Amazing Low Back Exercises to Try Right Now.

Sometimes coming up with exercises in your clinic room can be difficult. Even more difficult is finding some that you can recommend as good home care.

Last week we went over how to do a great exercise called the “Dead Bug”.

This week we’re basically going to flip that over and progress the exercise to something called the “Bird Dog”.

What I love about these, is you can do it right on your table, and they’re easy for a patient to do at home.

Once your patient is confident with doing this exercise on top of the swiss ball, we can make things more difficult by removing the swiss ball.

This can still be easily done on your table in your clinic room, but it’s just a bit more difficult and will build a bit more confidence than when you’re using the swiss ball.

 

Now we can ramp things up just a bit more after your patient is confident with these movements.

By using an exercise band we can make things just a little more difficult and still build more confidence in movement with our patients.

Give these a try.

Doing movements like these will reinforce everything you did with your hands on the table and bring about greater outcomes with your patients.

If you’d like to learn more on how to incorporate more things like this into your treatments, and generate greater outcomes, register for our newest online course “Clinical Applications Of Pain Management Using Therapeutic Movement” by clicking HERE

4 Ways to Bring These Low Back Exercises to the Next Level

The dead bug is one of the more popular exercises to help strengthen the low back. However, there are mutliple variations you can use in order to help your patients rehab a low back injury, or even non-specific low back pain.

Here are just a few variations you can use, starting with the simplest version.

Once your patient is really comfortable doing this simple version, and can do it with minimal discomfort for how ever many reps and sets you decide, then you can start to make it more difficult.

This next version is good as you’re more involved in the exercise with them. 

Just grab an exercise band and give them some tension while the use the band to stabilize the shoulders and strictly use the lower body for the movement.

 

This next version is only providing some stabilization through one shoulder, while the other shoulder and opposite leg do the work. 

If you don’t have a dumbbell or weight in your clinic, you can stand to the side with an exercise band and provide tension similar to how you did it in version #2.

This final version also involves an exercise band and makes the exercise just a bit more difficult, and a bit more coordinated.

If your patient is able to do all of the above variations this is a great option to continue increasing the difficulty and helping your patient with their low back strengthening.

As always your reps and sets will be up to your clinical decision making along with combined goal setting with the patient. Doing therapeutic movement with your patients doesn’t have to be complicated and most of what you need to do can be done right in your treatment room.

We just have to instil the confidence in patients that they are capable of doing it, while working together with them in their goal setting. Be confident and try doing some more exercises and movement with your patients. It will not only benefit them, but your practice as well. 

3 Exercises To Help Patients With Back Pain

As you know, we’re big advocates for therapeutic exercise around here.

This is one of those occasions where I’ve had to do some self care to help a little pain spot I deal with. On the left side of my mid to lower back I get this one little spot that flares up once in a while. so I went to a friend of mine to get a little work done in the area.

They recommended doing some back extensions on a machine at the gym, however, most of us don’t have access to a gym in our clincs.

So, I figured out a way that any of us could do some effective therapeutic exercise right in our treatment rooms just using a theraband, and here’s what I came up with.

Here’s how to do an Isometric, Concentric, and Eccentric load for extension.

 

Here’s some ideas for rotation.

Another great exercise for rotation is the Palloff Press (also one of the exercises my friend recommended for me). This is usually done with a cable machine at the gym but can easily be done with a theraband as well.

Takeaways

  • Communication with your patient regarding comfort level for length of time and repetitions are key.
  • Start with isometrics, then move on to concentric, then eccentric.
  • Remember, a bit of discomfort is okay, just don’t cause pain with the exercise.
  • Make sure your patient is comfortable doing the eccentric portion as it may cause more muscle soreness.

What Kind of Exercise is Healthiest?

Physical activity is now considered one of the “big four” lifestyle factors (along with smoking, nutrition, and drug abuse) that have major effects on health. In 2015, the Academy of Medical Royal Colleges put out a report summarizing the benefits of exercise, calling it both a “miracle cure” and a “wonder drug.” [1] The report observes that regular exercise can prevent dementia, type 2 diabetes, some cancers, depression, heart disease, and other common serious conditions — reducing the risk of each by at least 30%. This is better than many drugs.

