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
Read about keeping your hip flexors healthy and working well in Mike’s article, Nobody Names Their Child Iliacus. Video instruction of the exercises in the article is available. Jeff Tirrell gives five nutrition rules than can be broke. Find out the correct way to set up your dual action air assault bike.
Find out if you scalenes are causing problems in Mike’s article, Scalene Salvation. Read the inspirational stories of some Fenton Fitness members who conquered osteoporosis.
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.
Hip Lifts and Roll Outs
When designing programs for rehabilitation patients and fitness clients, I often pair up exercises. This practice is commonly called super-setting and it has multiple benefits:
Train efficiently—You get much more work done during your training time.
Abolish performance deficits—Most physical therapy and fitness clients need to work on glaring right vs. left movement asymmetries, postural restrictions, and stability limitations.
Lose weight—Fat loss is a primary goal of most fitness clients. Pairing exercises ramps up exercise intensity and creates the hormonal response that improves body composition.
Move better—Training neurologically related movement patterns improves motor control.
Hip Lifts and Roll Outs
An intricate system of muscles holds the spine upright over the top of the pelvis. This pair of exercises coordinates and strengthens this support system. If you sit all day long, have postural problems, or a history of lower back pain this pair of exercises is worthy of your training time.
This drill coordinates hip extension and lumbar spine stability. It is very beneficial when progressed to the single leg version. Lay with your shoulders across a bench with the head supported. Place your arms out to the sides. Plant the feet on the ground with the knees bent 90 degrees and the shins perpendicular to the floor. Drop the hips to the floor and then push back up with the gluteals and hamstring muscles. Hold at the top for two counts and repeat.
The roll out can be scaled to serve any fitness level. Beginners can start with a large 65 centimeter physioball, and as they become more proficient, progress to a smaller 55 centimeter ball. The closer the hands get to the floor the more challenging the exercise becomes. If you get strong enough, you can perform the forward roll out with a Power Wheel or Sorinex roller.
Kneel on a mat to keep the pressure off your knees. Your femur (thigh bone) is positioned perpendicular to the floor and the hips are hinged at 45 degrees. Place the hands on the front of the ball and the elbows directly under the chin. Brace the abdominal muscles and roll out onto the ball until you feel a challenge through your midsection. Hold in the challenging position for three counts and then return to the starting position.
Perform twelve repetitions of the hip lifts, rest 30 seconds, and then perform ten roll outs. Rest and repeat the cycle. Work up to three sets through this exercise combination.
View video of Mike performing these exercises here: https://youtu.be/Xf08rFU7A4w.
-Michael S. O’Hara, P.T., OCS, CSCS
Three Gifts I Would Give And Three I Would Take Away
Santa Gives You Gluteal Activation
You need a responsive and strong set of butt muscles to function at optimal levels. Many gym goers have gluteal muscles that are neurologically disconnected. The term physical therapists and strength coaches use is “gluteal amnesia.” Our sedentary lifestyle involves very little of the glute recruiting sprinting, deep squatting, and climbing that activates the butt muscles. We mistreat our gluteal muscles with hours of compressive sitting and little in the way of full range hip movement. Most fitness clients are in need of some intensive gluteal training. The hip lift is a simple exercise activity that produces a superior response. See the attached video for a demonstration.
Scrooge the Lumbar Spine Flexion
Drop the sit ups, stop doing crunches, ditch the glute ham developer sit ups, and forgo the toes to bar competitions. Father time, gravity, and the stress of prolonged sitting are already bending our lumbar spines forward all day long. The last thing you need to do is accelerate degenerative breakdown of the lumbar segments with more repetitions of spine flexion. Please forget about isolating abdominal muscles. Instead learn how to control the team of muscles that hold the lumbar spine stable. It is a neural event that is worthy of all your efforts.
Santa Gives You Medicine Ball Throws
Life is an up tempo game. What you do in the gym is reflected in how well you can move during activities of daily living. If you continually exercise at slow tempos you will get better at moving slowly. The capacity to decelerate a fall requires fast reactions. Gracefully traveling up the stairs and getting out of the car are only improved with exercise that enhances power and speed of movement. Medicine ball throws are the easiest way to improve power. Medicine ball throws can be scaled to all fitness levels and are safe as long as you use a properly sized and weighted ball. The large, soft Dynamax balls are a good choice for beginners. They rebound well off of the block walls in the gym and are easy to catch. Do not overload your medicine ball throws, a two to eight pound ball is best for most gym goers. Get with one of the trainers for instruction on adding medicine ball throws to your training program.
Scrooge Sitting Down in the Gym
Movement happens in an upright, standing position. “Seated exercise” is an oxymoron. If you want to improve how your body functions, you must stand up and defy gravity. Every athletic endeavor is performed in a standing position. Seated exercise reinforces poor postural habits and diminishes your capacity to move. I call it the “illusion of exercise” and it will always be highly visible in commercial gyms because it is easy to sell.
