Non-specific low back pain and personal training: part II

I argued in my last blog the goal of good movement quality depends on (to borrow from the Feldenkrais people) a well-organized spine. The ability of the spine to disperse load during movement is important for efficiency and ease, but how does this translate into training? 

Before I dive into this topic, I think it’s important to show what the research suggests regarding non-specific low back pain (NSLBP). NSLBP means there isn’t any known reason for the pain, and outcomes for acute NSLBP are quite good, with most experiencing significant improvement within 3 months (Wand & O’Connell, 2008). The research is comical. In no particular order, a quick Pubmed search of the topic shows:
a) Proprioceptive training offers no consistent to reducing pain in individuals with neck and low back pain (Mccaskey, et.al, 2014).
b) Evidence doesn’t suggest Pilates is better than other forms of exercise for individuals with NSLBP (Yamato, et.al, 2015).
c) Clinical evidence has not proven core stability exercises to be better than conventional exercise for treating NSLBP (Davin & Callaghan, 2016). 
d) Evidence does not support that motor control exercises are better than conventional exercise of manual therapy in treating NSLBP (Saragiotto, et.al, 2016).

What does appear to help NSLBP is exercise. Insoles, back belts, and education were not as effective for treating NSLBP as plain, old fashioned exercise in a literature review consisting of more than 30,000 subjects (Steffens, et.al, 2016). This leaves the exercise professional in a bit of a quandary when programming for NSLBP. The conclusion that could be drawn from the above research is that exercise is important, but the type of exercise doesn’t really matter.

Before everyone throws out motor control exercises, “core” stability exercises, and proprioception exercises, I would like to point out that when you actually read some of these studies, the subjects are simply “individuals with NSLBP.” There is no separating subjects into groups controlling for anxiety, hypermobility, hypomobility, disembodiment (because you know science researchers love to explore how disconnected people are from how their bodies move), etc. However, this idea isn’t without its flaws. Wand and O’Connell do a nice job explaining the concept of sub-grouping and why research doesn’t fully support subgrouping as the reason interventions have such a low success rate. They argue (convincingly) that NSCLBP may be neurological in nature, with incongruence existing between the body part (for instance, the lumbar spine), and the brain’s perception of that area. This fits nicely with research done by Moseley (2008), that found in a small group, individuals with NSCLBP had a distorted body image of their backs and were unable to feel tactile feedback on the area of the spine where they experienced pain. 

Think of this from a cueing perspective. A client walks in with a rib flare and an anterior pelvic tilt. Now, research shows posture doesn’t indicate pain; however, we also know this isn’t an ideal position for dispersing load up the spine during lifting tasks (or, as trainers, we think we know this because of basic biomechanics), and since we are hired to generate an individualized exercise program for the person in front of us, it is reasonable to assume there is value in improving rib cage to pelvis position for specific movements, such as a push-up, TRX row, or deadlift. Let’s pretend this is my client and I don’t want to waste time putting the person on the floor because it is 6 years ago, and I have yet to fully understand the value in teaching people body awareness. I ask the person to soften the ribs on the exhale. Nothing happens. I ask if the person softened her ribs (vigorous nod). I decide to try a different approach, and place two fingers on the person’s back, right below where the scapula are pulling spectacularly off the ribs. I ask the person to move her back into my fingers. Her upper back rounds. Flummoxed, I decide to work on segmented cat cows, because I will teach her how to do this thing she doesn’t know how to do in 3 minutes of work today. I ask her to articulate one vertebrae at a time as she rounds her back, starting at her pelvis. She rounds her upper back. Nothing happens below T4. 

This is an excellent example of someone that doesn’t understand how to move a specific part of her body. She is disconnected from her low back, and there is a good chance if I had her lie on the floor, with her knees bent and her feet flat on the floor, and I asked her which part of her back she felt on the floor, there would be no feeling in the low back. It would feel as though it weren’t touching at all. (Which, in extreme cases of this particular holding pattern, is possible. However, more likely, is there is there is a distortion in perception. What she feels isn’t actually what is happening). Interestingly, tactile discrimination (where subjects were asked to identify the touch stimulus) was found to effectively decrease pain and improve tactile acuity in subjects with chronic regional pain syndrome (Moseley, et.al, 2008). Feldenkrais asks practitioners to feel the floor; Gyrokinesis and Qi Gong both involve tapping movements to provide sensory input to the brain. These are excellent ways to begin improving body image and allowing people to “find” body parts that might be otherwise unclear.

