Trent and Coach D return for round 4 of the series on lower back pain, wrapping up the topic with a meaty discussion about exercise for treating chronic low back pain as well as acute pain from injury.
As mentioned in previous episodes, it's very important to first get an accurate diagnosis to understand what you're dealing with before getting back to training. Hard neuro symptoms such as loss of motor function, drop foot, etc. are more serious and may require a different approach to treatment than chronic sciatica, for instance. The diagnosis helps identify the source of the pain, and provides some idea of the likely healing time of the tissues affected (muscle, tendons, bone).
Once an accurate diagnosis has been made, treatment should -- in most cases -- begin immediately. Rarely is rest the right answer, unless the athlete is dealing with a severe injury. At this point, the coach or medical provider should begin educating the athlete about the nature of their injury and some of the things they may experience during the rehab process, being careful not to catastrophize the injury. Sometimes they are going to experience pain during their workouts, but using the exposure without danger principle discussed in Part 3 will help rewire their pain response while giving the tissue the best environment to heal.
From here, Coach D likes to break down the exercise progression into several steps, with pain and knowledge of the injury and the typical healing times for different types of tissue serving as the guide.
The Exercise Prescription
Bodyweight movements while laying on the back. At this point there should be little or no loading of the spine, just introducing light movement. Bridges Knees to chest Trunk rotation Bodyweight movement, progressing to sitting. The athlete should focus on keeping the spine neutral and using the back as a rigid lever during these movements. At this point we have still not introduced loading beyond bodyweight. Sit to stands, from a high box to progressively lower box if necessary. Hip hinges, using the back as a rigid lever Compound movements, with light loading. This is a good time to break out the training bars, broomsticks, and PVC pipe. Adjust the grip, implement, or movement pattern as necessary to accommodate for pain tolerance. For instance, if the lifter is having a hard time holding a regular barbell, try a safety squat bar or buffalo bar. Loading should be conservative at this point; there will be plenty of time to progress to heavy later. Squats using a light bar, kettlebell, or even bodyweight squats to a box, but using full range of motion. Planks and side planks in short intervals, increasing duration over time, for athletes who still have trouble loading their spine in a horizontal position. Sled pulls and drags Weighted carries with dumbbells or kettlebells Compound movements with progressive loading. At this point it's time to reintroduce the compound lifts -- the squat, press, and deadlift -- with some load. The lifter needs to pay special attention to executing the lifts with perfect or nearly perfect form. At this point the athlete's pain should be low to moderate on the pain scale, and they can load the lifts using pain as the guide. Use common sense with the progression: a 400lb squatter coming back from a minor adductor strain need not make 5lbs jumps every workout, but he probably should not make 50lbs jumps either. Likewise even a strong lifter coming back from a more severe injury such as a hamstring tear may need to make more conservative jumps while the tissue heals. In both cases the progression model will look the same, but the timelines will be different: the lifter with adductor strain may only need 2-3 weeks before he is back to squatting 90-95% of his previous loads, while the hamstring injury may require months, depending on the severity.
At first the athlete should be doing these movements every day. Once compound loading begins, as the loads climb they can start tapering their workouts from every day to every other day, eventually back to their original workout schedule, such as 3 times per week.
The key thing when dealing with pain is motion is lotion, and movement as soon as possible after an injury is the best way to promote healing in the damage tissues. For those suffering from chronic pain and not necessarily an injury, movement is still the answer! Progressing to compound movements with load:
increases blood flow to the tissue, which brings nutrients, facilities cellular waste removal, and brings growth hormones to the tissue reduces scar tissue, as the muscle is encouraged to heal in the direction that it is used, as opposed to randomly scarring, which can increase the chance of injury in the future reduces muscle atrophy improves motor sequence firing and increases muscle stamina, which help make movement and everyday tasks easier
Further Reading on Back Pain, Pain Science, and Exercise Intervention for Pain
In the Spine or In the Brain: Recent Advances in Pain Neuroscience by Nijs J, Clark J, Malfliet A, Ickmans K, Voogt L, Don S, den Bandt H, Goubert D, Kregel J, Coppieters I, Dankaerts W Effects of Functional Resistance Training on Fitness and Quality of Life in Females by Cortell-Tormo, Juan & Tercedor, Pablo & Chulvi-Medrano, Iván & Tortosa-Martínez, Juan & Manchado, Carmen & Belloch, Salvador & Perez-Soriano, Pedro Exercise in the Management of Chronic Back Pain by Dreisinger T The Effects of Strength Exercise and Walking on Lumbar Function, Pain Level, and Body Composition in Chronic Back Pain Patients by Lee JS, Kang SJ Individualized Low Load Motor Control Exercise and Education versus High-Load Lifting Exercises by Aasa B, Berglund L, Michaelson P, Aasa U Core Strength Training for Patients with Chronic Low Back Pain Which Patients With Low Back Pain Benefit From Deadlift Training? by Berglund L, Aasa B, Hellqvist J, Michaelson P, Aasa U
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