Low Back Rehab Program: Two Diagnostic Tests

So clearly I'm putting alot of faith in Stuart McGill's expertise. Of course, I'm also putting alot of faith in my ability to understand what he teaches and then use it intelligently to make this the last time I have to "rehab" my back. This is probably simple hubris, though, because the book itself is written to help the working clinical professional and my plan is to simply go it alone. I finished "Low Back Disorders" and I'm ready to get cracking on working out again as long I'm not risking another tweaked back. First though, there are a two simple tests that I think are instructive.

Back Bridge Test
The first can indicate whether a person is correctly activating the glutes for hip opening. This back-bridge test is performed lying flat on your back, legs bent, knees flat on the floor. Tense your entire "core" muscles to maintain a nuetral spine as you open raise your hips off the floor, opening your hip (it's kind of like what they are showing here, but don't extend the one leg at the knee). Use your hands to feel (the fancy word is "palpate", but just start poking and prodding) which of your muscles are most strongly activated. Feel your abs (not just the six pack but all around your abdomen), then check your glutes, check your hamstrings, and check your quads. Which are working the hardest? Can you feel them working? I

Go ahead, do it now. Once you know what it's supposed to feel like you'll never do it the same again.

Your glutes should be most strongly activated. The hamstrings should be only slightly activated However, in people who have had lower back injuries, it's very common to have the hamstrings and the extensors in the lower back take much of the effort rather than glutes. This places much more of a compressive load on the spine. If you pretend to squeeze a coin between your butt and activate your quads slightly, you can feel how the glutes and hips can take the load, and this is how the body is supposed to function. Retraining hip opening to emphasize the glutes will be key.

Abdominal Muscular Enduance (aka my Spinal Fran)
OK, so now to the good measurable stuff, testing muscular endurance. Given that endurance in the 'core' musculature is protective of the spine, defining any defficiencies in this area will help guide the rehabilitation program. It will also provide a useful measuring stick of progress. This will be my "Spinal Fran" benchmark. There are three static hold tests and by comparing the length (in seconds) of static holds in these different positions, one can determine what underlying defficiencies are limiting long-term recovery in low back pain patients. So, I put together a crude test lab in my living room (see picture) and, after a trial run to get everything right, here's what I got on my second tests

Left Side Bridge = 61 seconds
Right Side Bridge = 75 seconds
55 Degree Flexion = 153 seconds
Back Extension = 138 seconds

To interpret the results, he notes that the following ratios are statistically significant in populations with low back pain. I believe these values also have some use as predictors of future back pain.

55 degree flexion/back extension >1.0 -->My value is 1.11
Right Side Bridge/Left Side Bridge outside the range 0.95 to 1.05 --> My value is 1.23
Right Side Bridge/back extension > 0.75 --> My value is 0.54
Left Side Bridge/back extension > 0.75 --> My value is 0.44

So, if I've done these correctly, this indicates that my flexion/extension ratio is aberrant (>1.0), indicating that my back extension endurance is low. I'll be working these with Bird Dogs.

It also shows that the right side lateral abs have statistically higher endurance than my left (RSB/LSB outside the range 0.95 to 1.05). I'll be working both sides with Side Bridges.

Finally, it also shows that the relative endurance of my lateral abs to my extensors is OK (less than 0.75).

Interesting. And it will be interesting to see how these change over the next few months.

A Review of Stuart McGill's "Low Back Disorders" - Part 1

In an effort to resolve my own chronic back issues once and for all, I am making the effort to read -- and try to really understand -- Stuart McGill's "Low Back Disorders: Evidence-Based Prevention and Rehabilitation." This review is an effort to very concisely summarize some points that he makes in the book. The book is intended for professional clinicians, which I am not. I will try to summarize in the least technical terms possible the points that are helping me to shift how I think about my back and how I can get to a permanent pain-free situation; one where I don't have to worry about my back giving out every time I head out on some little trip. I encourage anyone who is actually working through their own back pain to consult the original source, it's entirely possible that I've completely misunderstood entire portions of the book.

Parts 1 & 2

The book is divided into three Parts: 1 - The Scientific Foundation, 2 - Injury Prevention, and 3 - Low Back Rehabilitation. I'm still working through Part 3, so this review only covers the scientific foundation and injury prevention. I know, if you're reading this all you really want o know is what to do, but I haven't gotten there yet. The first two parts are164 pages long. I took 8.5 pages of notes in very small print, so obviously I'm leaving alot out.

