Recently I published a blog looking deep into the causes and potential treatment approaches for the shoulder. I was pleased with the response from that posting, and am here to now take a look at another problem area; the lower back. Through my work as an Exercise Physiologist, I spend a lot of time looking into causes and treatment plans for people who come in with non-specific lower back issues. Much like any issue, the approach is the same and all starts with an Initial Consultation. From there, a plan can be devised to regain function and improve all aspects of the body, and get the lower back on its way to being pain free and functional again.
Initial Consultation:
During an Initial Consultation regarding lower back pain, it is important to establish whether the patient is experiencing this pain as a result of direct trauma or ongoing non-specific causes. Obviously this will be where the patient discloses their history of pain and some clarity can be made of the situation. A lot of the time, pain in the lower back is a build up of discomfort over time. It has certain triggers but generally is “always there” and can be “restrictive and annoying”. If this is the case, which it quite often is, I then begin a thorough movement assessment. Just because the lower back is the site of the pain, does not mean that it is not stemming from elsewhere. I find it very helpful to be thorough with assessing the entire posterior chain in both active and passive movements. In order to do this, I would perform the following assessments, working from the ground up:
1) Knee to wall.
2) Active straight leg raise.
3) Active hip flexion (Knee to chest).
4) Hip internal and external rotation.
5) Thoracic rotation side lying.
6) Supine shoulder flexion.
7) Single leg balance.
Upon taking a look at these movements, we begin to see where restriction and referred pain might be stemming from. It is quite common for tight hamstrings and calves to be present within those who have lower back pain. Poor thoracic rotation is usually seen as well, but again, I don’t like to generalise. If however we do see a lot of posterior chain restriction, we tend to have a good place to start.
Creating a program:
In order to create a program that is specific to the person who has been screened, we need to address a few key areas such as:
1) Can this person get up and down from the ground or is a bench/table going to be required.
2) Will this person train within a gym or at home, if so, what equipment do they have access to.
3) How many days per week will this person commit to this program and what approach is going to be best.
From here, the program can start to take shape and the results can begin to happen. In the case of lower back pain, I always prefer to take a mobility and release work first approach, followed by some compound movement/strength work. It is important to get the balance right initially and remember that a patient who is in a lot of pain will be very reluctant to start grabbing barbells and lifting weights. My go to mobility drills for working through posterior chain tension are as follows:
1) Supine wall L sit crunch.
2) ASLR toe touches.
3) Incline board calf stretch with forward lean to box.
4) Incline banded Jefferson curl.
5) ½ Kneeling pole lat stretch with rotation.
6) Thoracic rotation side lying.
7) Thoracic extension over foam roller.
8) Elevated pigeon stretch.
These are not in any way ordered based on importance, nor is the dosage listed as it’s always individual. These are just a handful of ways to get the process going, depending on the situation. In some cases, foam rolling might be a better choice to begin with for example. In some other cases, more specific loaded trunk flexion might be required in order to work more on the abdominals, it’s always case by case.
Strength training:
To me, strength training now comes in 2 different varieties. There is traditional lifting as well as mobility and position specific lifting. In order to work through injury, you need to balance the program between the 2 to gain optimal results. If somebody is just coming off of a 4 week block of mobility drills and foam rolling, I hardly see a barbell being the next step; not for a while. I always begin to teach from a movement perspective first, and then load later. This might be a hinge with a stick on the back, progressing to the front, then to a Kettle bell and so on. I’d take this approach over direct loading initially in order to see how the patient responds to the hinge and understands the function of the movement, rather than loading because we feel they “need to be stronger”. Speaking more so to the specific position and movement capacity statement, it is important to form a good relationship with the cable machine in the early stages of lower back rehab. Movements such as ½ kneeling presses and rows as opposed to traditional dumbbell movements will allow the patient to form solid hip strength and stability whilst working their upper body. Exercises like this, and trust me the list is hundreds long, will be the way to go initially. I know I am being general here, but as this is my job, I can’t give away all of the secrets.
Goal setting:
Secondly, with strength training, it is important to have an end goal and work backwards. Maybe we want all of our patients to be able to perform pain free RDL’s and Dead lifts eventually, or something similar, but where are they now? If you are performing movement which can eventually get to this goal on some form of continuum, then you are well on your way. I like to look at any rehab plan as if it was a performance plan dialled back slightly. We still progressively overload, we still block periodise and aim for 4-5 solid weeks and we still de-load. Each block should have foresight into the next and at the end of every 4-5 weeks, we should be aiming to achieve something that we could not perform prior. For some, it might be a pain free hinge and for others it might be touching the floor within the thoracic rotation mobility drill. Goals drive the program and ensure the patient remains motivated and aware of what is required of them. If goals are not met, discuss and work out a plan to achieve this goal at another time. This sort of approach is detailed, methodical and can change at any time.