I train a lot of individuals that have at some point suffered from low back pain. About two years ago I stumbled upon the Franklin Method, which resulted in me buying the Franklin balls and using the sensory exercise he teaches with the balls on either side of the sacrum, observing the weight on the balls, and lifting one foot while observing pressure changes (and trying to maintain constant pressure as the foot lifts). This exercise (or awareness exercise, whatever you want to call it) works really well for people disconnected from this area of their backs. Inevitably, once the person removes the balls, he (or she) comments on how amazing his back feels (mostly because he can actually feel it on the floor), and then wants to know where the balls can be purchased. (It is unfortunate I don’t carry Franklin balls, because everyone that has used the balls ends up purchasing them on Amazon). The great thing about this exercise is because it posteriorly tilts the pelvis, it also relaxes the ribs, so I can bring awareness to that area as well. I do this before I integrate breathing, segmented cat/cow, or cueing with the person in an upright person because I am trying to help the individual I am training create an internal map about the body and how it works. 

As trainers, movement professionals, strength coaches, or yoga teacher, where can we go from here? How can we begin to design safe, individualized programs for people experiencing NSLBP? We know exercise appears to help NSLBP in both cases. What I propose (and what I put into practice with clients), is instead of getting too caught up in which “core” exercises are most effective and which stretches are best for sciatica, we look at the person in front of us and figure out how to help that person move more efficiently. 

I am fully aware there are other things that play into NSCLBP. Research performed by Rabey et.al, (2015) looked at pain thresholds among individuals with NSCLBP. They found the individuals with the lowest pain thresholds were the ones getting the least amount of exercise, the least amount of sleep, and were suffering from depression. It is convenient that exercise is a widely accepted way to reduce depression and might even improve sleep, but unless the individual is seeing a mental health professional, increasing exercise might not help. (Or it might. You can’t make absolute statements in these situations). Further, research performed by Lloyd et.al, (2016) found individuals with NSLBP with the highest levels of pain related distress were more likely to infer movements that were non-threatening would cause pain. In my career, there have been two instances where I worked with individuals that feared movement. No matter how creative I got, there was a perception of threat even with the smallest movements in areas that weren’t related to the back. I referred both of them out when it became evident I wasn’t going to be able to help them.  Fortunately, most of the time when I am referred individuals with NSLBP, they are otherwise healthy individuals that have a frequent backache for no obvious reason. 

For instance, pretend a young man of 65 has been referred to me because he has heard I am good. Upon his initial consult, he tells me his back hurts when he stands for long periods of time, but he is otherwise pretty healthy. I watch him walk, and notice that while his arms swing, there isn’t much movement in his rib cage area. When he lies down on the massage table, his feet point straight towards the ceiling, and when he comes into a standing position, I notice his weight stays back in his heels, which throws off his body weight squat. I observe his breathing pattern and notice there is very little movement in his ribs. What can I discern from this situation and where should I proceed?

There is no “right” way to develop this program, and there are a myriad of places I could start. This is simply what I find generally works as a decent starting point in a situation like this. I would have the person lie down on his back, with his knees bent, feet flat on the floor hands on his ribs. As he inhaled, I would cue him to feel the expansion and movement underneath his hands. We would focus on the inhalation for about four breaths, observing the rib cage expansion. After four breaths, we would switch to observing the effect the exhale has on the ribs, how they soften and come towards each other. Breath not only influences rib mechanics (as noted in part I), but research is also beginning to explore the effects it has on movement efficiency (Caggioni, et.al, 2015). I use it to teach position of ribs to pelvis and to increase awareness of the deep abdominals, but I don’t start with forceful exhales. Rather, I begin by allowing the person to explore the effect it has on the rib cage region. I might shift the person’s awareness to what is happening to the pressure of his back against the floor as he breathes, or I might save that for later. I might move the person into a child’s pose position to have him further explore how the breath expands the ribs and contracts the ribs in the back body, assuming hip mobility is okay. From here we would begin allowing the exhales to be a little bit longer than the inhales. I might also use bolsters to prop him up so he isn’t wasting any undo effort struggling in the position, allowing him to focus on the breath). 