1 - Most chronic low back pain issues are not the result of a single traumatic incident (unless of course they are the result of, say, a snowmobile accident (see first image), or a fall from height which applies a very high load in a single event); they are the result of "cumulative trauma pathways." This is either the repeated application of a low load (ex, repetitively flexing the spine while picking light objects up off the floor; see second image) or a sustained load for long duration (ex, slouching while sitting at a computer or a carpenter constantly bending over to put nails in a floor; see third image). These loads are typically well below what people believe is damaging to the spine but repeated or prolonged exposure is indeed damaging. So, even though I typically can pinpoint an incident where I 'tweaked my back,' it is more likely that the hours of sitting slouched at work and poor control of lumbar flexion in other everyday tasks is the real culprit. These are the low-level loads that permit me to 'tweak' my back.

2 - Using the "core" musculature (extensors, anterior abdominals, and lateral abdominals along with a bunch of other supportive tissues, like the lumbodorsal facia, is discussed) to lock the rib cage onto the pelvis supports the spine in a neutral position is key to reducing loads on the spine during all everyday tasks from getting out of bed to opening a door to picking up a pencil off the floor.

3 - Interestingly, muscle endurance (NOT strength) and lower (NOT larger) range of motion is protective of the spine. So, even though it's common to think, "I need to be stronger and more flexible," you really need to be more precise. You don't need strength so much as you need endurance in your stabilizing core muscles so that they can maintain the low-level contractions necessary for stabilizing the lumbar spine in all of your everyday tasks; from opening doors to tying your shoes to shoveling snow. Further, more flexibility in the lumbar spine makes you MORE likely to get injured. Now, it might be that you need to increase flexibility in the hip (say, the hamstrings or psoas), but you need to stretch those muscles correctly; which is to say, keeping the spine neutral and being conscious to not accidentally stretch the lumbar extensors. This error is particularly common in the toe-touch type of hamstring stretches, where you bend over (or sit) and touch your toes. This is stretching your extensors more than your hamstrings and exacerbating instability issues in the lumbar spine.

4 - I've already commented on how poor motor control can lead to spine buckling and injury, even when picking up very light objects.

5 - McGill encourages you to think about your spine this way: it's a fishing rod with the reel end on the ground (this is the flimsy flexible spine itself) supported by guy wires that allow it to support a load (the guy wires are the anterior, lateral, and posterior musculature that, when stiff, permits the spine to bear massive loads. The key points: 1 - without stiffened (slightly taught) musculature, the spine is flimsy and flexible under even the most modest loads (few pounds); and 2 - if any of the guy wires are more or less tight than the others, this will lead to instability so all the muscles must work together.

6 - Spinal flexion early in the morning should be carefully avoided. The spine lengthens while you sleep overnight because the spinal loads are lower than the osmotic pressure, therefore the discs fill with fluid. These engorged discs greatly increase the pressure of any flexion in the morning, so absolutely no flexion stretches in the morning (no toe touches, no bringing your knees to your chest, etc) and be very careful when putting on your socks and tying your shoes.

7 - Sciatica symptoms are the result of nerve irritation. Therapy is two-fold: 1 - avoid end ROM in the spine, and 2 - perform "nerve flossing." There's a demo here, but I can't verify that is done absolutely perfectly, but that's the general idea. If you have sciatica, best to review this with you PT, and not rely on a blog or youtube.

8 - It is useful to remember that muscles and other soft tissues are not rigid and static but creep (slowly elongate when under load) and have more viscoelastic properties. This comes up several times in the discussion of herniated discs and how the nucleus of the spinal discs can 'migrate' or flow depending on the posture of the spine. In diagrams, the nucleus is typically shown in the middle of the annulus, but it's useful (if not completely technically accurate) to think about the nucleus moving closer to the edge of the annulus in response to repeated flexion (or extension) or prolonged flexion (or extension). When the nucleus is off-center and then full range of motion flexion/extension or large loads combined with flexion/extension are performed, it is much more likely to result in a herniated disc. Best to give the disc a few minutes to equilibrate while in a neutral posture before beginning to load it. This comes up again and again. It also affects the order in which rehabilitation exercises are performed, so it's an important concept that requires more detail than I can provide here.

9 - Some specific advice for preventing low back disorders:

a - avoid end ROM in the spine, keep it neutral;

b - reduce the reaction moment on the spine by keeping loads close to the body, directing force vectors through, or around, the lumbar spine, and simply reducing the weight or load itself;

c - avoid exertion after prolonged flexion (ex, immediately picking and moving boxes after sitting for awhile, instead stand-up, move around for a few minutes first, then begin exertion);

d - avoid high torques on twisted spines (note that significant torque should only be applied to neutral spine);

e - use momentum properly to reduce loads (note that slow and smooth isn't always the best way to spare the spine);

f - make seated work less demanding on the spine by constantly changing positions (there is no "perfect sitting posture"!), get out of the chair as often as possible (maybe every time the phone rings?), and get a little exercise in the middle of the workday;

g - Limit flexion early in the morning;

h - do as much variety as possible, repetitive work, even at low loads, can be very damaging over the long term;

i - co-contract the lower back and abdominal musculature to stabilize the spine even with very light loads.

