Finally the finishing touches to my back pain series. This was prompted by the epidemic of back issues that have been posted all over my social media lately. It seems that this winter many people have decided to “throw out” their backs. And this is something that is completely avoidable. The problem lies in that you’ve already likely done it to yourself. Now we have to make sure that it doesn’t happen again.
In July I wrote two articles on back pain. The first one which you can find here was about identifying what and why back pain typically occurs. The second one, which you can find here was about movements you can use when you’re feeling stiff or sore to help provide relief for general stiffness and soreness.
This part is about the exercises. Now, most therapists and trainers would identify that you need “more core strength”. What does that actually mean? Many people will think that yoga, pilates or even just simple crunches will do the trick. As I said in Part Two, the “core” is a very complex thing and can’t be isolated into one or two muscles. You have to strengthen the entire complex, and this stretches from the pelvis all the way up to the shoulders and even down into the legs.
So how do you begin? Well, a good place to start is by working on movements that you have to perform daily anyway.
My number one exercise to develop and improve back strength and resolve symptoms of back pain: The Deadlift.
In fact, if you were only allowed to do one exercise for the rest of your life, this would probably be my first recommendation.
Pretty simple, right? Picking something up and putting it down. This is not actually true. There is a lot of proper technique and intention behind this movement and I strongly suggest you have a competent coach (not your “brother-in-law who lifts”) teach you the movement and all of its’ parts. It includes the ability to squat, hip hinge and also keep your spine engaged throughout the movement, all individual components that you need to be aware of.
The good thing about this exercise is that it can be regressed so that my 103 year gold Grammie can do it, or progressed to an Olympic lifting level. It is very versatile and hits most of the muscles in your body in a very good way. One of my goals with any of my clients (even those with compromised backs) is a good solid deadlift.
My second choice for back strength actually involves the hips more than anything. Strong hips (and you can feel free to think “glutes” here) are essential for spinal integrity. Therefore my number two is: Hip Thrusters.
Now, this can be an uncomfortable position for many so I typically suggest starting this movement on the floor, then progressing to a Swiss Ball for mild loads, then a bench or modified floor position for heavier ones. You also need to make sure that your legs are in the proper position and you can actually hinge at the hips before you can do this properly. Again, please consult a professional coach to help give you the right technique.
Easy regression is an isometric hold in the up position (on the floor or a mat) for 15-20 seconds to start. Focus on pushing through the heels and pretending you’re holding a pencil between your butt cheeks and not letting it go.
Now, we also need a movement that takes place in the frontal plane – which means up and down if you’re standing up. This makes sure that the spine is being trained with forces that it will experience frequently. One way that people frequently hurt their backs is by extending a load over their heads they have no business lifting.
Most people also have very little upper body strength in relation to their lower body or vice versa. Men are horrible at this because they want to have a big upper body and never make their legs strong so their poor spine is like a pipe cleaner balanced with a big rock on top of it – and easily collapsed.
Therefore my next exercise for proper back health is very simple: The Pull-Up.
I realize that most people can’t do one full pull-up properly. Therefore I’ve given you two pictures that show easy ways to do these assisted in a gym or at home. If you need more ideas feel free to email me or google it and you’ll find a few more. I have at home clients do this with a bed sheet and a door frame sitting on the ground.
This movement not only is great for loading your spine in a frontal plane, it also hits those often neglected upper body pulling muscles that don’t get a lot of use. I encourage all of my clients to get to the stage where they can do pull-ups without much assistance. There are also a variety of choices in terms of grips and adjustments to enhance the strength in your shoulders without wrecking them. Please be careful and progress things appropriately.
Oh, and yes there is some debate over whether this is a frontal or sagittal plane movement. I believe it is a frontal plane movement. If you want to debate it, feel free to call me out.
There is a long list of complimentary exercises that I would add to this list. Some of them include:
- Overhead Pressing
- Romanian Deadlifts
- Back Extensions and Reverse Back Extensions
- Loaded Planking with movement
- Lateral Side Flexion
- Loaded Trunk Rotation
- Split Squats
And the list can go on. However, if you want to get started on the path to good spinal strength, these three are your first and best bet towards good spinal strength.