A recent analysis of data from more than 60,000 respondents found that people exercising 1-2 times per week had a 30% reduction in all-cause mortality compared to those who got no exercise. There was a 35% reduction for people who exercised 3-5 times. [2] Similar studies have concluded that a sedentary lifestyle is a primary cause of 36 diseases, and that exercise is an effective treatment to prevent them. [3, 4] Numerous experts have observed that if exercise came in a pill, it would be the most effective and widely prescribed medicine ever developed.

While the evidence supporting the health benefits of exercise is undeniable, I don’t find the metaphor of it being “medicine” totally appealing. First, medicine is something most people would rather not take, so the marketing is not very good. Second, the term medicine suggests cure of a particular disease, which is misleading.

Physical activity can improve your health in many different ways, just as light, water and soil will nurture a plant. But it’s not a targeted intervention that “fixes” a specific problem.

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I think a better metaphor for the benefits of physical activity is one recommended by Katy Bowman and Nick Tuminello: movement is like food. This analogy works on many different levels. First, nutrients in food are beneficial when consumed in some goldilocks amount — not too much and not too little. For example, you need a minimum dose of iron to avoid anemia, but too much is toxic. Many kinds of inputs to the body follow this pattern, even water. With physical activity, some minimum amount is essential, too much is toxic, and there is a broad range of happy mediums.

Another analogy between food and movement is that you need a well-balanced diet of many different nutrients, all of which have a different optimum dose. If you have a deficiency in Vitamin A, it won’t help to double up on Vitamin B. The same is true of physical activity. The bench press is a fine exercise, but if that’s all you ever did, you would become deficient in other areas of physical function.

If movement is like food, how do you eat a balanced diet? Part of the answer is that … it depends. A twenty-year-old athlete will need a different diet of movement than a 65-year-old with knee pain. In fact, two 65-year-olds with knee pain might benefit from completely different programs. To find what works best for an individual, you will need to explore a wide landscape of different options. The good news is that some parts of the landscape are more worth exploring than others. To get a rough idea where they are, we can look to two sources of data: (1) formal recommendations from government health groups; and (2) research analyzing the physical activity of hunter-gatherers living in natural environments. I think of these guidelines as major landmarks for orientation on the movement landscape. Fortunately, they both point in the same basic direction.

Recommendations From Health Groups

Numerous governmental agencies, including the World Health Organization, the U.S. Department of Health Services, and the National Health Service in the U.K., have published physical activity guidelines. [5, 6] They are based on expert analysis of the voluminous research looking at physical activity, fitness, and health. Here is a brief summary of their advice, which is almost the same for each source.

The Amount

The guidelines suggest at least 150 minutes per week of “moderate” physical activity or half as much “vigorous” activity. (See below for definitions.) But this is just the minimum, and a better goal would be 300 minutes of moderate activity per week. Adding more exercise may continue to reduce mortality until as much as 750 minutes per week, after which point the health benefits of physical activity seem to flatline. [7]

“Moderate” Activity Defined

Moderate activities are usually light aerobic exercise — continuous cyclic movements done at an easy pace. Examples include:

  • brisk walking

  • hiking

  • gardening or yard work

  • jogging, cycling, or swimming at an easy pace

Moderate exertion feels like you are working, but not in a way that is unpleasant or difficult to continue. Heart rate is about 60-80% of maximum, and breathing rate is elevated to a point where it would be difficult to sing, but easy to talk. You may break a light sweat but will not become significantly overheated. After finishing a session of moderate physical activity, you could probably complete another one if necessary.

“Vigorous” Activity Defined

Vigorous activity is higher intensity work that can be either continuous or intermittent. Examples include:

  • resistance training with weights, machines, bands, or bodyweight

  • sprinting or high-intensity interval training on a cycle or rowing machine

  • continuous running, cycling, swimming, or rowing at a challenging pace

  • heavy manual labor

During continuous vigorous activity such as running or cycling, you are approaching the fastest pace you can sustain for twenty or more minutes. Your breathing rate is high enough that you cannot have a conversation. Intermittent activities like weight lifting, sports or sprinting cannot be performed continuously, but only in intervals. Vigorous physical activity feels hard and requires willpower to continue. When you are finished, you will probably want to rest at least a day before completing a similarly tough workout.

