Originally published at www.t-nation.com
Editors Note: This might be my favorite low back pain article ever. I find myself sending it to people all the time. Cant believe it was posted 13 years ago.
Sometimes the simplest solutions are, in fact, simple.
As a physical therapist and conditioning specialist, one the most common ailments that sends people my way is low back pain. I'll spend hours working with clients teaching spinal stabilization exercises, performing joint mobilization, manual traction, stretching, and instructing proper spine mechanics with lifting or working. Most people usually leave my care feeling much better and think their problem is gone; but there are those that return with the same issues, if not more.
Now, this doesn't mean that I'm a bad physical therapist; it means that these people are continuing to do something that's irritating their backs, whether they realize it or not. I often tell my patients that you wouldn't expect your headache to go away if you took Tylenol, and then proceeded to bang your head against a wall. The treatment, be it at the hands of a skilled clinician or the advice of a conditioning expert, can't be effective if you continue habits that cause or aggravate your condition.
You see, the solution to low back pain is not the hour you spend in physical therapy each week, or even the hour or two you spend in the gym, it's every other hour you spend living your life. From standing, to sitting, to lifting, to sleeping, every position you take has an impact on the health of your spine.
Most people can attest that low back pain can occur after excessive compressive loading. However, what they don't realize is that most low back pain originates from long static positions, such as sitting on your office chair or standing at your SUD (stand-up desk). Even though these static positions are so insulting for the back, people don't know how to modify them so they don't continue to be debilitating and painful.
In this article, with the help of my co-author Cassandra we're going to show T-nation readers that the worst enemies of the spine are actually those that you wouldn't normally think about twice. We'll explain how simply altering the little things in life will have a huge impact on all types of back pain, from slipped vertebrae, to just slight discomfort.
With that said, get ready to get off your chair and read this article between frequent breaks because one of the top ways to limit low back pain is to keep moving!
First, a short story
A few weeks ago, a group of us celebrated Tony Gentilcore's birthday, (his age will be left unmentioned…) at a restaurant called Fire and Ice. Between mouthfuls of good food and great beer, you'd hear many atypical conversations carried out such as Tony's idea for a new type of training program, and Eric Cressey's plan to give up power lifting and become a tennis pro (just kidding Eric).
One conversation right in my field of expertise was with Cassandra Forsythe. Some of you might recognize Cassandra as a former T-vixen, or more recently as the low-carb expert. For those of you who don't know Cassandra, (or for even for those that do) for more than 10 years she's been dealing with a serious low back disorder known as spondylolisthesis.
Spondylolisthesis is a spinal instability condition that affects the posterior elements of the spinal vertebrae, also known as the lamina. These lamina attach to the vertebrae via the pedicles; and, at the top and bottom of the lamina, are the facet joints. The facet joints provide static stability, and to a lesser extent, help with load bearing. However, the main load-bearing structure of the spine is the strong vertebral body.
For people who have extensive lumbar lordosis, or participate in activities that involve repeated lumbar hyperextension, especially under a considerable load (like gymnasts and weightlifters), the load-bearing responsibilities are shifted away from the vertebrae and placed upon the smaller posterior spinal structures (the lamina and facet joints). Since these relatively weaker posterior elements aren't designed to deal with this kind of load, they eventually succumb to the stress and become fractured. When the fracture occurs on one side of the spinal vertebrae, the result is termed spondylolysis. When these stress fractures are experienced on both sides, this is termed spondylolisthesis. In both conditions, the result is pain, especially with excessive or loaded extension.
The difference between spondylolysis and spondylolisthesis is that in the later condition, the fracture on both sides of the lamina allows one vertebrae to slip forward upon another. Thus, spondylolysis is simply a spinal fracture where spondylolisthesis is a fracture and a slip. Spondylolisthesis is usual graded on a 1 to 4 scale, depending on the degree of slippage.
Those with a grade 1 are usually able to still compete, while a grade 4 requires immediate surgical fusion.