You might also notice that none of these first three exercises are traditional “core” exercises. However, all of them load your spine quite nicely and give you the benefit of adding strength in a bunch of other places as well. This is essential for total body health.
All of these exercises can be progressed and regressed by a competent coach. Always remember that exercise is tailored to the individual, and a good coach will adjust your program based on need and result (and goal).
I’m planning on putting together a proper E-Book on Back Strength coming soon. If you would like a free copy, feel free to subscribe to my site by adding yourself to the list at the side, or follow me on Twitter at @strengthottawa, Instagram at @strengthrehabottawa and on Facebook at Strength Rehabilitation Institute of Ottawa. I’m also always interested in your thoughts and feedback, so feel free to Share this as well on any social media.
Take care of your backs!
Any active person has had it happen. You are doing whatever activity you enjoy and suddenly feel a bit of a pull, cramp, sharp pain or something not quite right. Hopefully you’re smart enough to stop what you are doing and not push through the pain to complete whatever you are doing, but maybe not.
Then the inflammatory feeling starts kicking in. Your tissue will feel full, there may be lingering low level pain or sometimes acute high level pain when you move. Sometimes you can’t move without your body telling you not to through a jolt of pain. Often this is a bit indicator of the severity of whatever injury has happened.
So you realize that this is beyond a simple pull, mild strain or simple fatigue. You’ve done something that may require intervention and some sort of attention. You’ve injured yourself.
First things first: if you have acute high level pain and can’t move a limb or joint please GO TO A HOSPITAL. You will wait a while because musculo-skeletal injuries aren’t triaged as a priority but at least you will likely get some imaging immediately. There may also be things going on underneath the surface you have no idea about so better safe than sorry.
If that’s not the case, what is your next step. Well, there is a simple routine that you should follow, and it can be done in this order:
This is what you do immediately. The biggest thing to do with any injury is STOP MOVING IT. Don’t stretch it right away, don’t think that you can “push through the pain”. You will make things worse. Stop what you’re doing. Your body is very intelligent and is already doing what it needs to in order to start fixing things. Give it a chance and don’t make things worse.
Don’t ignore pain. Pain is a signal saying “QUIT IT”. Your body is literally telling you to stop what you’re doing just like taking your hand off a hot stove. Once you have stopped moving, the next step is…
Some questions to ask yourself:
- Is the pain acute with movement or does it come and go, for example it stiffens up during sleep or is painful at different times of day?
- Is my strength compromised for certain movements, ie can I not pick something up, reach over my head or extend my leg without a problem?
- Is there soft tissue damage? Swelling is one thing, but bruising typically means a much more severe trauma that requires attention faster.
The more you have information, the easier the next step will be because you can figure out which practitioner to see first and not waste your time. Have a soft tissue problem? Massage might be best? A serious joint issue? Maybe an osteopath or chiropractor (more on this later in the article). Arming yourself with answers and figuring things out on your own can be valuable in not wasting your time. That leads us to…
This does NOT mean going to someone like me and asking them what it is, because I have no authority to diagnose anything even with my years of experience. What is does mean is going to someone with the words Doctor in front of their name and ideally getting some testing and/or imaging. I always tell my clients to push for imaging because ultrasound and x-ray can reveal things simple testing cannot. If MRIs were more easily accessible that would be my default for many things. For those of you in Canada, remember that some provinces (ie Quebec for those of us in Ottawa) do allow paid MRI’s – you just have to pay for it.
As much as I appreciate the access to General Practitioners or walk in clinics, regular MD’s have little to no experience with bone and joint injuries and often will suggest exactly what I just said anyway, so don’t waste your time. And if a GP does give you a “maybe it’s this” diagnosis please get it confirmed by someone with experience and ideally imaging as I said.
