Rosencutter Ultra Fitness & Performance

I gave a presentation for a class the other night on back pain and how massage can help with it and decided to do an article with some of the concepts I covered in my presentation as well as some added info.

Low back pain is extremely prevalent today and its not unlikely that you have experienced or do experience issues; or know someone who has or does experience issues.  Some interesting statistics on low back issues follow.  These are taken from the amazing book Low Back Disorders by Stuart McGill, which is basically a must read for anyone who deals with client's backs in any way, shape or form. 

The American Medical Association guidelines for quantifying degree of back disability are based largely on loss of spine range of motion although excess ROM has actually been shown to exacerbate and/or create problems in many people.   This is something that appears to have been chosen for legal convenience rather than positive impact on low back troubles.  (McGill, Low Back Disorders, P. 3)
Now, loss of spine ROM could be an issue for some individuals but could never apply for everybody across the board.  It really is unfortunate that something like this is the case.

It is often said that 85% of back troubles are of unknown etiology.  The limiting factor here is specialists and clinicians who only look in their area of expertise.  The "one size fits all approach" simply does not work.  Back troubles do not just magically come about.  There is a reason that causes them.  The reason that so many cases are of "unknown etiology" is that many specialists either don't know what to look for outside of their area of expertise or don't refer out where or when needed.  For example, if an orthopedic doctor doesn't see something going on with someones passive tissues (discs, ligaments, vertebrae, etc.) they might simply assume that the pain is just there. In reality, it could come from a repetitive movement fault and/or soft tissue problem.  This is not always the case but does occur across the health field in various professions. 

There are many inadequacies in care and prevention of low back disorders. A few major ones follow.

Studies on "backache"
I'm going to go ahead and let this one speak for itself.  A broad, garbage term equals broad, garbage studies.

Relationship of intensity, loading duration, and rest periods- "Years of specific sub failure activity can cause progressive development of conditions.  This could possibly be avoided with evidence-based prevention strategies that include optimal loading, rest periods and controlling the duration of exposure” (Low Back Disorders, P. 8)  An example of this is the mechanism for herniated discs in the lumbar spine.  McGill has found that a large number of repeated flexions of the lumbar spine gradually leads to a herniated disc.  The nucleus is pushed out of the annulus more and more until finally one day someone bends over the wrong way to pick up a pencil and it fully herniates.  Correcting movement and doing the proper prevention exercises can prevent things like this from happening.  It seems that many professionals miss this point and simply treat symptoms instead of using clinically proven prevention strategies.  I have personally witnessed professionals in various fields giving clients exercises that have been clinically proven to cause spine issues (I know of someone who prescribed ill advised exercises from a friggin magazine!).  This is a problem.

There are also plenty of bad prehab/rehab recommendations that are given out (as I just mentioned).

Strengthen torso muscles to protect the back-  Although this can definitely help in certain situations, much research shows that muscular endurance is more important in the torso muscles when it comes to preventing and rehabbing back issues.

Sit up prescription- Each situp produces low back compression levels close to the National Institute of Safety and Health action limit!! and doing so repeatedly has been shown to cause issues.  This occurs because of the attachment of the psoas muscle to the lumbar vertebrae.  When you do a situp, the psoas contracts to flex the hip, which puts lots of compression on the lumbar spine (low back). Add in the fact that most people who do situps perform them incorrectly with a rounded low back and the problems get worse.  If someone has back problems, situps are probably not their best bet.

Bend the knees, not the back when lifting things-  As I've discussed many times, optimal movement patterns are absolutely essential to spare the back when lifting.  Broadly saying to "bend the knees to lift things" is not a good recommendation by any means.  It ultimately comes down to moving correctly through the hips while staying stable in the low back.  Bending the knees can put excess stress on the knees and still allow the back to move into less than desirable positions.  Furthermore, the optimal position and lifting pattern that is needed will vary depending on the situation at hand.  What is the size of the object? What are the biomechanical leverages of the person doing the lifting? It will always depend.

Tight hamstrings lead to back troubles
While they can, this is not the case for everyone.  As I've mentioned in previous articles, if someone's hamstrings actually are stiff (and are actually having a negative impact), then yes they may potentially need to be lengthened.  In many cases, stiff hamstrings is a misdiagnosis.  If any hip flexor muscles are stiff or short, the pelvis will be pulled into anterior tilt (see previous writeups to see more detail on anterior tilt). When the pelvis is pulled into this position, the hamstrings are put on stretch which will cause them to seem stiff; however, they are already on stretch.  It is the hip flexors that need lengthening (could also be that something such as the obliques need strengthening, see post on relative flexibility).  Once this is done and the pelvis is back to neutral, the hamstrings will be fine. 