Besides causing pain, spasm, and episodes of giving way, spinal instability can act as a catalyst to disc degradation, as shear forces can place excess strain on the spinal discs, leading to potential herniation. In addition, the spinal nerve root space can become narrowed, causing nerve damage and compromised function of the structures it innervates. Therefore, people with this condition have to pay particular attention to spine mechanics and avoid anything that makes their symptoms worse.
Cassandra's condition results from a combination of competing as a gymnast and being hypermobile. Her grade 2 spondylolisthesis is sometimes so painful that she can't sleep at night, but she doesn't let it ruin her life. She's learned to reduce her symptoms by staying strong and fit because whenever she becomes inactive, her aches flare up.
In our conversation, Cassandra explained to me that although she's visited several so-called back specialists and surgeons, she's still trying to understand why her back hurts because no one has given her a clear answer. One sports medicine doctor she visited actually told her that she worked out too much and that she needed to cut back. Cassandra took one look at this overweight, out-of-shape physician, laughed, and promptly left his office.
You see, Cassandra like many other athletes with low back pain, works out because it makes her feel better. When she hears comments that she should sit more, she immediately knows that the information she's receiving from certain doctors is complete bull-crap.
Some of the best information about low back pain that Cassandra has gathered has been from conditioning specialists like Mike Boyle, Mike Robertson and Jimmy Smith. Boyle clearly told her that she should stop loading her spine and start focusing on single-leg and body-weight exercises. Robertson and Smith identified some blatant muscle imbalances that needed serious attention and gave her corrective exercises to perform each day, like glute bridging, and bent-knee bird dogs. Even though this all advice was hard to take because giving up squatting and push pressing for Cassandra was almost as bad as telling Fat Albert that he had to give up ice cream, she did it and has noticed much improvement.
However, there's another part of Cassandra's life that, like other professionals, makes up a huge component of her day. It's called work, and it involves long hours of sitting or standing. Cassandra knew that sitting was bothersome because, after a few hours of sitting at the computer or behind a steering wheel, her back always felt awful. What she didn't know though was how to limit the static nature of these activities and, essentially, take the load off her spine. Through our conversation, I showed her some simple ways to correct these problems; and, since this information was novel, she encouraged me to write about it and share it with all T-nation readers so they could benefit too.
It's the Little Things That Add Up To Cause Pain
In my career, I've spent a great deal of time studying spondylolisthesis and various other spinal conditions, and I can certainly attest to the vital role that changing the little things in everyday life can have in influencing the pain you experience. Of all the techniques and exercises I've learned, I believe no treatment is more effective that the skilled modification of daily tasks and positions.
In fact, both the subjects of my Doctoral and fellowship case studies had made dramatic improvements in low back disorders, despite an initial bleak prognosis. For example, a patient experiencing severe pain and disability was able to significantly reduce her symptoms and recover to proper neurological function to the extent that she cancelled her scheduled surgery. What she simply did was stand still for no longer than 10 minutes and sitting no longer than 15 minutes in any given hour. She was hesitant to do this but was desperate, since all other approaches had failed. Despite having several weeks of symptoms prior to adopting my suggested regimen, she noticed significant improvement, and in 6 weeks, was able to tolerate stabilization exercises and extend her functional capacities.
Not every case is like this or Cassandra's of course, but hopefully it reiterates the importance of simply modifying your position with basic, everyday tasks for treating and preventing spinal dysfunction. To fully appreciate the effect of the simple modifications to daily tasks, let's first quickly delve into the many factors that compromise spine health and then explore the solutions.
Enemies of the Spine
The following enemies of the spine are closely related, and mostly faced in the context of day-to-day tasks, as opposed to the confines of the gym. They confront you when your guard is down and your mind distracted, not when you're focused and alert.