Be proactive – once you have a diagnosis, learn everything about it that you can. It will not only educate you on what the injury is, hopefully it will make you realize WHY it happened and how to prevent it in the future. Often during my initial consultation I have found that clients have never had their injury properly explained to them by anyone and have no idea what happened to them and why. Knowing the why is very important for any recovery model. And that allows me to discuss…
After you have a diagnosis, depending where you get it the first suggestion is always physiotherapy. It’s covered under benefits, didn’t you know? The only problem is that there are lots of other ways to treat an injury and in my experience physio yields the worst results overall for my clients and others I have spoken to. If I was going to suggest the order you should look into things and why, here’s my list. Again, not to knock any practitioners – there are lots of good and bad ones out there – this is simply my experience in dealing with all of them frequently.
#1: Osteopath. These people frequently have had experience in another modality and decided to move into osteopathy. From an assessment and treatment perspective the results from these practitioners seems to be consistent, and they don’t ask to see patients frequently.
#2: Massage Therapist. With the disclaimer that this is for soft tissue injuries only, a good massage therapist can help with things like scar tissue, blood flow to improve tissue and relieving stiffness and immobility. This should be included with any recovery plan.
#3: Chiropractic – Again, with the disclaimer that this does NOT mean back cracking or neck cracking. A good chiropractor who knows other treatment protocols like ART or myofasical release, or even relieving nerve entrapment are usually your best bet.
The thing with chiropractors is that a lot of them are salespeople who try to lock you into long term treatment plans where you see them three times a week – please don’t fall for this and if it is suggested, find another practitioner. This generally doesn’t have any interest in your recovery, it has interest in your wallet and benefit plan. If you need to see a practitioner three times a week they need to justify it.
#4: Physiotherapy. Again, there are good physios out there. The problem is that in my experience they are few and far between. Look for someone who doesn’t use outdated methods, someone who will actually spend time with you individually (not hook you up to a machine and walk away or leave you with an assistant), and who will progress you session to session properly.
How long does it take for proper recovery? The general rule for serious soft tissue injuries is 6-12 weeks, more serious damage like tendons and ligaments can be up to 3-6 months. Anything requiring surgical intervention can be 6-12 months. This is not carved in stone, but it will give you some perspective in that you need to assume that this is a long term fix and not a temporary thing.
In my opinion surgery should always be a last resort. It is done when there is no other option for restoring tissue. Full tears, severe arthritis, and things like broken joints often carry this load and it is totally necessary. If you have the option, see how well you can get first without it and then see about surgery if all else fails. Realize that if you meet with a surgeon, they are going to likely push for an operation – that’s their job. You have options, consider them all wisely before making a decision that can affect your body for the rest of your life.
As a final note, the number one thing I see that causes injuries to recur is that the person rushed back into exercise and doesn’t do what they need to do to fully recover. This just makes things worse and more often than not will result in a worse injury down the road. Listen to your body and ease back into exercise. Sometimes my clients have to start off ridiculously easy and it drives them crazy, but it takes time for recovery and having a guided path is absolutely essential.
So you’re hurt – there are lots of options for you to pursue and the good news is an injury doesn’t have to be the end of the world. If I told you the laundry list of injuries I’ve had (including a disc herniation and multiple tears in various places) you would be surprised – but I can still move easily and lift heavy things without a problem. Be smart, apply things properly and keep moving forward.
If you liked this article feel free to SHARE it on Facebook and follow me on Twitter @strengthottawa. And of course if you have any questions you can contact me at any time via phone or email. Stay mobile!
This title is a bit of a misnomer, because there are probably about a hundred or more benefits to additional strength. That’s the reason I primarily focus on it within my practice. Over my many years of working with people and improving their situations after injuries and special conditions I’ve seen some pretty cool things. However, recently I was treated to not only one, but two big examples of improved quality of life and the ability to deal with situations physically.
About a year ago I wrote about the success that one of my clients Randi S had after recovering from severe SI Joint dysfunction to the point that we couldn’t even move her during her initial month of training. She progressed to the point where she was able to bike for 26 km in the mountains and achieved a big goal. You can read about it here.
