Spinal Rehab: Time to stop babying it!
Last week I posted an article outlining the correct form for what I feel is the most effective overall strength building exercise, the dead lift. Before the article I noted that clinical care should always be transitioned into physical conditioning. Further that progressing the patient into more advanced physical training exercises, following the initial rehabilitation is importance in order to both improve the patients performance, as well as to gain higher levels of strength and muscular control in order to prevent future injury occurrences.
A few days following this, I taught one of my patients how to correctly perform the dead lift. This patient was suffering from chronic low back pain for which we have done a considerable amount of therapy, as well as basic core rehabilitation. Thus I felt that the patient now needed some more advanced, functional training…hence teaching him the lift. The patient performed some sets of the lift on Friday. On Monday morning, I was surprised to hear that he had once again requested to see me. After speaking with him, he explained that he was suffering from a great deal of “pain” the next morning which lasted through the weekend, and that he thought that he re-injured his lower back (keep in mind that this patient is in good physical shape, and that he has been weight training for years). He further explained however that upon rising that Monday morning, that the pain was considerably better and that his back was feeling great.
I further questioned the character of the pain that was described as ‘soreness’ in the erector groups bilaterally that was tender to touch. After a quick examination I determined that the patient was suffering from good old fashion DOMS (Delayed onset muscle soreness). DOMS of course, in any other area
of the body provides the ‘good workout indicator’ the next day after training. However in the lumbar spine (and neck for that matter), it seems that we (the therapists), and them (the patients), have been conditioned to equate any discomfort in the spine as a bad thing. If the same patient had been rehabilitating
a shoulder problem and was assigned exercises, they would fully expect a certain degree of soreness in the rotator cuff the next day. So why is it such a bad thing in the spine?
The moral of the story is that the physical medical profession has wrongly instilled this mentality in others (IMO) by failing to transition from our rehabilitation protocols into conditioning of the spinal muscles. We have been told about “spinal penalty” in research so often that we look at the spine as an incredibly delicate structure that should be handled with ‘white gloves.’ Many times I see people training hard in gyms doing bench presses, bicep curls, or calf raises with progressively heaver weights….then proceed to do the same “core” exercises prescribed by their PT or DC 5 years ago!! The majority of them drop down to perform the ‘Bird-Dogs’ (as per Stuart McGill’s work). Not to say that this, or other rehab exercises are bad mind you. However the basic governing ‘rule’ of both rehab, and training is PROGRESSION. Without it, the body can only reach a certain stage of improvement.
A note on rehab/training…..
Rehab, the way I see it, can be summed up as such:
“provide a small, but progressing amount of “insult” to the tissues in order that they will adapt by making changes that will make them better able to handle said insult” (me, 2010, unpublished)
….that’s it, rehab in a nutshell (just saved you from reading numerous texts whereby people randomly group exercises together and call them “rehab protocol’s”)
– By loading (insulting) a muscle during weight training, the body adapts/responds by both improving the efficiency of the neuromuscular connections involved in the exercise, followed by increasing the volume (and amount) of muscle tissue needed for the movement
– By stressing (insulting) the cardiovascular system, the body adapts/responds by increasing the capacity to utilize oxygen (increased RBC’s, and mitochondria), as well as producing more efficient motor patterns.
– By loading (insulting) the bones with weight bearing exercise, the body adapts/responds by, well…. adding more bone in order to ‘deal’ with the load.
When the progression stops, so do the adaptations. This occurs often in the gyms where people do the same routines, with the same intensity, then complain that they no longer are making any gains. This same principle has to govern rehabilitation in order to attempt to prevent further injury.
Getting back to the low back, people are conditioned to believe that there should be little to know insult to tissues in this area in order to avoid injury. Thus, exercises never change…. Thus the tissues never get stronger, gain endurance, or improve neuromuscular efficiency.
Rehabilitation of the lumbar spine needs to progress to exercises with increasing intensity levels (be it strength, or endurance) just as is needed in any other area of the body. We must train spine to be able to handle higher loads in order that the patient can function safely. Even if we tell people to “lift with their legs,” there are things in the world that people will eventually have to lift that cannot be accomplished simply with their legs. We must therefore ensure that the patient has strong enough lumbar muscles for such an occasion in order to avoid a ‘blow out.’
These exercises must also progressively resemble activities that people do on a daily basis. This concept is clear to us when dealing with athletes as we prescribe the so-called “sports specific” exercises. Why is it any different for non-athletes? Further, why are knee and shoulder rehab ‘programs’ different from the lumbar spine? The concept of “functional training” must apply in all scenarios (and for all areas of the body) whether it be sports specific training, work specific training, or ADL specific training.
Of course, the progressing to more advance spinal exercises must be taught in the proper manner. I feel that it is the job of the therapist to be well versed in said exercises as they are the best able to safely progress the patient.
….now for your enjoyment, here is a video of a gentleman who has no clue how to execute a safe and effective dead lift