In my clinical practice of chiropractic, I mostly manage pain and the majority of that pain is back pain. In school, we docs are taught that back pain from discs represents perhaps 10-15% of all cases of back pain. However, other research points out that when back pain becomes severe enough to prompt a person to seek care, roughly 50% of that back pain is related to the lumbar disc. If you know what to look for, you can pick up that irritated disc on clinical exam well before the disc injury becomes significant enough to cause neurological symptoms.
My practice has been informed by the works of my mentor, Craig Liebenson, and thus by Vlad Janda, Pavel Kolar, Karel Lewitt and Stu McGill. Gray Cook came along and turned the rehab and personal training world on it’s ear by suggesting that rather than battling over turf, trainers and rehab professionals should work to liase and thus improve patient and client outcomes. I’ve been fortunate in my practice to work hand in hand locally with some cracker jack trainers like Chris Bathke, Tony Gracia and powerlifter and coach Chris Duffin. Here’s what guys like this know that many of us in the rehab world are missing. The magic is in the movement, not in the therapy.
Most back pain significant enough to prompt a person to seek treatment is flexion-intolerant. Much of that pain will ultimately progress to become discogenic if it isn’t already. In the clinical world, we can apply the McKenzie derangement model, some steam and cream, some rubby-dubby and some poppy-cracky to that back all day long and walk on water. “Thank you doctor for helping me get out of pain!!!” Then, when the pain professional cuts the patient loose and says to go back to the job/game/whatever, the patient re-injures themselves, that patient is back in the pain management racket. When the patient says “What can I do to improve my FUNCTION?”, that’s when the pain pros get vague. “Well, maybe you can come in on a regular basis so that we can keep you ‘in-line’ and that might help”. Coincidentally, that’s what the pain pro learned from the MBA in the practice management seminar over the weekend. Luckily most DCs don’t use the type of $$$-first, patient-second tactics identified below. If you’re a patient and you get this kind of treatment, laugh at the “doctor” and walk out of the room…please!
So in the context of the flexion intolerant back, here’s what the personal trainer knows that too few DCs and PTs know…That client’s back hurts because their squat and deadlift pattern sucks! Shout it out trainers! Your squat and deadlift sucks! Fix that crap and your back will get better. The way I explain it to patients, the simplest way of understanding the flexion intolerant, discogenic back is to realize that they have an inappropriate hinge in their lumbar spine and it should instead be in their hip joint. I love it when I see those patients that come back after several years for the odd computer-neck and note that their back pain got WAY better when the found this great trainer who taught them how to squat. I always get those trainers’ cards and keep them on hand so that I have a pool of references when patients want help in the gym.
Now, here’s the dark side…don’t be the trainer checking your email while your client cranks out 3 sets of 10 “bicycling”, performing spine flexing/compressing “core work” because some ACE article said it provided the “highest EMG activity of any ab exercise” (while loading the spine in flexion). Never mind that while you were friending Joe Dowdell on Facebook, your client was gassing in the captain’s chair demonstrating hip and lumbar movement dissociation and flexing that lumbar spine under a compressive load and inching closer to my office. Don’t be the gal wondering if “those are real” on the woman across the gym while your client drops below their functional squat range under load and flexes their lumbar spine. Instead, catch that crappy squat and deepen their functional range with Stu McGill’s cues to “bend the bar” and “spread the floor with your feet”.
Recently Charlie Weingroff had an interesting post on the flexion intolerant back through a McKenzie and an SFMA lens. As I read I remembered Stu McGill’s admonition to us years before when managing a compromised back…Job 1. Correct the poor movement pattern. Fix that crappy squat. Pick up your purse without a lumbar hinge. Move the hip with the spine stabilized. Roll over in bed with the abs braced. Perhaps as Mike Boyle suggests, shift that client to a split squat or Bulgarians rather than a heavy back squat to spare the spine.
A few months ago I put together my clinical approach to the flexion intolerant back in a self-help education and exercise focused website called FixYourOwnBack.com. I encourage those with flexion intolerant backs to:
- Correct the lumbar hinge and restore the hip hinge
- Use McKenzie-influenced extension patterns as “First Aid” to help with the back and leg pain.
- Use McGill’s Big 3 and the DNS influenced Sternal Crunch and Diaphragmatic Breathing from Craig Liebenson to stabilize the spine
- Use the FMS-influenced correctives to address common hip and T-spine mobility deficits
- Integrate the stable spine with the mobile hips using more FMS-based correctives
- Build strength, agility, power using kettlebell-focused basic movement patterns with low tech, low cost, low objection exercises like TGUs, swings, front squats, etc.
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