Finding Fitness With Lower Back Pain
The number of USA emergency room visits, pain medication orders, injections, imaging studies, and surgical interventions directed at lower back pain continue to rise. I frequently meet people who report their fitness efforts have been hampered by low back pain. I have five recommendations that can help fitness clients with lower back pain have more success in the gym.
#1 Do not exercise first thing in the morning: Ergonomic experts have found that many more industrial lower back injuries happen in the morning. The theory is that the discs in the lower back imbibe or gain fluid overnight and are more likely to deform with a physical challenge. Give your lower back one or two hours of walking around time before starting an exercise session.
#2 Isometric strengthening of the spinal stabilizers: The function of your “core” muscles is to limit movement of the lumbar spine and pelvis. Stop all crunches, toes to bar, sidebends, sit ups, seated twisting, and learn how to perform bird dogs, side hovers, Pallof press, planks, and carries. Compliance with this single hint would reduce USA expenditures on lower back pain dramatically.
#3 Enhance the function of your hip flexors and gluteal muscles: Please cease all the forward spine flexion, toe touching, spine twisting activities. Greater lumbar spine range of motion is associated with more–not less, lower back pain problems. Learn how to foam roll and mobilize the hip flexors and gluteal muscles. Prolonged sitting and most popular “cardio training” deadens these muscles. Properly functioning hip flexors and gluteal muscles keep the pelvis stable and take stress off the lower back. Reawakening dormant gluteals and hip flexors is the magic that resolves long term lower back pain.
#4 Focus on single leg strength training: Ditch the front loaded hip hinges–deadlifts, cleans, snatch, and drop the loaded squats. Swear off the lower lumbar deranging leg press. Reduce spinal compression and train the legs, one at a time. Single leg training reveals the right / left side movement asymmetries that drive lower back pain. Resolving these asymmetries and sparing the spine goes a long way to abolishing back pain. You will need some guidance on exercise selection and execution- this brings me to #5.
#5 Get some help: Exercise is the most powerful medication on the planet. Nothing else comes close. Take the proper dose of appropriate training and the results will be amazing. Take the wrong dose of an inappropriate activity and the results can be devastating. This is especially true for people with a history of lower back pain. Find a qualified physical therapist to guide you through your fitness journey. One way or the other, you are going to spend time and money on your health. Proactive spending is always cheaper and more beneficial than reactive spending.
Michael S. O’Hara, PT, OCS, CSCS
In the January 2018 issue, Mike O’Hara focuses on strengthening your hamstrings. Exercises to make your hamstrings stronger, not longer are given along with video demonstration. Jeff Tirrell tells us how to make incremental changes in our diets to see positive changes, and the spotlight is on Fenton Fitness member, Robin Forstat–a nationally ranked power lifter.
Learn how to keep your spinal stabilizers strong by performing side planks. Mike O’Hara explains this in his article, “Learning to Lean”, and includes video demonstration and explanation of the importance keeping your stabilizers strong to stand up to the demands of daily life. It’s time for another Fenton Fitness Love Your Jeans Challenge–see page 3 for more information. In his article, “The Periodization of Nutrition”, Jeff Tirrell gives tips on optimizing dietary intake.
Movement You Should Master
Modern medicine is keeping us alive longer, so now we need to put some effort into staying lively longer. Mastering specific movements will improve our quality of life and help us stay independent and injury-free. I have come up with several exercises you can use to make yourself stronger, more durable, and develop a healthier, more functional body. An exercise that requires no equipment and has bountiful benefits is the Push Up.
Push ups strengthen the pecs, deltoids, triceps. They also allow free movement of the shoulder blades (unlike the bench press) and build stability in the core if done properly. There is no need to get overly fancy with these. If you can’t do a true push up with your chest touching the ground and your core locked in, start by elevating your hands instead of resorting to “girl” push ups on your knees. Guys should try to work up to 3 sets of 20 reps at least a couple of times/week. Women should strive for at least 10 reps but by no means need to stop there. Watch the video and give it a try: https://youtu.be/7oQ-_J8FjEU
-Jeff Tirrell, CSCS, Pn1
Movement You Should Master
Modern medicine is keeping us alive longer, so now we need to put some effort into staying lively longer. Mastering specific movements will improve our quality of life and help us stay independent and injury-free. I have come up with several exercises you can use to make yourself stronger, more durable, and develop a healthier, more functional body. An exercise that I have found to be essential for overall strength is the Deadlift.
At some point in your week, you will need to pick something up off the ground. If you have ever moved furniture or loaded your push mower into the back of your car for repairs, you have seen the value in this task.
