Don’t judge a book by it’s cover: why your low back pain may have little to do with your lower back

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A few important points:

  • Low back pain (LBP) is one of the leading causes of activity limitation and workplace disability.
  • While some incidence of LBP can be attributed to an actual diagnosis (radiculopathy, disc herniation, spondylolisthesis, vertebral fractures, osteoporosis, etc.), as much as 85-90% of patients present clinically with non-specific LBP. This means there is no pathoanatomical cause for the pain.
  • When pain is anticipated, people often report a worsening of pain, while activities that are expected to be pain-relieving can be an effective means for producing placebo analgesia.

Four out of 5 adults will experience at least one episode of back pain at some time in their lives.  As lifters, we place even more stress on our lower back than the average sedentary individual.  Still, many of the clients I have worked with present with non-specific LBP without a history of injury and no diagnosed pathology.    I want to take a minute here to talk about the importance of referring out, and more importantly, understanding when it is necessary.  Even though most cases of LBP are non-specific, you still need to rule out any red flags.  The obvious ones would be things like pain that radiates to the lower extremity, atypical pain (occurs only at night, is unrelenting), weakness or numbness in the lower extremity, etc.  However, even pain that lasts more than 6 weeks or pain in persons younger than 18 or older than 50 years old warrants further investigation if your client has not consulted.  Don’t assume, don’t diagnose, and make sure you surround yourself with a network of health care providers that you can work in collaboration with.  As trainers, we are movement specialists, not clinicians.

All that being said, here are 3 movement-related causes of LBP that have nothing to do with the lower back:

Your bracing strategy is suboptimal.

Even in upright, unloaded posture, the lumbar spine segments are subjected to anterior shear forces because of the interaction between the lordotic position, body weight, and ground reaction forces.  In lifting (like in a deadlift, for example), the muscular force of the erector spinae reduces anterior shear forces.  Note that the functional unit of the spine is the motion segment composed of two adjacent vertebrae and the associated soft tissues (ligaments, muscles, fascia).  So, while some shear is normal and necessary, excessive shear is undesirable.  Ideal bracing involves co-contracting the core muscles, lats, quad lumborum and erector spinae for 360◦ stabilization.  Yes, I know…I haven’t taught you anything new about bracing.  What I really want to talk to you about is your bracing strategy.  My friend and business partner Simon Ferland-Chapdelaine uses a great cue when he talks about this with trainees.  He says “restez en situation de travail”, which roughly translates to “stay in a work situation”.  What this means is that you need to stay rigid even in the portions of the lift where there is relatively “little effort” (or at least, it feels that way because the other portions of the lift were so much more effortful).  Surely you have had those clients who sit into their hips at the top of the deadlift, leaning waaaaay back (or tilt their pelvis anteriorly at the end of an overhead press).  This is a strategy for “resting” within a set.  Problem is, it dumps the forces right into your lower back.  Having an optimal bracing strategy, or staying in a “work situation” (rigid), means that at the top of the deadlift, you’re still pushing through the ground and pulling on the bar (or at the end of an overhead press, you’re still pushing through the ground and pushing the bar up).  Truth is, there’s no opportunity to rest until the set is done, and if you’re needing rest within a set, you may need to rethink your loading parameters.

Your mobility and stability are suboptimal.

Movement can be defined as “the ability to produce and maintain an adequate balance of mobility and stability along the kinetic chain while integrating fundamental movement patterns with accuracy and efficiency”.  By now you know that mobility and stability are intricately linked.  The lumbar spine is a complex that should have stability while the thoracic spine and hip complexes should have mobility.  If they don’t, the lumbar spine will give up a degree of stability to compensate for this, leading to excessive and potentially painful movement.  Thinking further along the kinetic chain, suboptimal mobility and/or stability leads to suboptimal length-tension relationships between antagonist muscles/groups of muscles/joint movements, and altered motor control patterns due to ensuing facilitation/inhibition.  Where there is an inability for one muscle to contract at the appropriate level to execute a pattern, another muscle tends to be overactive (or, it’s the over-rider, depending which way you look at it).  Let’s go back to our deadlift.  To make things simple, let’s describe our deadlift (hip hinge) as a combination of closed-chain hip extension and open-chain trunk extension.  This means that your pull involves both pushing through the floor to bring your hips forward through extension and pulling up (and back) on the bar to bring the trunk up through extension. If the hamstrings and gluteus maximus (hip extensors) are not solicited, the erector spinae will attempt to perform this considerable task by itself.  And what may cause the hamstrings and gluteus maximum to not be solicited?  Principles of facilitation/inhibition due to mobility/stability issues.

Suboptimal mobility and stability to my next possible cause for LBP:

You have pain anticipation.

Your body is very smart and will inhibit force production if it doesn’t feel safe letting you produce force from a position that is uncomfortable or not easily accessible.  If you lack mobility/stability in certain positions, you’re typically not very strong in those positions.  If you’re still lifting with compensation from these positions, you may have experienced LBP for any of the above-stated reasons.  What do you do then?  You rest for a while, treat the lower back locally and then return to these same activities while still lacking the appropriate mobility and stability.  But the body remembers.  The anticipation of pain has a priming effect on nociceptive circuits (pain circuits), and the sensory nervous system’s response usually results in a subjective experience of pain. What’s worse, this tends to have a snowballing effect leading to avoidance of these positions and an even further decrease in mobility, which is small enough to go unnoticed at first but will largely impact range of motion in the long run.  A vicious cycle thus begins…

To conclude:

As you can see, postural deficits, inefficient motor control, altered proprioception, loss of mobility and restriction of function all contribute to pain and to the chronification of pain.  Non-specific LBP is a great example of why we need problem-solving approach that involves both a global (functional) approach and a specific (movement) approach.

-MLD

 

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Post-clinical
Rehab

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Movement
optimization

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