Stuart McGill, a professor at the University of Waterloo and Chief Scientific Officer at Backfitpro, gives us an in-depth look at the trainer’s role with clients who suffer from back pain and discusses the causes of back pain and disorders.
Most back-pained patients who are referred to me have symptoms caused by trainers and clinicians. Now I have your attention! So, I will also acknowledge that the trainer can be the most effective professional in reducing back pain. I hope that the story that follows will empower both you and your clients to reduce pain and enjoy the pleasure that comes from disciplined and competent movement.
Let’s be clear, there is no such thing as non-specific back pain. There is always a cause. Nearly always, the pain is worsened by specific motions, postures and loads, and yet may also be relieved with specific motions, postures and loads. Trainers who work within this reality create able-bodied, robust clients.
The medical system is woefully inadequate for dealing with back pain. Most patients rarely receive the most important part of the prescription to get rid of back pain from their doctor — the knowledge and understanding of their condition required to become their own best advocate.
Typically, they receive a ten or 15-minute appointment that simply is not sufficient to diagnose back pain. The person remains clueless and frustrated, left in the dark about what behaviors must be stopped to alleviate the cause of their pain. And they have no guidance as to what is required to build a foundation for pain-free movement.
Simply getting passive treatments such as prescriptions for pain medication, or a modality such as ultrasound, without a plan to stop the cause itself rarely creates a long-term solution. While medication may be a part of a broader approach, a thorough assessment of an individual’s specific pain triggers will identify a pain mechanism and guide a targeted treatment plan. Performing the exam to find the pain triggers is not difficult. I will coach you through the process.
There are several popular myths about back pain that can thwart recovery. “Non-specific back pain”, “Idiopathic back pain” and “Lumbosacral strain” are terms used to label patients with back pain. These non-specific diagnoses indicate that the patient has not had a competent assessment of their pain mechanism.
Yet another popular diagnosis is degenerative disc disease. I am so disheartened when a distraught patient expresses their fears to me regarding this supposedly progressive disease. When I tell them that in actuality they have no such disease, their reactions vary from relief to anger towards the person who mislabeled their condition.
A degenerative disc disease diagnosis is the equivalent of telling your wrinkled mother-in-law that she has degenerative face disease. Surprisingly, many people can be guided through a more thorough self-assessment, assisted by their trainer or clinician that will reveal their precise pain triggers. This approach often introduces patients to the first accurate assessment of their unique causes of pain that they’ve ever received.
Based on the pain triggers, the next step is to guide movement strategies that allow motion while avoiding the triggers. By treating patients as individuals, they are able to understand why one approach may be very effective to remove pain for one patient but may hurt the other. Using the knowledge gained from their assessment they can both remove the pain triggers and create the foundation for pain-free movement.
The Assessment
Trying to diagnose painful back disorders based on anatomical structure alone is possible but difficult. But the only type of clinician who benefits from the tissue-based diagnosis (the type that comes from looking at X-rays, scans and “poking around”) is the surgeon who is only looking to “cut the pain out”. The evidence shows that the mechanism of back pain is almost always aggravated by a particular motion, posture or load. Motions, postures or loads that exacerbate the back pain together with those that are tolerated can be identified through a series of simple diagnostic tests. Here is an example:
The client sits upright and pulls up on the chair (approximately 10kg) to add compression to the stacked spine. Then they slouch and repeat the compressive load. This will reveal if posture and spine curvature affects the pain. Many clients will be pain-free in the upright, stacked posture while the slouched will be uncomfortable. This reaction shows that flexed spine positions must be reduced when under load to reduce the pain sensitivity.
Many other tests will reveal if the head or hip position changes pain sensitivity or movements such as lunges cause or relieve pain. Shear testing will show which clients qualify to perform a kettlebell swing and who should avoid them. Now you have an inventory of the client’s precise triggers. Now you must create a prevention plan to eliminate the specific pain triggers. The complete rehabilitation plan is then designed to enhance function while avoiding these triggers.
By following this system, back patients are categorized based on their intolerances. For example, workers with spine flexion bending intolerance will probably have their pain exacerbated by sitting, tying shoes, etc., yet find they possess very high load tolerance when the spine is not bent and the motion is transferred to the hip joints. The prevention plan and rehabilitation approach becomes clear. You will identify clients with extension intolerance, shear load intolerance, and many others. For the first time, you have given the client knowledge of how they can avoid their pain triggers.
Coaching the client with specific drills to reduce the habitual postures throughout the day helps prevent the cause of some pain and is an essential part of winding down pain sensitivity. This is a “secret” to building people into clients who can tolerate skilled training.
