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
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
In this issue, Mike O’Hara, PT gives ten reasons to love lunges. Video of lunge exercises/progressions are included. In Going Grizzly, Mike presents the exercise combination of Crawls and Sandbag Carries; a combination that helps you train more efficiently and move better. Watch the video for instruction on these exercises.
Testing Fitness Readiness
Isometric Spinal Extension Strength Test
A big problem in the fitness industry is that there are no standardized performance evaluations that participants must achieve in order to begin or progress in an exercise activity. Anyone, no matter how deconditioned, posturally flawed, and orthopedically challenged can walk into the gym and get a workout. As a strength and conditioning coach, the present “free for all” system is a challenge that at times can be very frustrating. As a physical therapist treating orthopedic injuries on a daily basis, the present system keeps me busy. Performance tests and movement assessments identify asymmetries, strength deficits, and potential pain problems. A good coach uses assessments to determine the appropriate exercise prescription for their client. I will be posting some basic user-friendly performance assessment tests that should be a part of all fitness programs. If you pass the tests, congratulations and keep up the good work. If you did poorly on the tests, you need to get to work on improving your performance.
Isometric Spinal Extension Strength Test
The muscles around your spine and pelvic girdle are designed to reduce and not create motion. They are isometric muscles that brace the torso and pelvis to create the pillar strength you need to carry in firewood, lift the wheelbarrow, or push the lawn mower. The Isometric Spinal Extension Strength Test is an assessment of the component of core stability that isometrically resists spinal flexion. This test is used in industrial medicine to assess a worker’s ability to return to material handling tasks. In my evaluation of fitness clients, it is often the stability test with the most significant deficits.
You need a Roman Chair or Glute-Ham Developer Bench to perform this test. The support pad of the bench should be on the front of the thigh just set below the pelvis. Position your body so that the ankles, knee, hips, and lumbar spine are in one long line that is parallel to the floor. Cross the arms across the chest and hold a solid, floor parallel position as long as you are able. Pain with the test is a fail and you need to be evaluated to find out why the test is painful. Less than thirty seconds is a poor grade. You need to improve your performance, and in the meantime, avoid activities that require you to resist spinal flexion-resisted squats, deadlifts, kettlebell swings, and bent over rows. Thirty to sixty seconds is a fair grade and clears you for most resistance training. Athletes and those involved in occupations that require lifting and carrying need the isometric strength that permits a sixty-second hold.
Michael S. O’Hara, P.T., OCS, CSCS