Deadlifts are an amazing exercise to work the quads, calves, hamstrings, glutes, core, and entire back all the way up to the traps and forearms. As useful as deadlifts are, they are also one of the most butchered exercises in the gym. I would highly recommend the help of a skilled professional and/or a mirror before implementing this movement into your routine. I find that for the general fitness population, 2-3 deadlift variations are all you need for the bulk of your training. Watch the video and give them a try:
1) One Leg Romanian Deadlift (mimics picking up smaller items around the house or yard; minimizes shear forces on the spine)
2) Hex Bar Deadlifts (great for maximal strength and the occasion when you have to pick up something really heavy) Note: This version offers virtually all of the benefits of a barbell deadlift with slightly more freedom for individual anatomical differences and slightly lower shear forces on your spine.
View video of deadlifts: https://youtu.be/CRbbXOMSeww
-Jeff Tirrell, CSCS, Pn1
How Do They Know What Is Wrong Without An MRI?
This is a fairly common question in physical therapy. Patients with lower back, leg, neck, and arm pain know the test they need is an MRI. They have friends and relatives that tell them they should have an MRI. They are concerned that something is being overlooked and that the pictures from the MRI will make treatment more beneficial. I have some research information on the limitations of a spinal MRI.
In 1994, the *New England Journal of Medicine published a study on physician evaluation of lumbar spine MRIs. The MRIs of 98 asymptomatic individuals –-no pain, feelin’ good people, were found to have disc abnormalities (82% of the MRIs).
-52% had a bulged disc at one level
-27% had a disc protrusion
-1% had a disc extrusion
-38% had an abnormality at more than one disc
Since that publication, several other studies have backed up these results. Bulged, protruding, and extruded lumbar discs are a fairly common finding on a lumbar MRI. Changes in our lumbar discs are probably no different than the wrinkles on your face or the gray in your hair. Changes in a disc’s shape is not a indicator of pain problems
Another **MRI study of athletes revealed spondylolysis (vertebral fractures) are fairly common, yet less than 50% of the athletes with these fractures ever report any episode of lower back pain. It appears that lumbar spine fractures do not always produce pain.
In my years in the physical therapy clinic, I have received the MRI reports of many neck and lower back pain patient’s spines that show disc protrusions and foraminal stenosis on one side of the spine but the patient has all of his or her symptoms on the opposite side. I have treated patients with severe lower back pain and completely normal spinal MRIs.
MRI research has demonstrated that “abnormalities” in our spines are fairly common and difficult to accurately link to any specific pain problem. We do know that once a patient has an MRI, they are far more likely to progress to ***surgery. Please read, The Myth of Accuracy in Diagnosis, by Dr. Ron Fudala. In physical therapy, the resolution of a spinal pain problem starts with a history and thorough physical evaluation. Imaging tests are a small part of the “big picture” and often provide nothing but confusion.
*Jensen MC et al. Magnetic resonance imaging of the lumbar spine in people with and without back pain, New Engl J Med. Jul 14
**Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med, 2000 Jan – Feb.
***Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine 2003;28:616 –20.
Michael S. O’Hara, PT, OCS, CSCS
Standing desks are great for posture and health, but many people have difficulty when they first start using them. In this issue, Mike O’Hara, PT gives exercises that can help you stand for longer periods of time. Watch the video for instruction on these exercises. In his article, “The Biomechanics We All Need To Know, Mike agrees with the advice given by Stuart McGill. Be sure to read about Fenton Fitness Member Jan Pilar and her success with her program.
The New York Times recently reprinted an article by Jane Brody entitled “Posture Affects Standing, and Not Just the Physical Kind.” In the article, Ms. Brody talks about how poor posture creates problems across multiple areas of physical function. The respiratory, digestive, emotional, and neurological systems are all impacted by postural restrictions. You are even more likely to be a victim of crime if you have a slumped over posture. So how do you develop better posture?
Get Up Out of the Chair
Ergonomic chairs, elevated monitors, slanting keyboards, and lumbar supports are fine, but nothing works as well as standing up and walking around every fifteen minutes. Office modifications, while well-intentioned and generally a good idea, cannot compete with endless hours of desk sitting. In order to fight against the postural stress that creates pain, we need to get up and move. Everyone wants an exact number, so I suggest that after fifteen minutes of sitting, you stand up and walk/stretch for three minutes. The best advice is to get a standing desk and completely eliminate working in a seated position.