Santa Gives You Four-Point Training
Crawling is the neurological training tool an infant uses to develop the capacity to stand and walk. It is the pathway to better motor control and less pain. Nearly every physical therapy patient and most fitness clients benefit from a healthy dose of four-point position exercise. In your fitness program, reinforce the patterns of spinal stability and reboot the postural reflexes with some horse stance horizontal, crawling, and Jacobs Ladder training. Four-point training can be scaled to any fitness level. Watch the attached video for some examples.
Scrooge Elliptical Training
I know you love the elliptical. It is the no impact, cardio darling of the gym but it should be used as a fitness dessert and not a main course. Elliptical training has multiple drawbacks. Ergonomically, it is a one size for everyone apparatus that does not work well for taller or shorter people. When you walk or run, you improve the important skill of stabilizing your body over one leg. An elliptical keeps both feet stapled to the machine and deadens any neural enhancement of balance or single leg stability. Hip extension keeps our back healthy and our body athletic. Maintaining or improving hip extension should be part of every training session. There is no hip extension produced when you train on an elliptical. Many people maintain a flexed spine when they use an elliptical. Sitting produces the flexed forward spine we all need to work against in our fitness programs. The repetitive use of the shoulder girdle is a frequent generator of referrals to physical therapy for head and neck pain. Metabolic adaptation to elliptical training happens fairly quickly. In January, a 30 minute session burns 330 calories, but by June, your body becomes more efficient and that same routine creates only a 240 calorie deficit. The low impact, reduced weight bearing nature of an elliptical makes it a poor choice in your fight against osteoporosis.
I am happy when people are more active. Patients and fitness clients love the elliptical and they believe it helps. Use that belief to keep you motivated and training. I just want everyone to manage the drawbacks of this type of training. Injured people always say “Why didn’t someone tell me?” Before you jump on the elliptical, take ten minutes and improve your core stability and hip function with some four-point exercises and hip lifts. Learn how to throw a medicine ball and stay standing through the rest of your training program. Next Christmas you will thank me.
Merry Christmas and a Humbug to you.
See video of Mike in the gym demonstrating these exercises here: https://youtu.be/H0my94BPHNQ
Michael S. O’Hara, PT, OCS, CSCS
Fracture Facts For Men
Jane Brody of the New York Times wrote a great article on the risks men have for osteoporosis related fractures. The general public views osteoporosis as a “women’s health issue,” but management of osteoporosis and prevention of falls is just as important for men. Although men are less likely than women to sustain an osteoporosis related fracture, they are much more likely to become permanently disabled, or die, from the fracture.
In 2012, an international team of researchers and clinicians launched Too Fit to Fracture, an initiative aimed at developing optimal exercise recommendations for individuals with osteoporosis. In October of 2014, they released a booklet that is available through osteoporosis.ca on managing osteoporosis through exercise. Everyone should read this booklet and osteoporosis patients should follow their exercise prescription. Their work brings clarity to an issue that is currently clouded with poor understanding and a lot of bad fitness advice.
The Too Fit to Fracture researchers recommend that individuals with osteoporosis (with or without vertebral fractures) should engage in a multi-component exercise program that includes resistance training in combination with balance training. Balance train for ten to twenty minutes every day of the week and strength train for 30 to 45 minutes twice a week. Make sure your strength training teaches you how to move correctly and improves the endurance in your back muscles. If you have mild to moderate osteoporosis, balance train and strength train first and foremost, and use any extra time on some low impact cardio training. If you have been told you are at high risk for fracture, keep your focus exclusively on balance and strength training and keep the cardio activities to a minimum.
We know that individuals who participate in consistent resistance training exercises are more likely to have better bone density. Just like muscle, bone is a living thing that grows stronger in response to the force that is placed upon it. The best bone building exercise activities produce a growth promoting stimulus through your skeleton. Bone building exercises are easy to understand but they do require more effort than swallowing a pill or having an injection. Everyone can perform some form of bone reinforcing exercise. Proper exercise prescription and consistent progression can work wonders. See the trainers and physical therapists at Fenton Fitness and Fenton Physical Therapy for guidance.
-Michael S. O’Hara, P.T., OCS, CSCS
View the NY Times article here: http://www.nytimes.com/2016/10/04/well/live/men-get-osteoporosis-too.html?_r=0
Halos And Around The Worlds Are The App For That
Much like the collision avoidance computer systems built into automobiles, our brains run neural software that prevents us from overloading and damaging the spine. If we are unable to adequately stabilize the spine, our neural injury avoidance system prevents us from loading the arms and legs in positions that will produce a spinal injury. Developmentally, we master the capacity to control the muscles in the middle of the body first. What this means for the average fitness participant is that hip/shoulder exercise activities have little value if we do not possess adequate spinal/pelvic girdle stability. Training that enhances the coordinated control of the “muscles in the middle” enables our neural system to produce more efficient, graceful, and pain-free movement.
