5 Lessons Learned From Training Those With Low Back Pain
Fri Dec 11, 2015 by Dean Somerset
This post was authored by Dean Somerset and originally posted on Eric Cressey's blog. It's reposted here with permission.
I’ve had the distinct honor of working with a wide variety of clients. Some have been fresh from spinal surgical intervention following an injury, others had congenital issues where they were born with some sort of spinal irregularity, others just had low back pain. I’ve also worked with some Olympic champions, Paralympic hopefuls, professional sports teams, and pretty well every type of client in between, and today’s post is all about highlighting some of the commonalities among these very broad and different types of clients.
Here are 5 things I've learned from working with clients who have low back pain:
#1. They Usually Do Something Poorly.
I had the opportunity to do end-of-season testing on a local professional hockey team a few years ago. This meant I had direct access to some of the best hockey players in the world to see how they moved. While they could likely outskate and maneuver anyone on the ice, their ability to control their movements in the specific tasks asked were somewhat shaky on occasion, and in some instances, consistently so through the entire team.
Consider hockey players live their entire lives with their sticks on the ice and bent over. Shoulder pads prevent a lot of overhead movement, and getting checked into the boards frequently can cause some significant wear and tear on the shoulder joints, not to mention the rest of the body. Its no surprise very few of them had the ability to score well on an overhead squat assessment since they only ever put their arms overhead when they score a goal, and if you’re on an offensively challenged tem, that won’t happen much.
Additionally, since flexion is such as important position for their sports, they had no problem doing that, but had a lot of trouble controlling their spines into extension. The goalies could hit the splits in any direction, but many of their leg movement testing would have indicated that they were “tight” and required more stretching. If someone can go in and out of the splits in multiple directions, they don’t need more stretching.
With many people who aren’t elite athletes, they’ll also have some sort of a wonky movement pattern here or there. These may not directly cause injury, but they might increase the relative risk that something could happen. Think of a hip hinge, for example. A known mechanism of injury is low back flexion with loading and some degree of rotation. This is the common first timer setting up for a deadlift and not knowing what the heck they’re doing. In fact, that’s how Rob Gronkowski injured his back when he was a standout at Arizona and almost cost him a shot at the NFL.
The thing about increased risk is it won’t guarantee an injury occurs, just that there’s more likelihood that it would. If I bought a lottery ticket, there’s a 1 in 15,000,000 chance that I win big. If I bought 1000 tickets, there’s now a 1,000 in 15,000,000 million chance that I win, or 1 in 15,000 chance. It doesn’t mean I will win, just that my odds are higher.
Now, if I were to teach that beginner how to hip hinge well and reduce the pressure on their low back while also using their hips to produce the power for lifting the weight, there’s a greater chance that they will be successful and less of a chance they will get injured. Gronk showed even a great athlete who is unfamiliar with a certain movement can still do it with risk, and still get injured, just like a beginner stepping foot inside a weight room for the first time.
#2: The Value of Isometric Exercise Can’t be Overstated.
Dr. Stuart McGill’s lab at The University of Waterloo recently released a very interesting study that looked at the effects of using isometric exercises like planks and dead bugs as well as more dynamic exercises such as Russian twists and rotational throws to train the core in two very different groups:
a) beginners who were naïve to resistance training and exercise in general,
b) Muay Thai athletes who were savvy to training concepts and instructions.
Half of the naïve group did isometric training and half did more dynamic training, and the same went for the savvy group. There was a control group as well; they didn’t train for the 6-week duration of the study.
Afterwards, all training groups saw improvements in both their fixed core strength and range of motion, and also in their response to more reactive stress to the spine. The isometric groups in both the naïve and savvy groups saw bigger improvements than the dynamic training groups.
“Isometric moves not only extend your core’s time under tension but also reinforce its primary job: staying stiff to protect your spine and transfer energy between your limbs.” - Stuart McGill.
While isometric exercises may seem very rudimentary and “beginner,” they can still prove beneficial to more advanced athletes and lifters, especially in terms of ease of set-up, relative risk to the individual doing them, and - most importantly - in quantitative outcomes, such as those measured in McGill’s research. It’s very exciting to see that a basic staple exercise, performed well, can benefit individuals of all experience level.
Here's an example of a Dead Bug, demonstrated by Dr. Greg Rose. There are a ton more variations on TPI's site.
#3: Breathing is More Than Just Inhale/Exhale.
Getting beginners to do core-intensive training usually results in one question from me, repeated consistently through the entire series:
“Are you breathing?”
A go-to response for many is to hold their breath through core intensive movements. While this isn’t a bad response per se - especially if they’re trying to use a valsalva to increase spinal stability during a movement like a deadlift - not being able to inhale and exhale in pace with an exercise can actually reduce the effectiveness of the exercise. Additionally, the speed of breathing can dictate whether a movement is more of a relaxation or mobility movement or whether the goal is speed and reactive capability development. In either case, being able to breathe through an entire set is vitally important to see the best potential improvements.
