Thoughts on weight training or bending with a Hx of lower back pain?

• For me weight training is essential for anyone with a history of lower back pain, but you have to earn the right to commence weights training. Following an injury its important to put the ego aside. While ego and the desire to return to “normal activity” is a good thing it can also hinder progress. I always go through a process and explain its important to heal, beat pain, avoid surgery if possible and prepare for commencing strength work which will occur at a later time.

What kind of strategies or information do you give people that have had a history or back pain and are now quite fearful to use their back?

• I explain the process the back goes through, I like to outline some pain science approaches and inform the client about neuro tags in the pain that develop as the result of chronic back pain or fear avoidance. For me most back disorders are from accumulative load on a particular park of their back then they might have that culminating event like picking up their child’s toy and their back goes out. That of course ruling out something traumatic like a fall or a tackle in rugby or AFL which can cause substantial damage to the back.

• I often get a lot of client who have seen other physios/ chiros/ osteos and have been told “I have non specific low back pain” and for me there is always a specific cause of lower back pain, so I always educate the importance of a thorough assessment will reveal the cause. And the biggest thing we can do is listen, listen to the client and then find out what triggers the pain so that we can teach those triggers to the patient so we can avoid the triggers and teach them to desensitise the back pain.

• And as physios we often know for a lot of our clients bending or picking items up from the floor is a trigger. The Key with our education is to avoid the movement or posture that causes pain. This allows the tissue to settle and nerves to decrease their sensitivity, if you listen to the great Dr Stuart McGill who is a leading authority on back pain he explains that allowing pain to aggravate in the early stage of healing is like picking a scab trying to heal”. The reality is no one wants to be in pain, so the faster we identify the cause, stop the painful triggers, the quicker we can become pain free.

Which exercises would I recommend for people with a history of lower back pain?

• I think the first thing should be is which exercises do I avoid?
  • I stop all repetitive back bending like knees to chest, and the hands to the floor hamstring stretch that people so commonly reports “relives” pain.

• What I do encourage is spinal stiffness – so I follow the Big 3. We know that the core provides the spine with support, it acts as armour to protect us, and we know from research that the spine will start to bend, buckle and break with just 10kgs of force, and we also know that a lot of back pain is caused by instability at joints so they get little micro movements, and muscular stiffening removes those micro movements.

The big 3 are The modified curl up, the side plank and the bird dog, these 3 exercises create spinal stiffness but don’t overload the already painful back. For anyone with a history of lower back pain they have to do these daily and it should become like brushing your teeth, it should be apart of your daily routine.

Some rules I give my clients

• Do them daily
• Don’t do them upon waking in the morning
• Choose the reps and sets wisely don’t over do it – I use 10second reps in my programming and often use 6-8reps and 2-3 sets
• Bracing of the abdominal muscles
• Neutral spinal position

• A walking program, this a must – and for some people this begins with 10minute walks, 3-4x a day at a moderate pace. According to research walking activates the quadratus lumborum and obliques. So in other words walking is a way to engage the core muscles, and take the load off the body’s rear muscles and also work on relaxation so for me a walking program is the beginning of any strength training program for the lower back.

Are there positions or exercises that are not recommended?

• Again going back to my earlier point those repetitive back bending exercises, hands to floor hamstring stretches because they often don’t help with pain sensitisation they actually hinder progress.
• A lot of my clients say I started Yoga, it feels great during but afterwards im worse, often these client have instability and by prolonged stretching they are just worsening there issues. I’m in no way saying yoga is bad but during some stages of recovery, particularly the early stage we need enough mobility to allow movement and still allow us to create stiffness.
• Positions to avoid though are based on thorough assessment by a physio and together with your client you identify the pain positions and avoid them, not forever but we want to avoid picking that scab, settling the tissue and work towards becoming pain free.
• The other thing is avoid repeated passive treatments such as massage, needles, ultra sound etc they play a role but without a clear plan it won’t improve your lower back pain so avoid those treatments.

Following an acute flare up of back pain. When is it ok to return to training and what exercises are recommended?

• Once the acute flare up has settled yes it is essential to return to training, once we have settled the tissue down we must encourage movement. Often for me this is finding pain free positions within the gym this might be the bike, walking, jogging etc that don’t cause further aggravation and getting the client to start returning to their normal exercise program.
• You should never return at the same weight, this is where it Is essential to leave the ego behind, the same ego that drives someone to lift heavier is often the same ego that wont allow someone to return at a lower load or rest. And rest is ok, not absolute rest but deloading, reducing the intensity, going for a swim, even for “weight lifters” is ok as it allows the body to regenerate and repair.

Should you feel DOMS in the back?

• In my opinion NO, most commonly people say to me they felt DOMS after a big deadlift session, well this means you are performing the deadlift incorrectly. Low back soreness following deadlifts is an indication of incorrect technique.  If you are performing a deadlift correctly your low back should fight to maintain an isometric contraction the entire rep. This is why I cue neutral spine during a deadlift, so for a lot of my clients it means again removing the ego, reducing the load and we practice neutral spinal positions during a deadlift. It can also be useful teaching a simple hinge pattern or incorporating single leg Romanian dead lifts.

If someone has never had back pain before what would you recommend for prevention?

• I always use the big 3 – back to those modified curl ups, the side planks and the bird dogs, and these big 3 can be altered for anyone.
• I encourage conditioning and muscular endurance
• I build strength – this requires good programming, commitment, attention to detail and the knowledge of how to load a spine correctly without over doing it.
• I always say the worst thing you can do for back pain is nothing – move, just move because if you sit for 8 hours a day and then get home and sit on the couch well nothing is going to help your back pain.

Any other points?

• Back pain is so individual, both treatment and prevention become about thorough assessment.

For example

For some clients its about avoiding conventional deadlifts and getting them to deadlift off a block because they don’t have the hip mobility to allow for a conventional lift.

I also use alternate deadlifts such a kettle bell deadlifts, rear loaded deadlifts,  I use suitcase deadlifts, raised deadlifts, sumo deadlifts, because I often hear people tell me I will never deadlift ever again, but I always challenge that attitude and get them doing some form of deadlift and look to progress them as there movement patterns and pain improve.

I also think it important to look at other sorts of training, for so many people compressive load causes lower back pain but they insist on doing back squats, well why would you continue to load the spine with a compressive load, I remove that exercise add an alternative such as an lunge position with the weight loaded between the legs and this removes the compressive load but still allows for strengthening.

There are so many alternatives that allow for strengthening the lower back and body in general you just need a skilled clinician or coach to guide you, some of my favourite include farmers carrys, sled pulls, sled pushes and look to integrate activities such as skipping which boxers have used for years as it creates a stiff torso and but still allows them to complete cardio training

My last note about back pain is that every time you get back pain you reduce the trigger level, so the next time you replicate the offending trigger its triggers off at even lower thresholds so you become sensitized to the pain and that’s called central sensitisation. So find the cause, avoid the trigger, then you reset the sensitivity to a higher level so you become more resilient then you can do more things – that’s when we can discuss a progressive exercise program that can create a strong, pain free lower back.

My end note is treat the big 3 like brushing your teeth, do them daily and don’t fear strength training, and ill end with a corny point that strength is never a weakness.