10 - In general, workers should not wear any sort of lumbar back support. There's a whole chapter on this, if you really want to know why, check out the book. It's clearly stated and the supporting evidence is convincing (to me, anyway).

11 - During all daily activities and especially during rehabilitation exercises, prevent pain first. The pain is the result of injury and continuing to irritate the tissues causing the tissues to sensitize to even very minor irritation. In addition, the pain results in an entire series of cascading issues that basically makes gives your back a "limp." This "limping back" ingrains poor motion and muscle activation patterns that will prolong back pain and limit recovery and rehabilitation. Never work through the pain. This is not a "No Pain, No Gain" problem. Eliminate the pain first. Only work through a ROM that is pain-free. Always.

IMAGES: All the images above were photographed from Stuart McGill's "Low Back Disorders: Evidenced Based Prevention and Rehabilition" 2nd edition. They are provided here without permmission but with full credit.

Hitting the Books

As I eagerly await the delivery of Stuart McGill's "Ultimate Back Fitness and Performance", PSU interlibrary loan delivered his "Low Back Disorders: Evidence-based prevention and rehabilitation." Although the title of "Ultimate Back Fitness..." sounds like an amateur bodybuilder's roadmap to "mile-wide lats" and "shredded traps," neither book is directed towards bodybuilders, strength athletes, or other athletes. Rather it is directed toward the doctors and physical therapists who treat injured people, including athletes and workers.

I probably won't read "Low Back Disorders..." cover-to-cover like I will "Ultimate Back Fitness..." but I did start reading it and taking notes last night. I approached it like I do any textbook: skim the whole book emphasizing the figures and charts and their captions; then read the preface; then actually start to read it. Seeing as how this is pretty dry text, a few fingers of whiskey (see image) and some Screeching Weasel in the background help make this more enjoyable. Typically when reading or skimming a book like this I mentally note the points that AGREE with my worldview, but seeing as how my normal worldview is what keeps getting
me into this mess, I'm trying really hard to notice those things that CLASH with my current understanding. This won't be hard, since dispelling current "clinical wisdom" is one of the main points of this book.

Here's a couple of comments that caught my eye:

pg 8 Right off the bat, "Ill-advised Rehabilitation Recommendations" include 1) "Strengthen the muscles in the torso to protect the back" (her argues that endurance is more important than strength); 2) "...bend the knees, not the back" (he argues that very few jobs can be performed this way and there are better techniques) and 3) "Tight hamstrings...lead to back troubles" (maybe but not neccessarily). Interestingly enough, immediately after the recent aggravation, I started planning to really start strengthening my (lower) abs and lower back, stretch my hamstrings, and learn to better recruit my torso muscles to stabilize
my spine. I'm getting the feeling that learning to stabilize the spine is where I'm going to be spending the majority of my time.

pg.144 "Should Intra-abdominal Pressure (IAP) Be Increased During Lifting? Generally the answer is no: At least IAP should not be increased conciously..." with the caveat, "very strenuous lifts...will require the build-up of IAP to increase torso stiffness and ensure stability."

pg 150 "Is it advisable to maintain a reasonable level of fitness? ... well-chosen (ed: not situps, apparently) exercise is the most powerful strategy for preventing occupational back troubles."

pg 156 illustrates the proper way to roll-over in bed!

pg 157 "Reducing the risk in athletes. ...Without exception, they had to change the way they trained. Their backs were breaking down for a reason!"

pg 187 "Train to breathe freely while maintaining the stabilizing abdominal wall contractions"

pg 218 "Eliminating Unsafe Exercises" where three exercises are listed as "inappropriate exercises" that have been "prescribed for people with low back difficulties": sit-ups, leg raises, "traditional extensor exercises" (think back extensions and those "back extension" machines).

pg 239 "Training to Squat and Power Clean...If perfect starting position cannot be obtained, then other means are needed. Many great atheletes can not do these lifts."

SOUNDTRACK: "Three Sides" by Screeching Weasel from one of the all-time great pop-punk records "Anthem for a New Tommorrow". The lyrics "Three sides to every stupid question, three sidees to everything you see" struck me as appropriate last night as I look to challenge what I think I know about my back and my health.