Low Back Pain Low Back Pain Causes All athletes and exercise participants will, at some point or another, be sidelined due to injury. One of the most prevalent injuries that prevents sport or exercise participation is low back pain. According to one online poll, it is estimated that:  80% of adults will suffer from back pain at some point in their lives  57% of adults over the age of 60 currently suffer from chronic back pain  20% of individuals under the age of 60 currently suffer from chronic back pain  33% of adults have a significant disk abnormality but are not experiencing any pain or symptoms So how are we to interpret those statistics? In essence, the question is not if we will experience low back pain but when. Low back can be a result of or caused by many factors. Ironically, low back pain can be a result of too much activity or not enough. Some of the prominent causes of low back pain include:  Herniated disks  Spinal stenosis  Piriformis syndrome  Arthritis What we do or don’t do can either help prevent low back pain or make it more likely to occur. For example, some of the common agitators of low back pain include:  Prolonged sitting / standing  Certain sleeping positions (e.g., on your stomach)  Poor posture  Certain strength training exercises (e.g., back squat) As mentioned above, certain strength training exercises can, in some cases, increase the risk of low back pain or injury. Specifically, those exercises that directly load the spine (e.g., back squat, deadlift, and power clean) and place a significant amount of compression and shear forces on the intervertebral disks – especially when using heavy weight and/or performed improperly. Although it would be unfair to simply classify these exercises as dangerous and discourage their use entirely, it is important to recognize that they do pose a slightly greater risk of injury and/or prevalence for low back pain. For individuals who suffer from chronic low back pain, it may be worth considering either employing an alternate strength training exercise or performing a slight modification to certain exercises in order to reduce the risk of injury and low back aggravation. For example, instead of the back squat, individuals suffering from chronic low back pain could employ front squats, Bulgarian split squats, lying leg press, and/or dumbbell lunges instead. Additionally, individuals with chronic low back pain could deadlift using a trap bar with the weight elevated instead of deadlifting from the floor with a conventional straight bar. Similarly, individuals with chronic low back pain could perform hang cleans instead of power cleans in order to avoid high risk phases of movement as well as provide better low back support.

Posture Another predominant agitator of low back pain is poor posture. It only makes sense that keeping the spine in a flexed or overextended position (whether sitting, standing, texting) for a prolonged period of time will eventually lead to or exacerbate low back pain. Figure 3.4 below depicts the differences between a neutral, flexed, and overextended spine.

Figure 3.4. Neutral Spinal Position and Common Spinal Faults.

So how can we identify and correct for poor posture? Dr. Kelly Starrett, a physical therapist, renowned strength and conditioning coach, and author of Becoming a Supple Leopard, recommends the two-hand rule and belly-whack test (7). To perform the two-hand rule, place one thumb on the xiphoid process (sternum) and the other thumb on the iliac crest (top of the pelvis) with the fingers splayed and palms facing down and parallel with the floor. When the spine is in a neutral position, both hands are parallel (as shown in Figure 3.5). When the spine is flexed, the hands move closer together. When the spine is overextended, the hands move farther apart. The two-hand rule is a simple method of bringing Figure 3.5. Two-Hand Rule and Belly-Whack Test. awareness to the current position of your spine and making adjustments as necessary. The belly-whack test is another easy method of assessing your current posture. In essence, there is a certain amount of tension (albeit modest) required of the abdominal musculature in order to maintain a braced neutral spine. Being able to take a quick whack to the belly ensures you have enough abdominal tension in order to support good posture.

Low Back Pain Prevention / Recovery Techniques So what can be done to prevent low back pain or help facilitate recovery if you are currently experiencing low back pain? Provided at the end of this segment are some basic strength training exercises, mobility exercises and stretches that should be done regularly (in some cases everyday) in order to help prevent and/or recover from low back pain. However, it is first worth mentioning and addressing some of the common misperceptions associated with low back pain. As with graying hair and wrinkles, changes to the disks and bones of the spine are a natural part of the aging process and should be expected. In other words, there are incremental changes that occur to the spine as part of the aging process. Even so, said changes do not necessary equate to low back pain or represent the cause of low back pain (3). Figure 3.6 on the right provides a bird’s eye view of one of the lumbar vertebra of the lower spine. As depicted, there are several places within the boney structure of the vertebra that could be compressing against the spine and/or nerve roots thereby resulting in pain. For example, thickening of the pedicle, lamina, and/or hypertrophy of the facet joints. All of these adaptations are possible as a result of regular participation in strength training. In other words, said adaptations in and of themselves are not necessary bad, but when combined with an age-related disk abnormalities Figure 3.6. Anatomy of a Vertebra. may result in acute and/or chronic low back pain. According to current research, nearly 100% of all adults have some form of “spinal abnormality” (3). That said, just because you have a spinal abnormality does not guarantee that you will have low back pain. Similarly, it is also possible to have low back pain without a documented spinal abnormality (as seen on a magnetic resonance imaging (MRI)). So what does that mean? In essence, we cannot rely solely on MRI results to determine whether or not we should have low back pain. In fact, MRI findings can sometimes persuade both the patient and physician into believing that these socalled “abnormalities” are the responsible for low back pain when in fact they are not. Figure 3.7 on the left shows the relationship between age and the percentage of individuals with no back pain but have a documented disk abnormality as depicted on an MRI. Figure 3.7. Percentage of Patients with Documented Disc Abnormalities but No Symptoms.