I have a client who went to physical therapy for around 3 years and never got rid of his back pain.  He told me that they continued to stretch his hamstrings.  I looked at him for five minutes and discovered that his hip flexors (particularly rectus and psoas in his case) were extremely stiff; not to mention that he had little to no movement coordination.  By continually stretching his hamstrings, his pelvis was pulled farther and farther into anterior tilt, which made his back worse and worse.  We lengthened his hip flexors, turned on his glutes, taught him how to move properly and within a couple of weeks his pain was gone.  He is now in great shape and pain free.  Everybody is an individual with their own individual needs.  Simply doing something general like stretching the hamstrings for the heck of it is just unacceptable. 

Single exercise or back stability program is good for all cases
This is a big mistake that many people make and pretty much ties in with the last point.  Determine what needs to be strengthened, lengthened, stabilized, mobilized, etc.  Specific training is the only way to make backs optimal.

(The bold points are from Low Back Disorders; my own explanations following the headings)

Through my own experience working with people and learning from the some of the best in the industry, some of the major causes and contributors to back issues follow. I have touched on much of this in other articles so I'll keep it brief.
 
Excess Movement in the Lumbar Spine
The lumbar spine should generally be stable and many people move way too much through it.  Promoting motion here with bad stretches and exercises is not a good thing (certain yoga positions, cough:)

Poor Movement Patterns
We basically live in a society that has developed movement stupidity.  Most people you come across have absolutely no clue how to move properly.  You need to move and use the right muscles and joints at the right time.  Training does no good if you are practicing bad patterns and habits.

Stiff Hips and Thoracic Spine
Ideally, there will be mobility in these areas and stability in the lumbar spine.  Most people have the opposite.  If you can't move in the hips and tspine, then more movement and stress will go to the lumbar spine.  Another problem created.

Weak Gluteal Muscles and Stiff Hip Flexors (Lower crossed syndrome)
With overly stiff or short hip flexors, there is more stress on the back.  This also will often shut off the glute muscles.  No glute muscles equals less support for the low back which equals more back pain.  YAY!!

Weak and Improperly Trained Trunk Muscles
Having no support from the wonderful muscles that form a corset around the trunk and are supposed to protect the low back is not a good trait to carry.  The internal and external obliques, rectus abdominis (actually usually overdeveloped and dominant in many people), the quadratus lumborum and the transverse abdominis (very deep muscle that you can't see or touch) all need to be endurable and firing.  They also need to be trained to stabilize; not round the back and move in bad ways like many people do.

Poor Endurance in the Low Back Extensors
The low back extensors need to have good endurance in order to continuously support the passive tissues in the low back.  When they fatigue, things that we don't want to take up stress end up taking up stress and bad things happen. 

So taking care of these things is all wonderful and great but what if there are tissue restrictions that prevent someone from moving optimally or turning on muscles that need to be turned on?  This is where massage therapy and specialized soft tissue work is extremely effective and can play a huge role in developing an optimal back program.

I can try to teach you how to squat and pull correctly with quality hip movement and a stable trunk all day long but if your psoas is so stiff that you simply can't get lower than an inch into your squat then there is a problem.  If I work on your psoas and get it to relax, getting you to move properly becomes a whole lot easier and more effective. 

Following are some different things that massage can address in order to help with back issues. There are obviously tons of possibilities but here are a few common ones.

Stiff or Short Hip Flexors- If needed, treating psoas, rectus femoris, and/or tfl (whichever ones are overly stiff or short) can take tons of stress off of the low back and can free up the hips so that movement improves.  This also can make it much more possible to activate and strengthen inhibited gluteal muscles. In some cases, glutes might need work.  Always assess! 

Getting rid of adhesions and bunched up low back tissue-  As a result of cumulative trauma and stress, the low back tissues are often tensed up and fibrotic.  Massage can provide great relief here by freeing up the tissue, clearing out toxicity and built up metabolites and bringing new oxygen and nutrients into the tissue by way of increased blood flow.

Stiff or short pecs/anterior shoulder muscles that are leading to hyperkyphosis-  Treating these muscles can allow better thoracic mobility which can lead to a more stable low back and improve overall posture.

Neurological effects-  Releasing adhesions and trigger points can allow shut down muscles to retain their firing capacity, fix relative imbalances and improve overall patterns of movement.

With a combination of the proper movement and strength training and soft tissue work, low back issues can be dealt with very effectively.  While I have a lot to learn and a long way to go with massage therapy, I am very excited to be able to combine my own manual therapy with the strength and conditioning modalities that I already use in order to help people feel better, move better and perform better. 

