Lumbar Spine Fitness Guidelines
Janet injured her lower back while exercising in her local gym. She was taking a trip through her favorite “ab ciruit” when she felt a snap in her lumbar spine. The next day she was unable to stand up straight. Two weeks later, we met her in physical therapy for her initial evaluation. She was ready to return to her fitness program three weeks later. Janet was very concerned she may suffer another exercise induced back injury and requested some advice. These are the simple guidelines I give to physical therapy low back patients returning to exercise.
Mobilize the Thoracic Spine and Hips
Movement is supposed to happen at the thoracic spine and hips. Unfortunately, prolonged sitting, deconditioning, and poor training choices tends to restrict mobility in these areas. If you are unable to rotate and extend at the hips and thoracic spine, your brain will use other joints to make up for the deficit. Pushing extra rotation and extension forces into your lumbar spine is never a good thing. Dedicate some training time to improving thoracic spine rotation and hip extension / internal rotation range of motion. If you sit for a living, work on your mobility everyday.
Make the Lumbar Spine Stable
Most fitness clients believe that more lumbar spine movement is a good thing. They perform toe touches, back twists, and the many breeds of up and down dogs. Unfortunately, greater lumbar spine range of motion is positively correlated with a higher incidence of lower back pain. The incidence of low back pain escalates even further when we move those hypermobile lumbar spine segments against a resistance. What does keep lumbar spines healthy is high level of lumbar spine strength endurance. Can you hold the lumbar spine stable and prevent movement from occurring at the pelvis and five lumbar vertebrae. Your lumbar spine stays happy and healthy when you focus training efforts on planks, roll outs, crawls, carries, and Pallof press exercises. Avoid the sit ups, crunches, sidebends, toes to bar, and other assorted “ab” exercises that create lots lumbar spine motion.
Avoid Muscle Isolation Exercise Activities
The muscles that support the lumbar spine work together as part of a neurally connected team. Training activities that support better communication between the team members will create optimal performance. The neuroanatomy saying is “What fires together, wires together”. Ditch the “upper abs”, “lower abs” baloney and sprint away from anyone who trys to strap you into a machine in an effort to “isolate your obliques”.
On her discharge from therapy, Janet was unable to perform a single roll out and fatigue fairly quickly with a twelve pound suitcase carry. For the last three months, she has followed the guidelines and her progress has been excellent. Janet is currently performing a suitcase carry with fifty pounds and has worked up to ten full reps on an ab wheel roll out.
Michael S. O’Hara, PT, OCS, CSCS
In the April 2018 issue, Mike O’Hara discusses the benefits of the farmer’s walk exercise. Jeff Tirrell tells you how to reduce injury to your ligaments and tendons, and tips are given for getting back out into the garden.
Preventing Gardener’s Trauma
After a long, snowy Michigan winter, the first warm and sunny day, we charge outside and clean up the yard. The months snow bound in the house have made the gardeners eager to start the spring clean up and prepare for the summer to come. Most of us will spend the winter in a fairly sedentary physical state and with no physical preparation to launch into hours of challenging outdoor work activity. Every year at our clinics, we treat patients with gardening and yard work induced injuries that could have been prevented with some modifications of activity and preventative exercise. These are my four hints to help safeguard my gardener friends from an unintended trip to the doctor’s office.
#1: Set a Time Limit.
Most of the patients we see with gardener trauma report that they worked “all afternoon” in the yard. It is not uncommon to hear patients report they were bending, pushing, or pulling for five or six hours. Use some caution and limit the duration of your weeding, raking, and shoveling. Set a time limit of two hours and then stop–the garden will be their tomorrow and you will be less likely to have to undergo a springtime MRI.
#2: Use Proper Ergonomics.
Many gardening tasks place your body in challenging positions. Ergonomic experts go to great lengths to eliminate forward trunk flexion and sustained knee flexion from industrial work settings. Pulling weeds and cleaning out flowerbeds combines both of these positions and can create mechanical back and knee pain. Avoid being in the “hands and knees” position for extended periods of time by changing positions frequently. Use knee pads to reduce compressive forces on the knee joints and purchase gardening tools with extended handles so that you need not bend as far or as often.
#3: Avoid Lifting Heavy Objects.
After a sedentary winter spent indoors watching television and knitting, the last thing you should attempt is to hoist the 40 lb. bag of fertilizer into the back of the wheelbarrow. Lifting injuries increase dramatically with loads greater than 25 pounds. Lifting any object from the floor to standing is risky, and carrying unstable loads that can shift around increases stress on the body. Divide heavy loads into smaller portions and avoid lifting directly off the floor. Get a bigger, stronger, and fitter neighbor or family member to help with heavy lifting tasks.
#4: Prepare For Battle.
Gardening and yard work are challenging tasks that should be met with a degree of preparation. If you want to work for five hours in the garden and remain pain free, you must train your body for that level of activity. I have selected three simple exercises you can do to get yourself ready for action in the yard. Simple modification of ergonomics, limitations on work duration, and preparatory exercise can prevent a summer of pain.
Getting Ready To Toil In The Soil.
These three exercises can help you avoid injury and make your spring gardening safer and more productive. Ideally you will perform these drills three times a week for two or three weeks before getting outside and working.
Hip Flexor Stretches
This stretch elongates the large muscle that runs across the front of the hip and attaches to the spine. This region tends to tighten with prolonged sitting and can restrict hip and spinal motion. Place one knee up on a cushioned chair and the other foot slightly forward on the floor. Keep the spine tall and bend the front knee to stretch the hip flexor muscles. Hold for five to ten seconds and repeat five times. Perform the stretch on the other side.
Four Point Fold Ups
If you are going to spend time on all fours, it is a good idea to train your body for this task. Assume a four-point position, knees under the hips and hands under the shoulders. Keep the hands stationary and drop the hips back toward the heels. Go back to the point you feel a stretch and hold–do not stretch into pain. You may feel this in your hips, shoulders, lower back, or upper back. Hold for five to ten seconds and repeat five times.
Gardening and yard work involves a lot of squatting. Being able to safely squat allows you to lift with better body mechanics. Simple bodyweight squats will strengthen the legs and trunk in preparation for these tasks. Place your feet at least shoulder width apart. Check the foot width with a full length mirror– most people squat with the feet too close together. Keep the heels flat on the floor and squat down by pushing the hips back. Work on maintaining balance and control during the motion. Practicing this movement pattern will also improve your flexibility. Perform a series of ten repetitions and then rest and perform another set of ten.
Michael O’Hara, PT, OCS, CSCS
In the February issue of our newsletter, Mike O’Hara discusses ways to improve hip mobility and strength. Read Jeff Tirrell’s article on why dairy products may actually be good for you. Having back pain doesn’t mean you can’t have a fitness program.
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