After spending about 10 minutes bringing awareness to breath and position, we would move into standing drills. Each exercise would begin with an exhale to feel the sense of the ribs dropping towards the pelvis, and I would reference the floor work (“remember what this felt like on the floor?”). I would also have the person explore where he was weighted in his feet, allowing him to observe that by allowing the ribs to relax down with the exhale, there is a subtle shift forward in the feet, away from the heels and more towards the center of the feet. These cues would be the focal points of the session as we moved into more traditional body weight and cable work, with awareness drills in between exercises (I usually circuit two or three exercises, do an awareness drill, which can be any number of things, including a yoga pose, isometric hold, or seated somatic drill). We would end the session where we started, focusing on the breath and observing the ribs. As his sessions progress, the goal would be to improve posterior leg strength, provide balance between his outer and inner thigh strength, and eventually implement rotational work, both from a gentle, somatic perspective and through a more dynamic perspective.

Compare this to the young woman of 34 who was also referred to me. Unlike the client described above who trusted his referral source completely, she is skeptical, went through physical therapy for back pain about a year ago and, while it isn’t as chronic as it was, it still “flares up.” She isn’t sure what I can do for her that she isn’t already doing in the gym, but she thought she would come once and see what I had to offer.

During the initial consult I notice a lot of side to side movement in her pelvis when she walks. During one legged stance, she hikes up the pelvis of the leg that is lifted, and during her squats, instead of going into hip flexion she moves into lumbar extension. I ask to see her physical therapy exercises, and she shows me her bird dog (which involves extending her back to get the contralateral arm and leg up), bridging, which looks pretty good, and a dying bug involving a lot of pelvic movement. I ask her to lie down on her back, with her knees bent and her feet flat. (It is worthwhile to note she also uses her neck for just about everything). I place a very light object between her legs and ask her to begin breathing in through her nose and out through her mouth. Her shoulders lift up slightly when she inhales, and her exhale is forced. 

Again, there are many ways this program could be developed. I would begin with gentle arms movements, shrugging her shoulders up and down to feel her shoulder blades, gently lift the shoulders away from the mat and back down to the mat, coordination breath with movement, and maybe do some gentle neck rolls to begin to quiet her system. Instead of cueing her in any manner than involved “activating” or “working,” I would stick with gentle movements, bringing awareness to where her shoulders were located in space, maybe exaggerate them lifting towards her ears when she inhaled, and then explore what it’s like for them to not lift during the inhale. Rather than dying bug, I would have her place her hands on her ASIS, feeling the pressure of the bones against her fingers. When she lifted a foot off the ground during the inhale, I ask her to notice the change in pressure on her fingers. Once that is clear, I ask her to notice what her pelvis is doing against the mat. I have her exaggerate the movement, feeling the rocking, and then I ask her to do it without moving the pelvis. (It is difficult to correct something when the client doesn’t realize he is doing it. If proprioceptive drills aren’t your thing, video feedback also works). I place her on her forearms and knees, again helping her figure out where her body is located in space. If during the first session we move towards standing movements, I would cue a relaxed upper body posture and awareness of breath. My goal for her upon leaving would be for her to feel relaxed and a little more aware of her movements. If she continued working with me, I would help her understand the difference between hip movement and lumbar movement, I would strengthen the external rotators of her shoulders and teach her how the collarbones and shoulder blades are connected, eventually working on lower trapezius work, maybe in the form of L-sit prep or isometric straight arm lat pull-downs, emphasizing a reach out of the finger tips. I also might implement the cervical spine ELDOA stretches, and I would use PRI hamstring activation drills at first, moving into more dynamic and upright hamstring work. Her warm-up and cool-down would have a breathing component, with consistent cueing regarding shoulder awareness and rib position.