Perform Posture Correction Exercises Every Day
If you want to abolish the neural and connective tissue restrictions created by postural flaws, you need to work on it every day of the week. Two or three visits to the gym will not be enough. You need lots of repetitions over a long period of time to reverse the changes created by hours slumped over the desk or strapped in a seatbelt. Specific exercises that wake up your nervous system, strengthen your postural muscles, and reverse tissue shortening are required. It should take you no more than 90 seconds to complete one or two of the exercises listed below. Set a timer, enlist the help of your coworkers, and work at these exercises every day. See the exercise suggestions and video presented at the end of this article.
“This Feels Weird”
For most Postural Stress Disorder (PSD) patients, standing upright and sitting tall will feel abnormal. Their body positioning neural feedback mechanisms have been damaged by years of improper loading. Feeling better with a more upright and stable posture will take between six weeks and six months to achieve. Very often, “other sensations” go away fairly quickly– Migraine and sinus headache episodes are less frequent. That torn rotator cuff no longer creates shoulder pain. The arthritis in your hip is less problematic. The plantar fasciitis pain in your foot resolves. The pain symptoms caused by poor posture are far more widespread than most people realize.
You May Have To Avoid Certain Activities
Your gym program and recreational activities can make your posture worse. When you exercise, avoid movements or activities that pull your head and spine further into a forward bent position. The rowing machine and the exercise bike are often poor choices. If you have postural problems, do not perform sit ups, crunches, or any other repeated or sustained spinal flexion. Avoid exercises that shorten the muscles in the front of the shoulders such as bench pressing and flys. Most PSD sufferers sit too much, so refrain from any fitness activity performed in a seated position. The most important thing a good fitness coach can do for clients is put them on the path to postural integrity.
How Long Will it Take to See Changes?
Most physical therapy patients report that the exercises get easier and they feel better after three weeks. Postural correction is a long-term project and clients continue to see results twelve months after starting on a consistent program of postural retraining.
So What Do I Do?
The forward head posture of the average computer operator creates all kinds of adaptive tissue changes in front and in back of the neck. Some daily chin tucks can mitigate the damage. Stand at attention, pull your shoulder blades back, and push your chest forward. For many of you, this is going to be challenging. Place you finger tips on your chin and gently push your head straight back. Visualize your head being pulled upward by an imaginary string attached to the crown of your head. Hold for two counts and then release. Perform ten repetitions.
Office workers perform so many tasks with the arms forward and head down that they develop restrictions in the muscles in the front part of the shoulders and chest. Use a doorway stretch to reverse this adaptive shortening. Stand up with the elbows placed at shoulder level against the doorjamb. Step one foot forward through a doorway. Hold a gentle stretch for ten seconds and then lower the arms and rest. Perform two or three ten second stretches.
Overhead Back Bend
The sustained forward bent sitting posture tightens the front of the shoulders, inhibits thoracic spine extension, and can mess up your respiration. You can reverse all of these with some overhead back bends. Stand with the feet shoulder width apart. Reach the arms over your head and bend backward. Allow your hips to come forward and lean back into your heels. Breathe in through your nose and let your stomach rise. Breathe out through your mouth and let the abdomen fall. Perform three or four deep abdominal breaths while holding the arms overhead.
Standing Tubing Rows
Prolonged sitting weakens the upper back and shoulder retractor muscles. Standing tubing rows strengthens these muscles. Purchase an all-purpose band ($25.00) from performbetter.com and set it up in a door at work. Grasp the handles and stand tall with the arms extended and tension on the bands. Contract the muscles between the shoulder blades and pull the handles toward your body in a rowing motion. Hold the elbows back for two counts and then return to the starting position. Keep your neck relaxed during the exercise. Perform eight to fifteen repetitions.
View video of these exercises: https://youtu.be/KktwMew5Wks
Read the NY Times article here: http://well.blogs.nytimes.com/2015/12/28/posture-affects-standing-and-not-just-the-physical-kind/
-Michael S. O’Hara, P.T., OCS, CSCS
One of the best training tools is a set of all purpose bands ($25.00 from performbetter.com). These bands are a sturdy, dipped latex product made by Lifeline. They have two handles on one end and a loop system that makes them easy to anchor in either a closed door or around something stable and upright. The bands come in progressive resistance levels and can be integrated into many beneficial exercises. One of my favorite resistance band exercises is the posterior lunge and row.
I like exercise activities that produce a lot of benefit for the time invested in training. These are the big benefits of the posterior lunge and row:
In this month’s issue, Mike O’Hara discusses hypermobile joints and exercise, 4 steps to fitness success are given, and information on how to stop back pain from disturbing sleep is presented. Check out page three for a description of the latest class offered at Fenton Fitness– Suspension Shred.