When breathing for improving mobility or parasympathetic activity, inhales and exhales should be long and full. I usually recommend 3-5 second inhalations and 3-5 second exhalations. For speed and power development, inhales are best with more of a sniffing action where air is taken in quickly and with some development of negative pressure through the ribs and abdomen, and exhaled forcefully and quickly, much like a martial artist throwing a strike. Boxers do this very well, exhaling on impacts to improve not only their ability to not gas out, but to improve the stiffness of their spine to improve the power of their punches.
This short, sharp exhale causes the abdominal muscles to brace very hard and very quickly, essentially momentarily turning the core into stone to allow for a solid strike to generate some impact.
Try this while you’re reading this article: place a hand on your stomach and sniff in quickly through your nose and feel what the abdominal muscles do. Then exhale sharply through pursed lips, like you would if you were throwing a very crisp jab. Did you feel how hard the abs became for the second you inhaled and exhaled? That’s your power center.
Clients along the entire continuum from rehab to elite performance can benefit from learning how to use their breathing to develop the specific goals they’re looking to accomplish. Rehab clients can use the sniff inhale and hard exhale effectively, as it doesn’t necessarily apply aberrant stressors to the spine or connective tissue, but does have a beneficial effect on the strength and reactivity of the core girdle as an entire unit. Simply doing forceful breathing, when appropriate to do so, is itself an effective conditioning tool for many.
#4: Core Strength Training Should Trump Core Endurance Training.
What’s more likely to lead to problems: having to lift 5 pounds 50 times, or having to lift 50 pounds 5 times? Most people would say lifting the heavier weight would be riskier, and I would say if the person didn’t know how to move it to reduce their risks and to take advantage of their leverages, then yes.
However, many training programs heavily prioritize development of core endurance, with higher rep ranges and longer duration isometric holds. While endurance is important, I would argue the ability to generate repeated bouts of higher threshold contractions would have much greater implications to spinal protection, athletic development, and resiliency, while also making the lower threshold contractions less stressful to the body.
A simple way to do this is to alter the methods used to get to a specific volume of training. For instance, let’s say you want to do three minutes of planking. You could do one long sustained plank for 180 seconds, or you could do 18 bouts of maximum intensity 10 second holds, where the goal is to try to contract everything so hard that your hair follicles turn into diamonds and you make it rain like never before. The three-minute sustained plank will challenge you, but you’ll be able to still do something afterwards. The 18 rounds of 10 seconds max effort planks will wreck you.
Consider it for strength training as well. Instead of doing 3 sets of 10 with a moderate weight, use a more challenging weight to get through 6 sets of 5 and using an appreciably heavier weight.
For lower capacity clients, this can be a great way of building up volume for those who may not have the endurance to go through longer sets or bigger volumes all at once. It also allows for more set-up and learning opportunities for each exercise than doing one or two larger volume sets would allow.
#5: Core Training Should be Vector, Speed, and Intensity-Specific, Not Just Muscle Specific.
Training a movement like an anti-rotation press to overhead raise sounds awesome and does a lot to work on controlling stability through transverse and frontal plane, all in a relatively slow and controlled manner. Asking, “What does this work? Like, your obliques or something?” can be a fair question, but only scratches the surface of what’s going on.
For athletes who compete in relatively specific directions and actions without the elements of contact and chaos, they can benefit from training with a high degree of specificity to their goal activities (although the athlete should be sure to train in both directions). For the less specific athlete or for the non-athletic client, they can still benefit from more variable-dependent training, depending on their goals. For instance, a 50-year-old accountant with a history of low back pain may not need to do max velocity rotational throws, but they could still benefit from some rotational velocity training to help prepare them for the eventual frozen sidewalks that they’ll have to walk around in Edmonton in a few months, or perhaps for the games of golf they’ll play when they Snow Bird south for the winter.
For rehab clients, the direction-specific element speaks volumes to whether they have a directional intolerance to certain movements. For instance, some clients can’t handle flexion-based movements very well, so involving some flexion progressions they can work with would be good, whereas full range crunches probably wouldn’t be beneficial. Slower movements to develop control would be important, but involving some higher velocity movements they could control and replicate would also be beneficial in case they encountered those kinds of scenarios on their own. An example would be if they stepped off a curb and had to catch their balance before falling or jerking their spine into a potentially disastrous situation.
To recap, everyone from elite athletes to recovering spinal injury clients and everyone in between can involve core training into their programs in very similar ways, but with minor differences here and there to accomplish their specific goals. Most of the time it’s pretty easy to do, if you know how to do it.
Dean Somerset BSc. Kinesiology, CEP, CSCS, MEPD is a trainer who specializes in injury and medical dysfunction management through optimally designed exercise programs. Website: http://www.deansomerset.com/