We all sit at some point in the day, whether it is at the office, in front of the T.V. or in a car, but this position is one of the worst for spine health. It's been clearly shown that sitting results in high compressive loads upon the lumbar discs. Studies have correlated a higher incidence in back pain and onset of symptoms to greater durations of sitting, while reducing sitting often alleviates pain. These observations are true for nearly all types of lumbar conditions.
The question is, why is such an innocuous, low exertion activity like sitting so damaging to the spine?
It seems that the position of the spine is key. Sitting is typified by a sustained flexion position. The discs are disproportionately loaded, as the posterior elements of the spine (the facet joints) are not in approximation during this flexion; thus, their load-bearing function is eliminated. The result is greater strain on the posterior aspect of the disc. Furthermore, ligaments are stretched, and if sustained, undergo a phenomenon known in biomechanics as creep -- or permanent elongation. Creep is seriously bad as lengthened ligaments lose their ability to provide passive stability to the spine, and may lose their proprioceptive function.
So if prolonged sitting is a problem, then we should stand all the time, right? Not necessarily. If standing is relatively static, meaning little sway or change of position, then it can be problematic as well. This is especially true for those with spinal instability (i.e., spondylolysis, -listhesis).
Standing, especially in a hyperlordotic posture, will divert stress disproportionately to the posterior spinal elements and compress the facet joints. The spine becomes positioned such that shear is more likely, which involves sliding of one vertebrae in relation to its adjacent vertebrae. The exaggerated lordosis commonly seen in standing will also narrow the vertebral opening through which the spinal nerve roots pass through as they exit to the periphery.
Anything that exaggerates lordosis like high heels, or Nike Shock shoes, will cause more stress and more pain to attack the lower back. This is the primary reason that Cassandra, and other spinal instability sufferers, avoids wearing elevated heels at every opportunity. The look of a certain shoe is much less important than the feel of a pain-free back.
Frequent Forward Bending and Twisting
Both biomechanical and empirical research has established that frequent or sustained flexing of the spine, especially in combination with rotation, will result in excessive damage to the spinal discs. Add loading to these conditions, and a scenario for lumbar disc damage is almost guaranteed. Russian twists, various forms of sit-ups, and poorly performed good-mornings and stiff-leg deadlifts are some irritating examples.
In spite of these damaging mechanics, many people can abuse their spine by repeatedly performing these motions with little immediate consequences. Why is this? Perhaps it's due to the fact that damage to the discs occurs through a cumulative process as opposed to a one-time episode of flexion and rotation. Just like the formation of a cavity in a tooth, one exposure to a piece of candy won't cause the problem. Rather, repeated exposure to corrosive agents over months and years, combined with poor hygiene, will rot a tooth. A threshold is attained, and severe pain ensues. The analogy stops there however, as fixing a damaged disc is far more difficult, if not impossible, compared to filling a cavity.
Frequent extension of the spine under loaded conditions is often the catalyst for damage to the posterior elements. Those with spinal instability will be particularly sensitive to lumbar extension, due to the shear and compressive forces upon the damaged lamina and facet joints.
Even though most T-nation readers are smart enough to know that they should stay far, far away from any hyperextension exercise, for those with spinal instability, this is even more important.
Heavy Compressive Loading
This is perhaps the most obvious enemy of the spine, as it can cause damage to all elements. Of particular interest is that the main source of initial failure with excessive compressive load is the vertebral endplate, as opposed to the disc. Researchers, including Bogduk, Twomey, Taylor, and McGill have brought this to light. They report that vertebral endplate damage initiates the changes that lead to lumbar disc changes, making the disc susceptible to pathology. Both Bogduk and McGill propose that a healthy disc will not herniate, even if exposed to extreme loading, flexion and rotation. However, an unhealthy disc, damaged from the sequelae of events initiated by microtrauma to the vertebral endplates and outer elements of the disc, will eventually succumb to stress.
