Working Around Low-back Pain: How to Approach LBP With Clients
Working around an issue may sound counterintuitive to finding solutions for a specific problem. But with low-back pain, “working around” the area may in fact be a great approach toward improving low-back health. In many cases, low-back pain (LBP) may be a symptom caused by poor movement and dysfunction in other parts of the body. By ignoring the role played throughout the body, critical strategies may be missed, leaving clients caught in a potentially painful and frustrating cycle.
It is estimated that 80 percent of Americans will experience low-back pain at some point in their lives. Therefore, it is inevitable that most fitness professionals will encounter clients who currently experience, have a history of, and/or are destined to develop low-back pain. As fitness professionals, we cannot ignore this, nor can we afford to be unprepared. When working with clients with low-back pain, our scope of practice is limited and completely excludes diagnosing, treating or working with acute symptoms. Medical clearance is a must. However, once cleared, it is within our scope to be part of collaborative efforts to manage minor issues and general conditions.
The Risks of “Working the Area” – Stretching and Strengthening?
One of the most common low-back pain strategies suggests stretching and strengthening the low back. While this isn’t necessarily wrong, it is extremely vague and could perpetuate issues, especially when the cause of pain is a mystery, as is often the case. Stretching and strengthening would require moving and/or loading the vulnerable area in question. Considering the potential consequences of “making the wrong move”—stretching and strengthening the lower back may be among the last strategies we should implement. During the initial stages of training, we should focus more on the functionality and performance of the body as a whole. When other parts of the body are incapable of performing their roles effectively, excessive stresses can transfer to the low back, leading to and/or perpetuating risks.
For example, consider someone with tight hamstrings. The lack of extensibility in the hamstrings would limit an individual’s ability to “hinge” at the hips as he or she bends forward. Therefore, bending down to pick something up would require the person to generate movement elsewhere to reach the floor. For many, this results in a rounding of the spine as a compensatory movement, which places the spine in an inefficient and compromised position (see Figure 1). When this movement is applied consistently over time, excessive wear and tear can be the result. In this example, neither stretching nor strengthening the low back will do anything for hamstring flexibility and therefore will do little to remove the issue placing the back at risk.
Figure 1. Tight hamstrings restrict hip mobility and can result in excessive movement at spine.
The Mobility/Stability Approach – The Low Back and its Neighbors
Each joint in the body should have some degree of both mobility and stability. However, some joints are designed to be relatively more mobile, while others are more stable. Ensuring appropriate levels throughout the body can greatly influence back health. But arguably the most relevant relationship regarding the low back exists within the lumbar region and the joints closest to it—the hip joints and the thoracic spine. The lumbar should be relatively stable, while the hip joints and the thoracic spine should be relatively mobile (Figure 2). If the hips and/or thoracic spine lack appropriate mobility and movement control, the low back is stuck in the middle and will likely be forced to move and/or absorb greater stresses than it is designed to withstand. This can contribute to and/or may even be the cause of pain. By establishing appropriate core stability with multi-dimensional hip and thoracic mobility, the lower back will be called upon less often, greatly reducing wear and tear.
Re-educating the Body - Completing the Picture
Limitations in mobility and/or stability have a significant influence on how movement strategies are developed by the nervous system. When a movement strategy is repeated frequently enough, a habit or pattern is programmed neurologically, whether that movement is considered biomechanically ideal or not. These ingrained strategies are here to stay until they are “reprogrammed.” Simply removing a limitation (for example, reducing tightness in the hamstrings) may not directly influence new movement patterns. In other words, just because mobility and/or stability have improved does not ensure the body will change its habits. If a client has been rounding his back for years, it may be the only strategy he knows. Therefore, it is up us to help our clients retrain new movement patterns as the restrictions are reduced. Applying a strategy to reduce a restriction should be followed up with a strategy to reeducate the desired movement pattern.
Staying with the tight hamstring example, consider how the following two exercises can work together to improve overall functionality. The first exercise is designed to improve mobility in the posterior leg (hamstrings) and the other is designed to re-teach the hip hinge with the increased range provided by the first exercise:
Active/Passive Leg Raise
-Rest the left leg passively on the corner of a wall or through a doorway with the right leg lying straight.
-Slide the hips as close to the wall as possible without bending the knee (if the hamstrings are tight, the hips would not necessarily be close to the wall).
-Perform slow repetitions of straight leg raises with the right leg (eight to 12 slow reps should be sufficient).
-Be sure to rest the supported leg and avoid bracing or pushing it into the wall. This will generate more core stabilization.
-Repeat with the other leg. Observe right and left differences and provide extra work for the side that has greater restrictions to create symmetry.
Reprogramming the Hip Hinge – An Example of Re-educating
-Immediately after mobility work, stand and hold a dowel behind the back with one hand in the lumbar curve and the other in the cervical curve (picture A).
-Hold the dowel so it makes contact with the head, T-spine and the sacrum.
-With a slight bend in the knees, practice hinging at the hips, keeping the dowel in contact with the head, T-spine and especially the sacrum.
-Train whatever range of motion the client can control (maintaining dowel contact). Gradually try to increase the range with this form.
-Switch upper and lower hand grip and repeat.
“Working around” low-back pain is less about the low back itself and more about the functionality of the rest of the body. Developing a program that addresses good core stability and timing, along with multi-dimensional mobility of the hips and thoracic spine, can provide the platform to keep a client’s low back healthy and open up opportunities to build fitness with greater safety and effectiveness.
Stay tuned for my next blog on "Injury Prevention for the Low Back" for more exercise strategies.