I actually used a protocol very similar to this with a young graduate student. She began seeing me when she was 26. She had had (in no particular order), shoulder surgery on both shoulders, knee surgery on her left knee, and her low back pain had freaked out on her, leaving her a young woman feeling stuck in an 80 year old’s body. She did physical therapy for all of these and had made progress, but still felt scared to begin any sort of workout program. Her first exercises were very simple, motor control and breathing exercises designed to improve body awareness. (She sees me once every six weeks). The last time she saw me, about 18 months after we began, I sent her home with deadlift patterns, a dynamic plank variation, single leg squat work, and a side lying shoulder exercise, along with a breathing exercise. She has become significantly more confident in her strength and ability to do things without pain. While the exercises I give her are simple, I focus on the most basic regression I can think of first, let her master that, and the next time I see her (hopefully) move on to the next level. (I can guarantee if you asked her 14 months ago if she would ever be working on a deadlift she would have looked at you like you were crazy). The point is, when you are working with someone that, in the words of David Butler, has a “sensitive nervous system,” you don’t need to start with the most advanced version of an exercise to be effective. Sometimes, the regressions feel harder than the more advanced versions because they force you to address the basic skills that are often glossed over or left out in favor of the more impressive looking skill. 

Again, how is any of this practical and what can be done moving forward? I suggest that instead of getting bogged down with the exercises that are “most effective at targeting the TVA” or trying to isolate the glutes to strengthen the posterior chain, you look at the person in front of you, see what he or she struggles with in terms of movement, and teach that. Help the person figure out how his body works and where it’s at in space. These two things alone begin to impact how well load is transferred up the spine. In my world, I watch the person move, including how he walks. I don’t train gait, but it often tells me where a person struggles, for instance the person whose right hip kicks to the right side every time he walks. This gives me information, and it becomes a puzzle for me to figure out a way to give the person different options. If a person has a significant rib flare, I work on that. If the person’s pelvis rotates every time he lifts a leg in supine, I work on that. The benefit of studying many different things is I have options available to me if the original exercise or movement I pick doesn’t work. I try something else until I find one that does.

To break this down more simply from a spine perspective, after the client understands where his spine is, you can break movements of the spine down simply. First, can the person flex and extend different parts of the spinal column? (Segmented cat/cows are excellent for this). If the person can only go one direction, for instance, into extension, perhaps you need to spend a little more time teaching flexion and vice versa (all of this assumes no pain is present. If pain is present, work in a pain free range of motion). Within flexion and extension, can the person also resist flexion and extension? Planking and overhead reaching, either supine, prone, or standing fall into this category. Once the individual has mastered that, move onto lateral movement. Can the person laterally flex both sides of the spine or is there a lateral shift in the entire column that takes place when he tries? (I always cue, "it's like the ribs are opening up like an accordion." This typically disperses the bend more evenly). Next, can the person resist lateral flexion? This is things like side planks, one arm side hangs off of a squat rack, and human flags, because every 65 year old should be using human flags to train resisting side bending. (I kid. If a 65 year old is doing human flags, more power to him and he should continue doing that. For the rest of us, the side planking variations tend to work just fine). Finally, can the person rotate in a dispersed manner? And can the person resist rotation? (Pallof presses, anyone)? This is an easy way to figure out where to start. Check front to back, check side to side, and check rotation. During mobility work, make sure none of the segments are stuck or moving like a block. For stability work, make sure there aren't any little shifts where the spine "buckles." The goal is a well-organized spine that disperses load. Teach the spine how to be that.  