In conclusion, if you are dealing with back pain and have been tossed around and told that there isn't a "known cause," don't give up because it is very possible that your true underlying issues have just not been found. While there can sometimes be a possibility of an underlying issue such as arthritis, spondylosis, etc., dealing with components that I discussed in this article can go a very long way in both preventing and clearing up back issues. Proper training and tissue work seems to finally be getting closer to the frontline where it should be. Hopefully more and more people can begin to see beyond "disc disease" and other copout diagnoses and get better and better. 



        

Relative flexibility is a very important phenomenon that most people do not even begin to understand.  Shirley Sahrmann details this concept beautifully.  In her book "Diagnosis and Treatment of Movement Impairment Syndromes," she sums up the concept like this: "Because of the intersegmental variations in the springlike behavior of muscles, a reasonable hypothesis is that increased stiffness of one muscle group can cause compensatory movement at an adjoining joint that is controlled by muscles or joints with less stiffness."  Basically what this  means is that a particular muscle may not actually truly be stiff; it is just stiffer than a neighboring muscle or muscles. Here's a couple of good examples that I see all of the time and that Sahrmann discusses.

Lats are stiffer than the lumbar spine
I see this all of the time when I take new clients through assessments.  Someone flexes their shoulder (raises their arm overhead) and their low back extends (most likely hyperextends) rather than their shoulder reaching through to its end range. Since their lumbar spine is more flexible than their lat, this compensation occurs.  Chances are, if we can get their trunk muscles to stabilize their lumbar spine and get the stiffness in the low back up to par with the stiffness in the lats, the range of motion in shoulder flexion will improve.  It could also be a situation where you may need to decrease some of the stiffness in the lats AND increase the stiffness in the lumbar spine.  This is a great example of why assessments are so important.

Rectus Femoris is stiffer than the abdominals and supporting structures of the lumbar spine
In this situation, the rectus femoris (big quad muscle that crosses the hip and knee) is stiffer than the supporting trunk muscles.  When the knee is flexed, there will be excessive anterior tilt of the pelvis and the low back will extend.  At the same time, the knee will not flex to its ideal range.  In this situation, if we increase the ability of the trunk muscles to stabilize and stiffen, we might get better range of motion in knee flexion and less pelvic tilt and lumbar extension. In another light, it could be a situation that rectus is so stiff, that the body has to compensate by extending the low back and tilting the pelvis when the knee is flexed.  There are various implications that could be present and Sahrmann gets into great detail on them all.  But hopefully, this gives you a decent idea of what I am talking about.  In my experience, it is most often a combination of stiffness in the talked about muscle and lack of stiffness/weakness in the supporting muscles.  Both would be addressed to make the situation better.  Again, everyone has specific things going on so not every condition will be taken care of in the same way. 

A good real time example would be with the squat.  Someone with an overly stiff rectus femoris in comparison to their low back will generally stand with their pelvis tilted forward and their low back extended past neutral.  With this stiffness imbalance, there will be compensations within their squat pattern.  As they descend into a squat, they will get to a certain depth and when their hips run out of room to move, they will move where their relative flexibility allows them to, which in this case is their low back.  With someone like this, in most cases, the rectus will need some lengthening and their abdominals (usually the external obliques) will need some strengthening.  The glutes and hamstrings usually will need some work as well.  When you increase the ability of the muscles that posteriorly tilt the pelvis (abdominals, glutes, hamstrings, etc.) and improve the length in the muscles that anteriorly tilt the pelvis (in this case rectus femoris), the relative flexibility will be better and the squat will be a lot prettier with a stable trunk and mobile, nice moving hips. 

As I said earlier, it could be a condition where all you need to do is stretch rectus and your fine.  Could also be a condition where all you need to do is stiffen up the lumbar spine and your good.  From my experience, it is often some form of combination.  Whichever way it is, taking care of problems with relative flexibility can relieve a multitude of back, knee and shoulder pain and problems.

Hamstrings stiffer than the low back
Here is one more good example.  If you lay on your back and raise your leg straight up, how high can you go without your low back flattening into the ground?  If your hamstring is stiffer than your low back, your back will try to compensate by flattening in order to gain more movement.  A little trick to get your leg higher is to brace your abdominals as if someone is going to punch you in your stomach.  The added stability for your lumbar spine will allow your leg to raise farther without loss of a neutral spine.  This example is tricky though because if it is truly hip flexor muscles that are stiff, the pelvis may be anteriorly tilted to start; thus, giving the illusion of the hamstrings being the issue when in reality it is the hip flexors that are the issue.  See my past write up on misconceptions about hamstring stiffness to read more on this.  Either way, bracing the abdominals will help your cause with the leg raise. Being sure that the pelvis is in a neutral position to start can clear things up.

