Building an effective exercise plan for patients with back pain requires building a program from a structured framework. As discussed in part 1, the process to safely progress an athlete is as follows: introducing an exercise, stabilizing the response, and then progress the exercise.
However, this does not address the exercise selection process. There is currently no definitive evidence that one specific exercise strategy is superior when treating patients with chronic pain (Choi, Verbeek, Tam, & Jiang, 2010; Lederman, 2010). So theoretically, as long as the patient is doing some form of exercise program, they should benefit. This in not necessarily the case, the structure and selection do matter. Identifying the provocative patterns is crucial when working with these patients and that can only be achieved by really listening to what your patient is telling you.
The variables that we should consider are:
1. Historical postures, positions or movements that are pain producing.
2. Assess provocative positions and make appropriate mechanical changes whilst assessing response.
3. How much load to use when starting and how to progress.
a. Loading vs Capacity
i. If the load exceeds capacity, breakdown will occur.
4. Direction of the load application
a. Vertical, loads in squatting, horizontal loads in pressing/pulling, causing rotational forces to withstand or produce rotation
5. The load location in relationship to the spine
a. This regards the posture we assume
i. Are we front squatting, back squatting, goblet squatting?
6. Symmetry of the load
a. Pushing/pulling or carrying with one hand or two, stance, wide, staggered, kneeling, ½ kneeling.
Key Point: Understanding how postures and loads affect the individual will help to build the program.
We used the example of the box squat in part 1. Depending on the individual’s tolerance to the variables mentioned above, this exercise may not be tolerated and ultimately may produce pain. As the individual flexes forward from the hip, the load on the spine increases and may be a provoking factor. An alternative would be a trap bar pull from the floor, where the patient stands inside of the bar and the load is through the center of your body, the spine is more erect, minimizing forces on the back. Another possibility is performing a split squat maneuver where the spine is erect and the one foot is placed in front, and another behind as in the lunge position. This reduces forces on the spine and may be tolerated better without provoking pain.
Key Point: The name of the game is improving capacity, increasing the degree of movement, load that can be handled for a given time or in a given position. Loading that exceeds capacity will lead to breakdown and delays in progress.
The evidence at this time shows us that lumbar stabilization exercise is a useful strategy to manage individuals with chronic lower back pain and to restore function. It is no better than any other strategy in chronic cases. Clinicians and coaches need to consider the individual, understand the demand of the sport, and prescribe the least provocative exercises to restore the individual to the highest level of performance possible. Programs should consider the variables outlined, be progressive in nature, be consistent with the demands of life and sport, and fulfill the goals of the individual.
The key is to find which exercise program brings on the least symptoms. For example, if you have symptoms in the low back and down the right leg below your knee, side planking will cause pressure on the right side when in the right-side plank. This will cause significant pain for some individuals. Farmers walking or suitcase carries may also be problematic because it puts a large load on the spine with every step on to the painful leg. Chopping from a standing wide parallel stance or shoulder taps from an elevated surface may be better tolerated than the previous two exercises as this posture improves stability, reducing forces on the back through a wide base of support and serves as a progression.
The initial phase, which is the first 4 weeks after being symptom free OR stable at a low level of pain, will fall into this category. When training the core trunk musculature, the core/trunk work as a unit with no single muscle being more important than another (Stokes, Gardner-Morse, & Henry, 2011; Brumitt, Matheson, & Meira, 2013). In McGill’s book, Low Back Disorders, the core/trunk musculature required to maintain spinal stability during athletic activity is approximately 10% of its capacity. This supports the requirement for lumbar endurance training vs. training for strength. Again, this is dependent on your patient’s needs. If the goal is to lift heavy loads as in powerlifting, strength is key. For any athlete, analyzing the skills required in the sport is essential. If the goal is to perform yard work, develop appropriate programming approach to maintain stability and endurance through those specific patterns of movement (Krabak & Kennedy, 2008).
Weeks 0-4 initial functional restoration goal: Initiate exercise program that minimizes production/increase of symptoms. Select lower level exercise and assess effect. This is a good place to insert McGill’s big three of the bird-dog, side plank and curl-up. However, some individuals do not tolerate bridging or planking, some people are extension intolerant which eliminate the use of the bird-dog and planking variations. These individuals do better in a standing position, lower repetitions, low compression exercises.
The exercises selected must address the 4 sides of the core/trunk
o The abdominal wall
o The right and left sides
o Hips/back (extensors)
Movements that resist motion
o Anti-flexion
o Anti-lateral flexion
o Anti-extension
o Anti-rotation
Symmetric movements
o Press and row variations
o Squatting variations
-Split squat
-Front squat
-Goblet squat
Perform exercises individually with full completion and then moving to the next sequence
Balance challenges
o Single leg stance
o External perturbation at slower speeds
o Balance Reaching
Teach appropriate movement patterning
Build strength and endurance
Weeks 4-8 - Performance phase: Achieved stability of symptoms, variety of movement increases, demand increases, competence with movement.
General strength program: Progress load patterns of Squats, RDLs, lunging, standing presses/rows;
Assess demands of sporting motion - begin to include drills similar to these demands to improve sport skill.
Include agility/speed exercise
Asymmetrical loading
o Carrying variations
o Sandbag shouldering
o Unilateral pressing
o Unilateral squatting
Reactive movements
o Slosh pipe
o Sandbag
Balance on labile surfaces/multiple directions
Stability exercises with variable support/labile surfaces, stir the pot
Maintaining stability under muscular fatigue and deep breathing
Key Point: Limiting the variables allows you to decide which exercise is the better choice for the patient’s condition and when things go wrong, and which exercises to take out.
However, the process remains the same in respect to analyzing the effect of an exercise on pain. There must be reduction in load lifted, and a gradual build-up to previous working weight over a period of weeks. There must be gradual planned progression to the program after stability has been reached (pain does not increase with addition of new exercise).
Again, choosing exercises that are least insulting to your symptom. The key to your success is proper programming/loading, maintaining stability of the spine in a “mid range” avoiding prolonged or repeated movement into fully flexed or fully bent positions, and varying stress on the spine.
If you are having pain that is limiting your ability to perform the activities you enjoy, please reach out to me through Instagram at @arosportscoaching or @strengthspeedpower or at adam@arosportscoaching.com. We can schedule a video consultation and use the strategies outlined above to help you move towards your goals.