Thus, informed clinicians now refer to herniated discs as a consequence of lumbar disc degradation, as opposed to degeneration. The former implies a consequence of regional abnormal stress, while the latter is a consequence of normal age-related changes. It never made sense to me, and apparently to these researchers, that lumbar disc degeneration could be possible in a 25 year old only at one level, e.g. L5-S1. These "degenerative changes" were not like degenerative changes seen throughout multiple levels in the spine of older adults. Thus, the term degradation makes much more sense in younger people with isolated spinal damage.
So what are the Simple Solutions?
Sounds pretty daunting, eh? Just don't sit, stand, flex, rotate, extend or compress the spine, and your low back will never be in pain.
Thankfully, for those with a normal spine, you don't have to completely avoid the above stresses to be pain-free. However, for those with a back condition like Cassandra, or for those at risk for damage, (weightlifters take note) these stresses will either have to be modified or reduced so that further harm to the spine doesn't occur.
As we said in the beginning of this article, the key to eradicating low back pain, or preventing it in the first place, is to optimally manage and adapt to the little stresses that you face every day. If you have to sit for hours in your commute to work, or stand in one place for a long time, the following solutions will make your low back pain-free.
Given that the spine is generally intolerant to prolonged loading, especially injured spines or those placed in a less than ideal position (sitting), modifying or decreasing load will improve its health. This notion is the basis behind spinal traction, which is simply deloading of the spine.
There seems to be an aura of mystique behind traction of the spine, but the concept is really simple: if something is damaged, take pressure off of it. How do we treat fractured ankles, severely damaged knees, or post-operative hip replacements to enable them to walk while recuperating? We give them crutches -- which allow deloading of the limb. In most situations, the spine shouldn't be treated differently.
Unfortunately, most people don't take advantage, or are even aware, of the benefits of spinal deloading. You could use various apparatuses from several thousand-dollar traction tables that appear to be modern versions of medieval torture devices, to manually applied harnesses. In reality though, you don't need any special equipment. Instead, you can deload your spine easily while driving in your car or while standing at a counter.
Below are some examples that you can try several times through out the day. The more loading, sustained postures, or severe the back condition, the more frequent you should do them. Don't just do these only in response to pain, but rather before symptoms manifest.
Hold each for about 5-10 seconds, then take a brief rest, about 3 sec, and repeat for 10-20 reps.
Note: I don't recommend sustained traction. Holding or sustaining a deloading position for longer than 10 seconds could result in ligamentous creep. This can permanently elongate the ligaments and further contributing to spinal instability. Intermittent deloading provides the same benefits, without the risk.
1) To deload while sitting, you're going to essentially hold your body above your seat with your arms. First, place your hands on your sitting surface and extend your elbows so they're locked, then slightly depress your scapula. The load will then be transferred to your arms, with some remaining on your feet.
This technique is excellent to do when you are forced to sit for long periods without any break, like driving. Do this on regular intervals, such as every 3 songs for example.
2) To deload while standing, you have multiple options. If you're at the office, hold yourself up off the edge of your desk, and let your feet remain in contact with the floor while supporting most of your weight with your arms.
Also if standing, find something tall and sturdy that you could hang from while still having your feet in contact with the ground. A pull-up bar, lat pull, strong bands, or sturdy door jam would do. Grab on, sink into a squat, and let your arms take the majority of your bodyweight. Your feet should still be touching the ground, accepting about 10% of the load.
3) Finally, if you have the luxury of being able to lie on the floor intermittently during prolonged standing or sitting, then take it for all it's worth. Find a comfy piece of floor (but not too comfy, or you might risk falling asleep, and that's not a good idea especially if you're at work) and lay on your back with your feet on an ottoman or your chair so your hips and knees are at a right angle. This position applies the least amount of loading to the discs while giving you significant relief. While lying there, you can also lightly contract your abs and reset your spine to a neutral position.