It is also important to remember that although MRI results provide an extremely detailed picture of the disks and bones of the spine, they are not without their limitations. For example, MRI pictures are taken while the patient is lying down; however, the patient’s pain may only occur when they are sitting or performing certain movements. In other words, the underlying cause of the pain may not be able to be detected by the MRI while the patient is lying down. Additionally, and in most cases, back pain will resolve on its own within a couple weeks. So seeking invasive treatment options (e.g., corticosteroid injections, surgery) immediately upon the onset of low back pain may not be necessary. Individuals may want to consider more invasive options when they have associated pain, numbness, or weakness in the same nerve-related pathway as indicated by the disk abnormality on the MRI. If there is only back pain but no associated weakness, pain, numbness, or reflex changes, then the disk abnormality is unlikely to be causing a serious problem (3). Unfortunately, most people prefer to have something done to formally treat their back pain vice simply receive reassurance that it will get better on its own. Ironically, receiving verbal reassurance vice unnecessary MRIs and treatments could save them a bundle in terms of future medical costs and pain. Instead, most of what patients should and can be doing to address or prevent low back pain is independent of their actual MRI results.

Low Back ST, MOB Exercises and Stretches Although most physicians may recommend waiting a few weeks before scheduling an MRI or treatment options to see if the back pain will resolve on its own; very few, if any, recommend remaining completely sedentary in the interim. For example, Dr. Kelly Starrett recommends that individuals get up and stand every 10-15 minutes in order to avoid the negative health effects of prolonged sitting. Additionally, he recommends four minutes of mobility work for every 30 minutes of continuous sitting. When frequent mobility work is not an option (e.g., long car rides), Dr. Starrett recommends using some kind of lumbar support that will help to give support and keep the low back in a better position (7). In terms of back pain recovery and prevention, getting up and performing regular movement is paramount. Movement helps to loosen the muscles, prevent unnecessary loss of ROM, as well as bring blood and nutrients to the area to help facilitate healing. Although the exact recommendations for exercise type, frequency, volume and intensity will likely differ for individuals suffering from acute vice chronic back pain; in both instances individuals are encouraged to regularly perform a variety of strength training exercises, mobility exercises and stretches. Tables 3.5, 3.6 and 3.7 provide some basic low back strength training exercises, mobility exercises, and stretches. These simple exercise can be performed with minimal training and without equipment. It is recommended that these exercises be performed at least once daily (more if tolerated). If you frequently suffer from low back pain and/or are suffering from low back pain currently, it is important not to be overly aggressive when performing said exercises as doing so may lead to the worsening of pain and/or symptoms. Instead, perform a low-intensity warm-up (e.g., slow walk, stationary bike, elliptical trainer) for 10-15 minutes; followed by 3-5 strength training exercises; followed by 3-5 mobility exercises for 2-5 minutes each; followed by 3-5 stretches for 30-90 seconds (or longer as tolerated). Eventually (e.g., few days to weeks) the pain should begin to lessen or subside completely. Ironically, individuals often reduce the frequency of performing said exercises and stretches, or stop them altogether, as they begin to feel better. Obviously, this is not recommended. The unfortunate reality with low back pain relief is that it is transient and reversible. If regular strength training and mobility work are not performed, the benefits of and results from said training will slowly start to diminish and eventually dissipate altogether over time.

Low Back Strength Training Exercises Beginner

Intermediate / Advanced

Plank

Plank Runners

Side Planks

Glute Bridges

Bird Dogs

Table 3.5. Sample Low Back Strength Training Exercises.

Low Back and Hip Mobility Exercises

Cow to Cat Pose

Child’s to Cobra Pose

Rocking (Forward & Back) Frog Pose

Squat to Hip Hinge

Alternating Side Lunges

Rocking (Forward & Back) Single Leg Flexion w/ External Rotation

Table 3.6. Sample Low Back and Hip Mobility Exercises.

Low Back and Hip Stretches

Cobra

Pigeon

Lying Knee Hug

Kneeling Hip Flexor

Piriformis

Lizard

Lower Back Twist

Groin

Modified Hurdler

Lateral Hip Opener

Table 3.7. Sample Low Back and Hip Stretches.