Halos and Around the World drills improve the coordinated control of the pelvic girdle and spinal stabilizers. They act as a “neural reboot” of the software that controls stabilization of the spine and pelvic girdle. These exercises are easy to learn and require minimal equipment. An Airex pad under the knees makes the exercise more comfortable and you can use a kettlebell, sandbag, or an Iron Grip weight plate for resistance.
Kettlebell Halos in Tall Kneeling
Assume a tall kneeling position on the Airex pad. The knees are under the hips and the toes should grip the floor. Grip the kettlebell by the horns in an inverted position. Make the shoulder girdle muscles active by pulling out against the horns of the ‘bell.’ Brace the gluteals and abdominal muscles and maintain a tall and stable posture during the exercise. Start with the ‘bell’ in front of the chest and circle the kettlebell slowly around the head in the shape of an angel’s halo. Perform three to five halos in clockwise and then three to five counter clockwise.
Sandbag Around the World
Assume a half-kneeling position on the Airex pad. The left knee is under the hip and the toes of the left foot should grip the floor. The right knee is in front of the hip and the foot is flat on the floor. I like the unstable “shifting resistance” provided by a sandbag for this exercise but you can also use an Iron Grip weight plate. Make the shoulder girdle muscles active by pulling out against the handles of the sandbag or Iron Grip plate. Brace the gluteals and abdominal muscles and maintain a tall and stable posture during the exercise. Start with the bag or plate in front of the body at belly button level. Take the implement around the body in a very slow and steady fashion. Each repetition should take at least six seconds to complete. Do not permit the body to shift or shake. Perform three to five cycles in clockwise and then three to five counter clockwise. Switch the leg position and repeat with the right knee down and the left leg forward.
For the next six weeks, perform one of these exercises at every training session. It is surprising how many people report improved capacity to squat, lunge, overhead press, and get off the floor with some dedicated neural retraining of the “muscles in the middle.”
Video demonstration of kettlebell halos and sandbag around the worlds can be seen here: https://youtu.be/LGodn9ImRqc
Michael S. O’Hara, P.T., OCS, CSCS
The September 2016 newsletter contains information on preventing ankle sprains. Mike O’Hara, PT demonstrates exercises to prevent ankle inversion. Meet Fenton Fitness member Gay Adams and read her story on staying strong during a difficult time, and learn about the suitcase carry–a better alternative to weighted sidebends.
Fitness training for those of us past 40 years of age is more complicated. Physical performance and recovery capacity are dramatically different. If you need proof, look for the forty year olds in the NBA or NFL. The good news is that with proper planning, consistent performance, and the wisdom that comes with age, we can stay fit and active for a lifetime. I have compiled a collection of tips for the forty plus fitness client.
Manage Spinal Compression
As we age, changes occur in the joints, discs, and muscles that make up our spine. A lifetime of driving and sitting at a desk can create soft tissue restrictions and postural flaws. Statistically, the primary predictor for a future injury is a prior injury. By the age of 45, over 80% of the population will have lived through either a lower back or neck pain problem that was so severe it required medical attention. If you are older and have a history of lower back or neck pain, you should manage the level of spinal compression during your fitness program.
Compressive forces are at work on our spine from the moment we stand upright in the morning until we retire to our bed for a night of sleep. In the world of industrial ergonomics, we work to limit compressive forces that workers experience at the job site because we know increased compression produces more injuries. Recent dynamic imaging tests of lower lumbar and cervical spines placed under compressive loads have revealed surprising changes in disc dimension and spinal position. Rehabilitation and fitness professionals are now more aware than ever that the daily compressive forces our spines encounter is a major driver of pain and disability.
One third of our spinal length is made up of intervertebral discs—that is why we get shorter as we get older. Intervertebral discs are made up of compressible tissue. Under normal loads the discs can deform and then bounce back to their normal height, but inappropriate loading can damage the discs and alter their ability to absorb forces and create motion. Thinner discs create greater intervertebral joint stress and the environment for “wear and tear” breakdown of the spinal joints. Smoking, diabetes, and occupational sitting are some of the health and environmental factors that make you more susceptible to the damaging effects of excessive spinal compression.
Most people are unaware of the many fitness activities that create compressive forces on the lumbar spine. Treadmill running (greater if you hold on the treadmill handles), leg press, rowing machine, crunches, and leg lifts all create a compressive loading of the lumbar joints and discs. Be aware of the accumulated level of compression you place on your spine during a week of exercise. If you are uncertain which activities place a compressive load on the lumbar spine, you need to work with a physical therapist or an educated trainer.
-Michael S. O’Hara, P.T., OCS, CSCS