Movements That Challenge Strength

Most guidelines recommend that the above weekly totals should include at least two sessions that maintain or build strength in all major muscle groups. Although the majority of research on physical activity relates to aerobic exercise, there is a large and growing number of studies showing equally impressive health gains from strength training. Some of these benefits are not available with aerobic exercise, especially preservation of muscle mass, which declines with age, often to a point where function is significantly compromised. [8]

Movements That Challenge Mobility And Basic Coordination

Some popular guidelines, but not all, recommend inclusion of movements that maintain functional ranges of motion, and basic movement skills like squatting or single-leg balance. This doesn’t mean you need exercises specifically devoted to this purpose, such as stretching or corrective exercise. Many common activities challenge mobility and functional movement skills, including dancing, swimming, martial arts, gymnastics, climbing, calisthenics, or classic compound strength exercises like pushups, pull-ups, rows, presses, squats and lunges. On the other hand, if all you do is bike or run, you will not be challenging your mobility or coordination very much.

Physical Activity Levels Of Hunter-Gatherers

Another way to approach the question of how to move is to consider the physical activity levels of humans living in more natural environments. This is the same logic you would apply to analyzing the health needs of any other animal. If you had a pet cheetah and wanted to know how much running she should do to maintain good health, you would try to learn something about how much cheetahs run in the wild. If you had a pet chimp, you would take him to the climbing gym, not the swimming pool.

Anthropologists who study hunter-gatherer cultures observe that they generally enjoy excellent health and fitness, and have low to non-existent rates of chronic diseases associated with a sedentary lifestyle. [9] They engage in high levels of physical activity, but certainly do not consider it to be exercise or medicine. [10] Movement is simply inseparable from almost every meaningful event in their lives. Although each hunter-gatherer culture has a different lifestyle, there are some general patterns and averages that are informative.

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Men usually spend the day hunting, which requires lots of walking, occasional jogging, and the odd sprint. They sometimes climb trees, dig to find tubers, and carry food back to camp, which must be butchered. Women generally spend their days gathering plants and also caring for young children, who often must be carried. Back at camp, men and women engage in toolmaking, and food preparation. Downtime is spent sitting on the ground in positions like squats that challenge lower body mobility. [9]

Although they are moving all day, the pace is not grueling. Recent studies on the Hadza tribe in Tanzania show that they do about 135 minutes per day of moderate to vigorous physical activity. [11] That’s about 900 minutes of activity a week, just a bit past the point at which recent studies have found that adding more exercise stops providing any significant additional health benefits in terms of reduced mortality.

Some days involve hard work, but they are usually followed by easy days. Presumably, some days will involve maximum intensity effort, such as sprinting or carrying a heavy load. Interestingly, activity levels do not decline much with age. The 65-year-old elders keep up just fine with the young adults. A good percentage of the total workload is walking 5-10 miles per day. If you think in terms of steps, this is about 10 to 20,000.

How does this organic, all-natural program for fitness compare to the standard-issue government cheese? There are some obvious similarities. The majority of the work is moderate continuous movement like brisk walking. Vigorous activity is a smaller percentage of the whole and includes work that challenges strength (climbing, digging, carrying, butchering) or power (sprinting).

Many of the activities require mobility, coordination, and balance, such as walking over uneven terrain, climbing, and scrambling, digging, lifting and carrying odd-shaped items, throwing, and sitting on the ground. One major difference is that hunter-gatherers do a higher volume of low-intensity work, even compared to highly active modern humans. They are not doing more bench presses, but they are getting in more steps.