Randi recently experienced more issues starting in February and had some neck and heel issues as well. After several months of hard work, and even some competent physio work on her as well we were able to get her back up to speed. For her trip this year, Randi not only biked the full 46km – on a mountain bike (not an upright) which would previously have been unheard of for her back, she did paddleboarding, and even some cave climbing into cramped spaces. Again, all of these things two years ago would have caused Randi enormous pain and put her into bed for a week. Today due to being stronger she can do activities that excite and motivate her. The following week she even tried a spin class and has found a great yoga class.
One of the great things about my job is when clients get to the point where they don’t need me any more except for advice and maintenance. It sounds counter-intuitive, but I do believe that once people can do what they want or need to then I’m just a guide after that.
Success Story Number Two comes from Chris J. Chris came to see me about a year and a half ago due to back trauma from a car accident. He had worked with another trainer and had physio and seen little progress beyond more irritation. With a combination of MAT and proper strength work his back has been great for a while. He has been able to work as a volunteer lifting heavy things and walking a ton without any issues.
About four weeks ago coming home from Bluesfest with his mother in the car, Chris had a car run a red light and hit the car broadside at 60 kilometers an hour.
Everyone was fine, thankfully to airbags. But the amazing thing to me was that not only was Chris okay, he walked away completely unscathed except for a headache. His back was basically unaffected with some minor stiffness. I’d like to think that because he had more strength in his trunk, hips and shoulders that the impact (and think about hitting another object at 60km/h) didn’t cause any severe trauma. We have taught his system to kick in when it is needed to provide support at a time when it receives stress or load, and that happened in spades when he hit another vehicle.
I was astounded and quite happy to see such an obvious result simply from strength work. Think about applications for people who fall, play sports or simply want to do high impact activities like motorcycle riding. Being stronger overall helps with many situations and conditions.
Over the years I’ve managed to have an excellent track record when it comes to helping people who have conditions they previously thought were unmanageable. If you know of anyone who needs help or even just has questions about an injury or special condition feel free to send them to http://www.srottawa.com or to email me at firstname.lastname@example.org. You can also follow me on Twitter @strengthottawa.
Last time we discussed the origins of back pain and some quick fix solutions if you have issues in this area. For this article I want to get into a bit more detail on what you can do to be more aware of your back issues and some real solutions in terms of restoring mobility and keeping your muscles firing well.
First of all, most people will tell you that the reason you have back pain is because you have a weak “core”. What does that mean?
In simple terms this means that the muscles that support your spinal column, especially as it relates to your pelvis in the lumbar area, are weak and need strength. Most practitioners will have you start to work on things like spinal bracing movements, hip stretches and lower back strengthening. However, this brings me to my first point when it comes to back pain, and one of the most important principles:
You need to know what the source of the issue is!
Imagine a person with a weak ankle due to spraining it several times as a kid. This person stops being active and loses a lot of their ability to fire their leg and back muscles, and eventually every time they take a step their body is slightly tilted to take load off the ankle. This throws off the pelvis slightly each time, and this throws the lower back out of line and therefore causes the supporting muscles on one side to fire too much. If the ankle is the source of the issue, strengthening the muscles in the midsection will help, but it doesn’t ultimately fix the problem. It’s like taking an Advil for a headache.
So rule number one is get properly diagnosed. I don’t diagnose, I tell people what in my experience things are and (99% of the time I’m right), but it is always confirmed by another party preferably with doctor in front of their name after they get referred. Many practitioners will not look past the pain area – find one that will.
I’ve had clients come in with back pain that we have resolved by treating their shoulders. Or feet. Or even simply practicing walking properly. It can be that simple.
So what is the “core”? Well, the way I explain it to clients is that you want to stop thinking of “core” and start thinking of SPINE. More specifically you want to start thinking of how it relates to your pelvis (mostly) and also things like your rib cage and shoulder complex. There’s many more muscles involved than just your TVA, or just your lower back. In the deep abdominal area alone there are five layers mostly overlapping each other. And, when you move one joint, you affect every muscle that crosses over it – and your spinal column is made up of lots of joints. If you move your hip, you’re affecting your spine. If you move your shoulder, you’re affecting your chest, back and shoulder (and a bunch of other things). Take this into consideration when performing any type of mobility movement.
