I started the Pick my Brain segment of the blog because I get a lot of questions via social media and I thought it would be cool to share my thoughts and answers. If you want to ask me a question, please do so in the comment section and I will do my best to answer it in an upcoming segment.
I also get funny questions or comments via social. For example, someone asked if I could share more videos in French, because he likes my French accent. Of course, being French (from France), he is referring to my French-Canadian (Québecois) accent, which is quite different from his. Speaking of language, when I was teaching in France, I kept calling for a bathroom break, only to find out later that for the French, going to the bathroom means hitting the showers.
Another funny one…in French, socks are called “bas”. At least, that’s what we call them here in Québec. However, in France, they call socks “chaussettes” and “bas” is just that, your bottoms. So, when I taught in France and I told people to take their socks off, I was telling them every time to take their bottoms off.
Basically, for an entire weekend I kept telling them to take their bottoms off and hit the showers. They thought that was pretty funny. They also thought it was pretty funny to only tell me at the end of the weekend…
MUSCULAR LOW BACK PAIN
I had someone write in with a low back pain questions: “I have had muscular pain in predominantly my lumbar for a long time. What rehab moves, exercises do you recommend?”
Of course, that question begs another question, which is whether this person is certain that the pain is muscular and that there is no structural contribution or pathology. This particular individual indicated that they had had X-rays and an MRI that showed no pathology, and as such, they had what I would call movement-related low back pain.
This is the kind of question that is difficult to answer generically. I get a lot of those kinds of questions. “What do you recommend for shoulder pain/low back pain/ knee pain, etc.”. Unfortunately, the answer is pretty much always “it depends”. I like to think of individualizing rehab the same way we individualize training, which is why I always say rehab is training. So, the exercises I would recommend would be very dependent on the individual. There can be a multitude of exercises that you would use to rebuild the low back or correct movement impairments that may be contributing to low back pain. Why you use any specific exercises will depend on which one is best for that individual.
What I will say though, is that I did build the Low Back Fix program using exercises that I have found to work well with most clients.
REPROGRAMMING THE LOW BACK
Addressing movement-related low back pain is about finding movement strategies to distribute forces appropriately to relieve excess or undue stress on the low back. It’s not that we don’t want to load the lower back. The lumbar spine is a load-bearing region. It needs to tolerate load and will not benefit from being underloaded. If we decrease load on the low back altogether, we will have a longer road to travel to build it back up. However, when dealing with movement-related low back pain, we essentially need to reprogram HOW the low back gets loaded.
I generally approach rebuilding the low back in 3 phases: re-establishing lumbopelvic hip function, improving frontal plane stability and then direct loading for the low back. The important is more on the objective within the three phases than on the exercises themselves, because as previously stated, the exercises you choose will be those that best fit the individual.
Phase 1 – Re-establishing lumbopelvic hip function
In the first phase, the objective is to re-establish lumbopelvic hip function. We are looking at how the hips, pelvis and low back function together. There is natural movement that occurs between the hips, pelvis and lumbar spine call the lumbopelvic rhythm. We need to ensure that people have this mobility. Then, stability is the capacity to take this natural mobility and voluntarily limit it where and when needed. Essentially, this is the ability to dissociate movement of the hips from movement of the pelvis and lumbar spine. Specifically, we are talking about improving the awareness of hip extension and improving timing of the torso and the hips for an optimal hinge pattern. Any exercises that bring awareness to hip extension and timing should be the focus of this first phase. Check out this blog article for some dissociation exercises: Dissociation for Optimal Deadlift Form.
Phase 2 – Improving frontal plane stability
The second Phase focuses on frontal plane stability, or lateral stability of the pelvis. Frontal plane stability has been linked to low back pain in prolonged standing. Clinically, the sidelying hip abduction test has been correlated to low back pain, where the inability to maintain stability of the pelvis results in pain. Check out this interesting article by Nelson-Wong et al. From a practical point of view, I have found frontal plane stability exercises to be a nice bridge towards loading the low back directly.
When we think lateral stability of the pelvis, we think glute med. Every portion of the glute med produces abduction of the hip, regardless of the degree of hip flexion. So focusing on the glute med is important, but so is being selective as far as the exercises we choose. Side bridges and band walks can be part of Phase II, but single-leg work, loaded carries, unilateral carries and the likes should be part of it as well, as they provide a greater loading potential.
Phase 3 – Direct low back work
As discussed previously, the lumbar vertebra are built for load bearing. The low back needs to tolerate load and does not benefit from being underloaded. Phase 2 reintroduces compressive loads to the low back, but most people have pain that is related to bad hinge mechanics. Once we have established hinge ability in Phase 1, load tolerance and frontal plane stability in Phase 2, Phase 3 focuses on loading the low back directly to improve hinge capacity. For me, strength on the deadlift, or some variation of the deadlift according to an individual’s needs is a fundamental. If you want to hear more about this, read my blog article: The Fundamental Hip Hinge. Isolation exercises for the low back such as back extension, and variations of the deadlift are the kinds of exercises that go into this phase.
Exercises like reverse hyperextensions, back extension, and variations of RDLs and Goodmornings are great exercises to load the lower back directly. The latter can be progressed from a shorter lever arm towards a longer lever arm. For example, you might start with a Zercher Goodmorning and progress to an RDL and then to a Goodmorning,
THE STRATEGY VS THE EXERCISES
Although I know I haven’t technically answered the question “what rehab moves, exercises do you recommend”, this is probably the best answer I can give, and it hopefully helps you determine not which specific exercise you need to prescribe, but what the objective of each exercise you choose should be.
I also think we need to move away from thinking that specific exercises will solve a problem or injury and think more about what strategy we need to adopt to fix an issue. This will involve a multitude of exercises, not necessarily the same ones for two people with the same problem.
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Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U
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