Interestingly, walking is exactly the type of physical activity that modern humans would probably like to do quite a bit more, if only they had the time. Paddy Ekkekakis studies motivation to exercise and observes that although high-intensity exercise is quite effective at delivering health benefits quickly, most people don’t do it because … (prepare to be shocked) … they don’t like it. But people tend to enjoy walking. Under the right circumstances, say being with a friend in a nice environment, they do not consider it to be exercise at all, but an enjoyable and invigorating experience that delivers immediate rewards.

Another notable feature of walking is that it provides health benefits with only a minimal risk of injury. More intense exercise (e.g., a set of barbell squats) offers a relatively narrow window between too much and not enough. The difference between a good workout and an injury might be just a few extra reps or plates on the bar. But the margin of error with walking is huge. After a healthy dose of walking, most people could double it and recover easily.

It makes sense that walking delivers the highest bang for your buck because this is the movement we are best adapted to perform. Like any other animal, our primary physical function is locomotion, and walking is the most energetically efficient way to get the job done. If you did nothing else but walk a lot, you’d be in better shape than most Americans.

A Quick Summary

If you want to “play” with fitness as a way to improve general health, here are some “rules of the game” to keep in mind. Have as much fun as possible within these basic constraints:

  • Aim for at least half an hour and up to two hours of physical activity almost every day.

  • Movement should be varied in terms of volume, intensity, and type. Most activity can be fairly light. Walking is the most natural and beneficial movement for human beings.

  • Every few days, include some high-intensity work that significantly challenges your strength, power, and/or capacity to sustain high energy output for a short period of time. Climbing, running and resistance training are logical choices.

  • Include movements that challenge coordination, balance, and range of motion.

Or to put this in even simpler terms:

  • Move around a lot at a slow easy pace.

  • Frequently move with some urgency or pick up something heavy.

  • Every once in a while, move like your life depends on it.

And have fun!

Physical activity isn’t like taking medicine, you know.


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The preceding was an adapted excerpt from my new book called Playing With Movement: How to Explore the Many Dimensions of Physical Health and Performance.

In Defence Of The Advice To Remain Active For Back Pain

There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!

Firstly this HERE is from the folks over at Cochrane.

“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”

It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.

Now I am going to give you a bit of my opinion as well!

Being active, IMO : ),  is NOT a treatment. It’s about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.

It’s About Belief

Certainly, we don’t want to demonize the idea of resting or taking it easy if things are too painful, that is not evidence-based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.

This is highlighted in the two papers below that look at people’s opinions around what affects pain in the positive AND negative.

Darlow 2014 – Beliefs about back pain: The confluence of client, clinician and community.

Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives

We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self-reported perspective of what triggers back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare-ups

Costa 2019 – What Triggers an LBP Flare? A Content Analysis of Individuals’ Perspectives

Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.

Suri 2018 – Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

The implication might be that when we ask people to remember what triggered their back pain it is a simple ‘go-to’ blame physical activities (especially when other things are not considered), but when the flare-up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare-ups seems to decrease.

This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!

It’s About Positive Messages

Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.

I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple, and important message from my perspective.

There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.

But could our short term attitudes impact on the longer term?

Short Vs Longer Term

What we do seem to have some data on is that having low pain self-efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster – 2010, we see that low pain self-efficacy is related to worse disability outcomes at 6 months.

The question is how do our own attitudes, and other people’s attitudes as well, towards our backs influence our behaviours? Food for thought perhaps?

Key Messages From Advice To Remain Active

Hurt does not equal harm – It’s OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.

Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.

Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.

Motor Learning Pitfalls and Autonomic Resilience

Sometimes, I’ve found that teaching a movement cue to a client can backfire.

Coaching a neutral pelvic position or a braced core to do exercise, for instance, are great techniques to perfect a squat and deadlift and train a person to lift a heavy load. However, if a client experiences pain or discomfort out of a regimented exercise setting, are these necessarily the best strategies to focus on?

Very often, I’ve seen individuals become extremely hyperaware of their body mechanics, whether it was due to cues from a clinician or because the assumption is that patterns from high-load fitness routines need to be maintained outside the gym.

My experience is that this can result in a couple of problems.