Before I get into how to strengthen these areas (which will be for Part 3), I want to instead address mobility. This is the ability to move these joints without strain or compromising the muscles that control them. Typically this requires movement without a ton of load or force behind it. One of the biggest pieces of advice I can give here is:
Respect your body and allow it to move (or not move) as it wants to – don’t force it.
One major flaw people make with mobility work is that they push their muscles too hard and create even more strain. Instead of thinking of it as stretching, I invite my clients to instead think of it as allowing their muscles to achieve a longer range of motion within the involved joints. This goes across both sides of the muscle, the long and the short. If you lengthen or shorten a muscle too much, it is weak in that position and will often fire in order to try to get out of that position – which defeats the whole purpose of lengthening one side while you shorten another.
For example, if you are in a typical hamstring stretch you are lengthening the back of the leg, but you are also shortening the front (allowable to a certain extent until your knee reaches terminal extension). Always move within a point of mild resistance – never pain.
With the lower spine, the usual culprits for lack of mobility are the hip complex (especially in the front of the body) and the spinal erectors. General ranges that are restricted are spinal extension, pelvic movement, hip rotation and extension and lateral flexion (ie side bending – but be careful here – I don’t side bend anyone until they are much better).
So here are the top 5 mobility movements I prescribe to pretty much everyone with back pain as a start. Remember that as with any exercise program, a mobility program also needs to be tailored to you specifically – don’t necessarily take this as gospel. It is a good start for most of the population. As with anything else, if it makes your body uncomfortable or causes pain – DON’T DO IT.
Number One: The McKenzie position.
Stuart McGill, who is one of the most prominent back care specialists in the world advocates this as the number one movement, and I do as well. Place the hands under the shoulders and extend up, moving slowly until pressure is felt in the lower back and focus on dropping the hips into the ground. Repeat with movement but can also be done as a static hold if you have facet issues.
Number Two: Cat/Camel position
This can also be a good transition into childs’ pose for upper back mobility. Focus on moving the entire spine starting from the tailbone, not just the upper back as many people tend to do.
Number Three: Kneeling Hip Flexor stretch with movement
This movement may be difficult for those with knee problems. If you cannot get onto one leg a good modification is to do it standing up with one leg behind you. Oscillate the hip forward and back. Another fantastic stretch along this line is one popularized by Kelly Starrett – you can see it here but it is very advanced and should be modified for most people.
Number Four: Windshield wipers with feet on the ground
For some people with advanced back problems this gets removed immediately because it can cause tilting. Also, if you have diagnosed SI Joint issues please take this one out until they are resolved. This puts rotational torque through the hips, which for many is a good thing but for some is not.
Number Five: Standing Glute/Piriformis stretch.
This movement can also be done lying down, but is more effective standing. Again as with the others, don’t hold position, lift and lower the knee until a pull is felt in the hip/glute area. If one side is tighter, do that side twice. For example, if your left is tighter you would go left, right then back to left.
This covers 85% of the bases for most people who have issues. Again, for some with severe mobility issues all of these might have to be modified. Feel free to comment or message me for modifications if you need them.
So the next question begs – how often? My recommendation is always twice a day to start, ideally morning about twenty minutes after rising so you have moved a bit and established blood flow, and then before bed or after work – whatever works for your schedule. It can be a great way to decompress at night and focus on yourself after turning off all of your electronics and is a great way to establish good sleep hygiene. Think of this as general maintenance and even just by doing these movements – within what your body will allow – you can experience some relief almost immediately if you have the beginnings of problems in your spine.
Oh, and if you tell me you don’t have time, this whole routine takes about 5-10 minutes. You have the time. You choose not to use it in the right way. Choose to help yourself.
In Part Three I will be going over exercise. Again, we often think about “core” work as something simple and straightforward but for most people finding out what area needs the most help is essential. This can allow us to build an exercise routine that will work for that individual and bring a solution to the issue. Like I said in Part One here, if you’re at Stage One then these should help a lot. Stage Two or Three might need some help. but you’re starting in the right place.
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