Essential elements of function
Certain loads on the spine are necessary and actually part of maintaining a healthy back, but some are harmful and can, over time, accumulate damage. But each person is different in their reaction to loading because it is governed by one’s biology, injury or training adaptation, genetics and rate of repair. The healthy pain-free back is achieved with the optimal amount of load — not too much or too little.
Proper muscle function is important to support a robust and pain-free back. Without the surrounding muscles, the spine would be rendered totally useless and would be incapable of supporting the weight of the upper body. Muscles are contracted in a coordinated manner that allows them to act similarly to guy wires, preventing the spine from buckling and giving way under high load levels. By stiffening and stabilizing the torso, these muscles allow movement to be propelled through the arms and legs. This stress-free movement is only possible when there is a stiffened core and corresponding mobility at the shoulders and hips.
Just like a dump truck or a racecar, some parts are stiffened and some create motion to enable the desired ability specific to the task at hand. People often wonder which should be valued more, stiffness or mobility, when it is using the core to manage the human spine. It turns out that both are needed. Your spine muscles are constantly tuning this stability/mobility interplay. This sweet spot is governed by a set of movement principles.
The spine cannot bear load without a robust guy wire system. Your job is to build the guy wire system to stabilize the column and facilitate robust and pain-free movement. Unilateral carrying creates frontal plane stability, and essential strength with unique muscle pairings.
What causes back disorders?
While there are many causes of back disorders, the scientific literature evidence is strongest for several possible mechanical causes. Once the patient has experienced pain, and the nerve system is sensitized, how the person reacts to the pain is modulated by a host of variables that can increase or decrease the pain sensitivity. Biology, adaptation, size, and previous injury history all influence the reaction to load magnitude, repetition, and duration.
For example, the spinal discs have a fatigue life, in other words, a limited number of bends that they can withstand before they become painful. The possibility for ease of motion between discs is modulated by variables such as hydration (time of day), the corresponding load at the time of the bending motion, the direction of the bending axis and a patient’s routine and approach to training, among other factors.
If for example, an individual continues to bend a painful disc, by continuing to flexion-stretch their back, their symptoms will most likely worsen, or at least become a recurrent aggravated situation. The same mechanism is exacerbated by extended periods of sitting. Here the spine (particularly the lowest lumbar discs) is flexion bent. Strangely, these flexion-intolerant patients are sometimes told to pull their knees to their chest to obtain relief.
This motion activates the stretch receptors in the back extensor muscles, resulting in short-term pain relief, but unbeknownst to the patient, this bending has caused further damage and/or sensitization of the underlying pain mechanism. While the patient may have found a quick fix, they are actually sensitizing their pain trigger and inviting additional pain attacks in the future. These types of stretches initiate a dangerous cycle, temporarily numbing pain while inciting continued long-term pain.
While these types of patients often find relief through frequent posture change, and even fast walking, they simply cannot tolerate sitting. Sitting posture can be assisted with lumbar support in the form of a small cushion to prevent the lumbar flexion trigger. Special exercises designed to combat the cumulative stresses from sitting are also helpful. Here, encoding the hip hinge movement pattern to replace the spine bending pattern is important.
This is just one example in which provocative testing and classification of the back pain sufferer results in better prevention and rehabilitation than a classic rushed doctor’s appointment. There are many other sub-categories in which the specific strategies to avoid the cause and create a pain-free foundation will differ. By following a few rules for back health and function, a plan to build resilience to pain triggers is possible. Consider the specific movements used by athletes, construction workers or farmers. With an appropriately identified set of specific stressors, all of these individuals are able to modify these movements in order to eliminate the pain triggers and go about their required work in a more spine-sparing fashion. Like any other type of pain, the more the triggers are avoided, the faster the sufferer will be able to desensitize their reaction to them altogether.
What every trainer needs to know
Mechanisms of injury: Tissue damage has a specific cause. For example, spine disc bulges just don’t happen. They are caused by a combination of repeated flexion bending while the spine is under load. This could be from squatting too deeply for an individual with stiffer hips (assessing the hips is essential for guiding exercise decisions). Another example is disc tears. Disc tears result from excessive twisting while under load. Exercises like twisting slosh pipes and Russian twists with a loaded medicine ball will enhance strength over the short term, but then create delamination in the disc annulus eventually leading to tears where pain-free loading is no longer possible. End plate fractures, schmorl’s nodes etc., are from overloads of cumulative compression. This happens when trainers progress clients too quickly in exercises such as deadlifts.