Vern Gambetta, a well-known strength and conditioning coach, said “train the movement, not the muscles.” This doesn’t mean don’t teach the person how the joints work in isolation (the FRC system by Andreo Spina and Z-Health by Eric Cobb both do a nice job teaching isolation work). Instead, it means don’t get hung up on what muscle is doing what. The hardest clients I have are the ones who have done a lot of supine TrA work, and were cued the same activation pattern during all dynamic movements, never allowing the pelvis to move. Their pelvises are held rigid, and they often ask me if they should “engage their abs” during movements. (It’s kind of humorous. Laundry lists of injuries and conditions don’t phase me at all, but whenever I see this, I want to run and hide in the corner).  Again, from a movement perspective, my view on cueing abs is a) a person needs to be able to develop total body tension for higher level activities, such as picking something heavy off of the ground and b) a person needs to be able to relax and not be overly tense during low level activities, such as lunging backwards without weight. The reflexive stability should take care of itself, assuming good motor control, position, and joint coordination. 

I have rambled on long enough. This is a topic I care passionately about because I believe those suffering from CNSLBP are underserved. They often don’t feel comfortable in a class setting, and unless there is open communication between the trainer and the client, these are the individuals that come once and you never see them again because their low back flared up after the session. The bulk of the population needs more physical activity in their lives. The risk of injury or experiencing pain after exercise reduces the likelihood a person will continue to be active. I strongly believe much of this could be avoided if we spent more time on the basics, preparing the person disconnected from his body for the task at hand by a) looking at how the person moves and exploring ways to improve movement quality b) regressing the movement to the smallest level, c) encouraging efficiency, and d) encouraging the person to monitor body sensations, stopping at the first sign of pain. 

Yours in health and wellness,
Jenn

References:
Wand, B.M., & O’Connell, N.E., (2008). BMC Musculoskeletal Disorders, 9(11), DOI: 10.1186/1471-2474-9-11
McCaskey, M.A., Schuster-Amft, C., Wirth, B., Suica, Z., & de Bruin, E.D., (2014). Effects of proprioceptive exercises on pain and function in chronic neck and low back pain rehabilitation: a systematic review. BMC Musculoskeletal Disorders, 15(382). DOI: 10.1186/1471-2474-15-382.
Yamato, T.P., Maher. C.G., Saragiotto, B.T., Hancock, M.J., Ostelo, R.W., Cabral, C.M., Costa, L.C., Costa, L.O., (2015). Pilates for low back pain: complete republication of a Cochrane review. Spine.
Davin, J., & Callaghan, M., (2016). BET 2: core stability versus conventional exercise for treating non-specific low back pain. 
Saragiotto, B.T., Maher, C.G., Yamato, T.P., Costa, L.O., Menezes Costa, L.C., Ostelo, R.W., & Macedo, L.G., (2016). Motor control exercise for chronic non-specific low-back pain. Cochrane Database System Review, 7(1).
Steffens, D., Maher, C.G., Pereira, L.S.M., Stevens, M.L., Oliviera, V.C., Chapple, M., Teixeira-Salmela, L.F., Hancock, M.J., (2016). Prevention of low back pain. A systematic review and meta-analysis. JAMA Internal Medicine, DOI: doi:10.1001/jamainternmed.2015.7431.
Moseley, G.L., (2008). I can’t find it! Distorted body image and tactile dysfunction in patients with chronic pain. Pain, 140(1), 239-243.
Moseley, G.L., Zalucki, N.M., & Wiech, K., (2008). Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain. Pain, 137(3), 600-608.
Rabey, M., Slater, H., O’Sullivan, P., Beales, D., & Smith, A., (2015). Somatosensory nociceptive characteristics differentiate subgroups in people with chronic low back pain: a cluster analysis. Pain, 156(1), 1874-1884.
Lloyd, D.M., Helbig, T., Findlay, G., Roberts, N., & Nurmikko, T., (2016). Brain areas involved in anticipation of clinically-relevant pain in low back pain populations with high levels of pain behaviour. Journal of Pain, doi: 10.1016/j.jpain.2016.01.470. 
Cavaggioni, L., Ongaro, L., Zannin, E., Iaia, F.M., & Alberti, G., (2015). Effects of different core exercises on respiratory parameters and abdominal strength. Journal of Physical Therapy Science, 27(10), 3249-3253.