Ever watch a gecko on the hot sand? Notice how they constantly raise their feet to alternate which foot is in the air? The gecko has learned to modify his behavior to prevent his feet from burning in the scorching heat. Changing positions of the spine is a similar concept. If the spine is continually loaded, the accumulating stress causes aggravation via several mechanisms. The spinal joints, and most other tissues, respond best to movement and intermittent loading which optimizes joint nutrition, joint lubrication and avoids over-stimulation of mechanoreceptors. Many parts of the intervertebral structures have little or no blood supply, so they must receive their nutrients via passive diffusion stimulated by intermittent loading.
Unless you're a young child, most people get some stiffness in their joints after sitting or standing for a long time. This happens because the joints are starved from the protective effects of joint lubrication, which reduces friction and provides nutrition to joint surfaces.
Even if you adopt the perfect sitting posture (if one does exist), the spine is still deprived of its optimal stimulus for healthy function. To prevent this deprivation, avoid prolonged sitting by interrupting long bouts with deloading, standing and walking. Another benefit of changing your sitting position and moving frequently is that you increase your non-exercise energy expenditure (NEAT). In turn, you'll raise your total energy expenditure, which can help battle stubborn belly and/or gluteal fat.
Prolonged static standing can also be problematic. If you have to stand for long periods, shift your weight as often as possible. Even subtle movements stimulate intermittent loading and activate the spinal stabilizers, thereby enhancing stability and eliminating excessive load.
In a feature by Sports Illustrated on NBA star Steve Nash, he revealed his rationale behind his constant shiftiness. They wondered why he couldn't just stand or sit still. He, like Cassandra, has spondylolisthesis, and explained that his back freezes up if he stops moving. Therefore, the solution to his pain is simple: keep active and avoid static positions.
Consider a martial artist, who's about to strike an object with his fist. Imagine the effect if he struck the object with a flexed wrist: it'd result in both one pathetic strike, and likely a damaged wrist. Then imagine doing the same with the wrist in extension: you'd probably see the same thing. Now, place the wrist in neutral. The result would be an impressive blow with little compromise to the joint. Why? Because the wrist was in such a position that the joint was able to evenly distribute the impact. Thus, it tolerated the load optimally with minimal damage.
This consideration should be the same goal for the spine; learn to orientate the spine so it can optimal accept load. Doing so requires adjusting movement patterns that adopt and maintain neutral spine position. This usually requires a considerable amount of practice to enhance position awareness, otherwise known by kinesiologists as proprioception. Although proprioception can be severely altered with injury, it is very trainable and can be recovered.
Once you enhance your position awareness, you'll know where your spine should be in most day-to-day activities. From sitting down, to standing up, to picking up your groceries, knowing what a neutral spine feels like will greatly minimize injury and pain.
Although the methods of improving spinal position awareness can be complex and require skilled instruction, a simple tool involves visualization. While standing to achieve a profile view in a mirror, find neutral spine. If the protruding bones of your frontal pelvis, your ASIS, are considerably lower (greater that about 2 inches) compared to the posterior pelvic bone protuberances, your PSIS, then you'll need to slightly posteriorly rotate your pelvis with a subtle contraction of you abs and glutes. If the opposite is found, slightly extend your back.
A way to achieve this neutral position is to imagine you're holding 100 lbs in each hand. With this type of load, most people will instinctively adopt a sufficiently neutral spine position. Now, imagine a piece of tape is placed from the back of your head to the bottom of your tailbone. Then, when you do any tasks, try not to stretch or slacken this imaginary piece of tape. It takes some practice, but you'll be able to do it eventually.
For more concrete feedback on neutral spine, try doing various tasks while holding a dowel against your spine as depicted below:
Let's go back to the analogy of the martial artist striking a target with his fist. Assuming he's bright enough to put his wrist in neutral, consider the outcome if he didn't contract his forearm muscles sufficiently to maintain that position upon impact. As you could imagine, his wrist would likely collapse into flexion or extension, and suffer the consequences of a fracture.
Similarly, once we can identify neutral spine position, and have engrained new movement patterns, we must use the muscles that maintain dynamic stability and ensure the spine remains as close to this optimal position as possible.