Pain Science

 

One is a concept that you’re likely familiar with by now; that being catastrophization. If we, as clinicians, don’t mind our language during our movement coaching, often enough, a person can develop a belief that anything outside of these trained movement cues will result in injury.

As you can guess, believing that “losing form” will equate to pain can lead to that belief becoming a reality. This is classic fear-avoidance coping and is why someone can perform a 300lb deadlift and then throw their back out when they finally bend their spine to tie their shoes.

For this reason, it’s important to educate clients about the resilience of the body to perform non-deliberate movement as well as to mix these types of movements into their exercise programming. While it’s important for me to teach many of my clients how to do a proper hip hinge, it’s equally important to recondition them on how to round their spines to pick up a sub max load.

At the same time, it’s also crucial to teach clients that these cues are not meant to be minded for every movement in day-to-day activity. Again, this would enforce these fear patterns and lead to what we discussed above. However, it also enforces a reliance on deliberate thought to perform these movements, which takes us to our second point.

Autonomic Neuroplasticity

 

Once we remember to add in these additional “natural movement” cues to accompany exercise instruction, there might still be a disconnect between the clinic and real-world conditioning.

What we need to consider is that the conscious focus on movement in the clinic or fitness setting (whether it be a traditional exercise or a natural back bend) doesn’t necessarily translate to the nervous system being able to replicate those cues in a safe manner, subconsciously.

This boils down to neuroplastic deficits within the central nervous system itself following an injury, with altered motor patterns becoming the new norm (Grooms, 2016). We can describe this by thinking about the thought processes that lead up to movement. In an “exercise” environment, the signals that precede movement are directly to do with that specific motor pattern; sending the signal to the muscle and joint on what to do and how strongly and fast to do it. Outside of this environment, these thought processes are much more complicated and the movement will need to follow more complicated reactionary signals. For instance, often we will need to simply extend our arm, reactionarily, in order to catch an object rather than having that moment of anticipation to ready the nervous system and compute the necessary speed and force that will be required beforehand.

What this implies is that being able to do a back bend in the clinic when all of your focus is on it only gets us part of the way toward being able to do the same thing at home when relying on autonomic function instead of deliberate action. This is why athletes who have undergone ACL reconstruction and rehab can be, clinically, cleared to return to play yet still be 40 times as likely to reinjure their knee compared to their peers (Wiggins et al., 2016).

Clinical settings commonly revolve around focusing on internal cues when learning movement patterns, such as relaxing one muscle, stiffening another, or bending deeper at this joint. However, external cues, such as “reach for the floor”, “aim for the target”, or “focus on the field” have been observed as being incredibly important in sports settings. These cues help to bring the attention away from the body and to the environment instead, creating a more practical situation by decreasing conscious body control.

With ACL reconstruction, again, being the studied example (Gokeler et al., 2019), it is found that relying solely on internal cues does not provide the best outcomes for when external factors are finally challenged again. Even when rehab conditioning is extremely sport or activity-specific, an ability to do a maximal sprint in a controlled environment might fail someone when they attempt to do the same thing with real-world distractions added. For this reason, a lot of rehabilitation research is actually starting to involve the use of virtual reality (Grooms, 2015) to retrain autonomic capabilities.

Obviously, we don’t expect every clinic to equip itself with a VR headset. So that brings us back to the importance of mixing in external cues with the internal ones as we educate our clients in new motor patterns. The clinical setting can take a lot of great lessons on how to do this from the performance world, with a mixture of the two types of cues, periodization of a program, and an understanding of individual variance being hugely important factors.

Takeaways

 

So from all of this, we can understand that mechanical cues and deliberate exercise patterns are still a step in the rehab process. Throughout, however, we need to reinforce that a client’s well-being is not dependent on these patterns being maintained around the clock or that conscious control does not need to be exerted over their maintenance.

Finally, we also need to remember that the quiet, clinical environment is usually not one that our clients spend the majority of their days in, so we also need to prepare them for the real-life hazards, distractions, and mental states that their normal workplace, sport, and home settings will challenge them with.

A client’s life is individual, and so is the preparation for it that we provide.