo skeletal causes of LBP).

This scenario is rare, but can prevent a serious problem from getting worse. The other major reason you want to see someone is so they can educate you about self management strategies before you inadvertently make things worse.

2. Spend a lot of time investigating why the pain is there. I tell patients and colleagues this all time during my seminars: the patient always has the answer.

It’s up to the clinician to help them reveal it. There are many parts of the history that are used to reveal the answer, but the following questions are vital for tricky cases when the pain gradually comes on overtime with no clear event. If you are seeking treatment, make sure you have answers to the following:

• What makes your pain worse? Or put another way, if you were to receive $500 to bring on your pain, what would you do? When you get your answer, avoid this activity, think about other activities that involve similar motions and avoid those as well. As soon as symptoms calm down, then work to modify those activities. In cases when those activities can’t be avoided, immediately work on strategies to modify them.
• What activities make your symptoms better? Again, this tells you a lot about what to do to treat your back. For example, if someone feels better laying on their back with their knees bent and feet resting on an ottoman, then I’m fairly certain deloading activities will help them. Check out my T-nation article from several years ago for some pics of some deloading exercises.
• How has your life changed in the weeks prior to the onset of symptoms? Many times, changes in jobs, moving, weather (ie lots of shoveling, raking, or gardening) or less often changes in your workout, may serve as a catalyst for the onset of low back pain. This is vital to know, because it tells you that your treatment must eventually involve modifying these catalysts so the issue doesn’t resurface. Failing to do this is the reason why LBP so frequently reoccurs.

Remain as active as possible. Movement can help the diagnostic process, facilitate healing, prevent fear avoidance behaviors, keep you sane ( a big issue for fitness freaks like me and probably you as well who need to exercise), and has profound effects on the neurophysiology of pain. This can seem overwhelming or impossible, so yet again a great reason to have a good clinician/coach to help.

I hope you found this to expand your view of low back pain. I believe understanding the above issues with allow you to better prevent and treat low back problems while continuing to seek optimal performance. Feel free to let me know if you have any questions – I would love to help!

Author’s Bio

Dr. Stare is the Director and Co-owner of Spectrum Fitness Consulting, LLC, in Beverly, MA, where he trains clients of various fitness levels seeking weight loss, improved health, and performance enhancement. Mike received his BS in Kinesiology from the University of Illinois at Urbana-Champaign, his MS in Physical Therapy from Boston University, and his Doctorate of Physical Therapy from the Massachusetts General Hospital IHP. Mike is a Fellow of the American Academy of Orthopedic Manual Physical Therapists and also practices with Orthopaedics Plus in Beverly, MA as a Physical Therapist.

In addition to his clinical practice, Dr. Stare lectures nationally to fellow clinicians regarding the proper treatment and prevention of lumbar spine disorders and  fitness. He also provides seminars locally on weight loss, performance enhancement, and rehabilitation for young athletes to seniors. Dr. Stare has obtained the Certified Strength and Conditioning Specialist (CSCS) distinction, which is regarded as the gold standard certification in the fitness industry. Mike is also a Board Certified Nutritionist by the American College of Nutrition, and has been training clients for over 15 years. Mike resides in Windham, NH with his wife and three girls. To learn more about Spectrum Fitness Consulting, go to www.spectrumfit.net.