Identify the training goals: Exercises are simply tools used to achieve a goal. Every client should be able to answer the question, “What are your training goals?” Is it to reduce pain, enhance capacity for work or to have fun? Write these down then choose specific exercises to create the ability. Creating a program for health and a pain-free life are very different than for creating a specific athletic goal. For reducing pain, we follow the principles we have created over the years to reduce injury mechanisms and enhance capacity. For enhancing athleticism, we document the specific demand of a particular sport and then assess the client for what they possess and don’t possess. You train the things in which they have a deficit. This process is outlined in my book Ultimate Back Fitness and Performance.
How to assess a client: Understanding a pain history will give a starting point as existing weak points, then, pain provocation tests will reveal the specific pain triggers regarding the offending motions postures and loads. These will guide selection of movement techniques. The old idea of simply measuring range of motion will have little to do with your success with the client.
Know how to coach and cue movement: Coaching cues include verbal cues (simply describing the desired movement), internal cues (having the patient “feel” a specific muscle or movement pattern occurring) and external cues (reacting to a sound or visual cue). Every client has their learning style. An astute trainer is aware of the best cue for a particular client to achieve the desired pain-free movement.
Notice the coaching cues in this spine sparing pull pattern: The scapulae are depressed into centration, the posterior chain musculature is stiffened, and the pronated starting grip is robust radiating more control into the shoulder girdle and backside. All three styles of cues (verbal, internal and external) are employed here. All cues were customized to achieve pain-free ability by avoiding the individual’s pain triggers.
How and what and when to progress (or regress): Generally the rule of thumb is that an exercise must be performed pain-free, and with competent mechanics before a progression may occur. Failure to achieve this may require a regression. For example, an individual unable to perform a curl-up because of neck pain may require some remedial cervical exercise.
Remedial neck exercises are used to build tolerance before the subsequent modified curl-up exercises. Here the fists are placed under the chin with a neutral neck. The tongue is pushed robustly to the roof of the mouth to set the desired muscle patterns. Then gentle upward pushing with the hands is resisted with the neck muscles in a very neck sparing method.
When to refer to another expert: Obviously there are times where the situation is beyond the skill level or scope of the trainer, but the question is to whom you should make the referral? Good trainers have a list of competent clinicians with whom they have built a solid relationship. Make sure you do too.
Professional trainers teach the client specific patterns of movement to avoid their pain triggers such as pushing, lifting, squatting, carrying and pulling, which is the example of spine sparing technique shown here.
A note on Pain Science
There is a trend that it is detrimental to explain the pain trigger to a client, that it could create movement fear. Proponents suggest to just coach the client to continue moving. I have found that following this approach has created the most movement fear as the client remains clueless as to their pain triggers and never knows why they have repeated acute bouts of pain. This is contrary to the neuroscience of pain. Every time pain is triggered, central sensitization occurs. This is akin to hitting your thumb over and over with a hammer. Eventually, the thumb is so sensitized that the lightest of touches triggers pain – and fear. The key is to understand that the hammer is the cause and that it must be stopped. This allows the pain sensitivity to reduce so that slowly, over time, pain-free movement is possible. So the key is first to remove the cause then use the pain-free ability to create a wise movement strategy and exercise program.
The fact is that any movement approach can induce fear — the key is in the coaching. Explaining the mechanism of pain so that the client understands that they are in full control of their pain is very empowering. They begin to understand that moving to avoid the triggers will eliminate them. You also help them to remove the fear of never knowing when the next attack will occur. Coach your patient in the movement tools to avoid their specific triggers and you will create movement confidence, and the increase in pain-free athleticism they are paying you to create.
Authors Note
My new book Back Mechanic is a step-by-step guide to empower the client and the trainer to become their own best advocates in getting rid of pain. There is no such thing as a “one size fits all” approach. In fact, 95 percent of patients referred to me who have been told that their only remaining option is surgery, can avoid it by following this program. The book explains the essential steps to reduce pain:
- Assess the specific pain triggers.
- Remove the triggers from daily activity by practicing spine hygiene and movement principles (each person is different, and the book guides instruction for categories of pain).
- Build spine stability and appropriate mobility in the hips and shoulders.
- Guide progressions in movement patterns like pushing, pulling, lifting carrying, etc. to expand pain-free living.
- Guide strategies for a pain-free life such as how to select a mattress, how to have sex without pain, how to address specific conditions such as stenosis and kyphosis, to name a few.
This guide is key for any individual looking to take control of their painful spine and become their own health advocate. We are all capable of becoming our own Back Mechanic. Available now on Amazon and www.backfitpro.com.