Notice how all of these examples feature an issue with the lumbar spine being unstable and too mobile?  Stability and the ability to stiffen when needed needs to be developed around the abdominal wall and lumbar spine.  The inability to do this is one of the biggest and most repeated causes of back issues, knee issues and performance detriments that you will find.  Yet, tons of people continue to promote more movement here with blind stretches and exercises.  I've touched on this multiple times as have some of the best strength coaches, therapists and specialists in the world.  Rationalize what you do.  If you really do need more movement here, than by all means you better work on it.  In my experience, this is a rare case. 

Randomly and blindly training for flexibility does many people more harm than good.  If you took the person from either of the last two example and stretched his low back and trunk muscles, his problem would become worse.  Both strength training and flexibility training need to be individualized and specific.  Relative flexibility is a great and proven concept. Contrary to conventional wisdom, sometimes stretching might not even be needed to improve flexibility at a certain joint.  Simply balancing out the relative flexibility by increasing the stiffness at a supporting or neighboring joint will take care of the movement at the area in question.  Think about how this could revolutionize what you do in the gym or in your sport.  Pretty powerful stuff!

Where do you think his flexibility/stiffness imbalance is?

Franco surely had better relative flexibility for the deadlift than the guy in the last picture

Don't think this guy understands the importance of proper movement and his back isn't going to like him for it

Proper movement is the base point of exercise and performance.  I don't care how great of shape you think you are in or how many times a week you go and workout; if you are not moving the right way, you are wasting a large amount of your time. 

"Oh my knee hurts!"  Well, if you had any idea how to squat and use your hips and glutes the correct way, your knee probably wouldn't hurt so much.  When you squat with your weight on your toes, heels off the ground and your knees are coming forward so far it hurts to watch, you're probably giving yourself knee pain. If you do this throughout the day with work activities, etc.  you can only imagine the issues you are creating.   "Oh but I went to physical therapy and they said I shouldn't squat."  Well sorry to tell you, but if you ever want to get better, you're going to have to learn how to use your hips and guess what, squatting is pretty much the best way to do that.  If your therapist was any good, they would have shown you how to move the right way and fix this problem but since they probably have no idea how to  move correctly themselves, they screwed you.  Sorry.  "Oh well I've worked with another trainer before and they gave me a workout plan."  Really!?  Well that workout plan and that trainer must've really sucked because they sure didn't teach you the most important aspect of any exercise program:  HOW TO MOVE!!!

"My back hurts" Well, lets see you pick this ball up.  Well since you just picked that up with a flexed lumbar spine, and you do repetitive motion like that at work all day, five days a week, you are probably causing problems.  Let me show you how to deadlift properly and that should begin to help you.  "Well, my friend works out like all the time and he said that deadlifts can hurt my back."  Well, your friend just proved that he has no right to an opinion on the matter.  Picking feathers up off of the ground with the form you just showed me is bad for your back.  Deadlifting respectable weights with proper form will help you like you wouldn't believe. 

(These were just generalizations, not directed towards any individual)

If you are trying to exercise and you are not performing free motion, multi joint movements either because you are scared to or don't think you need to, you have two options.  A- Just stay home and eat chips because you are wasting your time and probably creating future problems for yourself  B-Get help from an expert who can actually teach you proper movement patterns with effective exercises for yourself.

If you are performing multi joint, free motion movements but have terrible neuromuscular coordination and movement patterns then props to you for at least trying to do something worthwhile.  However, you still should refer to option B from above.  Get help from an expert who can actually teach you proper movement patterns and effective exercises for yourself. 

Movement is so important guys.  You need to learn to move through your hips with a stable trunk.  You need to learn how to squat both bilaterally and unilaterally while utilizing proper hip, knee and trunk position.  You need to learn how to pull and push with proper thoracic mechanics.  You need to learn how to rotate correctly.  You need to learn how to perform locomotion effectively.  You need to understand how to fire the correct muscles at the right times to do all of these things our bodies are meant to do the right way.  Its not as simple as going to the gym and guessing your way through random useless things.  A home video can't teach you if you have no idea how to feel things.  A magazine is even worse.  A lot of health professionals that deal with the body can't even help you (also a lot who can). I know this because I constantly see people who have been to other health professionals and still have absolutely atrocious movement skills.  It blows my mind. 

It all comes down to movement.  There are many great exercises that can do a lot for you, regardless of what your goals may be; however, the fact of the matter is that no matter how great the potential of an exercise, if your movement pattern is less than optimal, the exercise is not going to do what it should for you. 

You owe it to yourself.  If you are going to invest your time in exercise and bettering your body and life, you owe it to yourself to invest some time in learning how to do things the right way. I have talked about and could get into all of the trillion other things that go into proper and effective training and programming but no matter what topic or aspect I talk about, it still comes back to proper movement.  It is the essential base point for everything else and has to be mastered first.  So give yourself a great gift this holiday season and learn how to move!!