Much has been written regarding the muscles of the trunk that contribute to spinal stability. Although I fully appreciate the complexity of anatomy and the related debates surrounding dynamic stability of the spine, I think some basic common sense could do a lot for most serious lifters without asking them to read every PhD dissertation regarding the biomechanics of the spine. So, here are the cliff's notes on the issue, and what you can do to improve stability.
Assuming you've already mastered the ability to identify neutral spine, you now need to demonstrate that you can perform a contraction to keep this position. Forget about hollowing your spine or just turning on your transverses or multifidus -- turn them all on! Brace your abdomen like someone's going to push you on your ass. As McGill says, lock your pelvis to your rib cage. The diameter of your abdomen should not expand (otherwise your transverses is not engaged), or hollow (or your global stabilizers aren't sufficiently engaged). Poke around your abdomen to ensure your trunk is solid. Once you've achieved this state of steel, you've perfected the brace.
Now, you've got to maintain this brace with a variety of movements, especially those performed in the gym. This requires mobility in the ankles, hips, thoracic spine, and shoulders, as well as coordination and strength endurance of the trunk musculature. See McGill's book, Ultimate Back Fitness And Performance, for an in-depth description of this process. To optimize your mobility, if you haven't done so already, your best bet is to invest in Cressey and Robertson's Magnificent Mobility DVD.
For best results, make sure you maintain a neutral, stable spine throughout sitting, standing, bending or loading. As we've tried to drill into your memory, modifying these daily positions and tasks will prevent or reduce most lower back pain.
Bringing it Back Together
As smart T-nation readers, we know that there are many great solutions to several different problems. Whether you're trying to bulk up or cut down, you have a plethora of nutritional tactics that you can employ. However, the secret behind any of these methods is to be consistent and give each one enough time to work. You'll never see results if you cheat a little here and there, or if you stop following the plan because you don't see results in two weeks.
The same concepts apply to your spine. Although there are many different back conditions, and many different symptoms, an underlying theme lies beneath each one. In some cases, you might have to drastically alter your training program, and in others, you might have to seek frequent clinical guidance. But, in all situations, any spine is attacked by 5 major enemies: sitting, prolonged standing, hyperextension, frequent bending and twisting, and heavy compressive loading.
It's almost a no-brainer that if you have any type of back condition, you should limit hyperextending, bending and twisting and heavy spinal loading. Most good trainers or experienced lifters are well aware of this issue and will modify training to suit these needs.
More importantly though for low back health is to modify the little things in daily life that are also insulting and damaging.
Cassandra and Steve Nash have now learned to use the solutions presented above to minimize the pain that inflicts their spines everyday. If Steve has to sit when watching films or stand between shifts on the court, he'll constantly move his body or deload by lying on the floor with his head propped on a towel.
When Cassandra has to sit for hours working on her dissertation (or on T-nation articles) she takes the load off her back by holding her body weight up every 15 minutes or gets up frequently to perform supine spinal bracing. These simple modifications in combination with proper mobility and specific strengthening exercises, have allowed Cassandra and Steve to remain successful and pain-free athletes.
So, the next time you speak with a doctor about a back problem and he tells you to take it easy, enlighten him on the first two enemies of the spine. Then show him how he can teach others to simply minimize their pain by taking a load off and moving their joints frequently.
Cassandra is a PhD student at the University of Connecticut studying exercise science and nutrition. She received her MS in Human Nutrition and Metabolism and her BSc in Nutrition and Food Science from the University of Alberta in Edmonton, Canada.
Mike is the Director and Co-owner of Spectrum Fitness Consulting, LLC, in Beverly, MA. Mike received his BS in Kinesiology from the University of Ill. at Urbana-Champaign, his MS in Physical Therapy from Boston University, and his Doctorate of Physical Therapy from the Mass. General IHP. Mike currently practices with Orthopaedics Orthopaedics Plus in Beverly, MA as a Physical Therapist. To learn more go to www.spectrumfit.net