Tuesday, January 14, 2014

Back Pain and Strength Training

My mother posted this article from NPR and asked for my comment: Pain In The Back? Exercise May Help You Learn Not To Feel It

There's a lot of good in this article. Though the specific exercise recommendations in it are dubious in my mind.


The Good

The basic premise is that strength training is good for back pain. I have no doubt about the accuracy and helpfulness of this recommendation. A lot of back pain is caused not by structural defects but by movement defects. Pain and movement defects form a positive feedback loop. A little bit of pain causes a person to avoid certain movements and move differently. These modifications end up contributing to more pain - and so the circle goes round.

Many pain-free individuals have MRI scans that look like a back problem with herniations and similar structural abnormalities. The correlation between these scan results and actual symptoms are fairly poor. But these kinds of scans encourage the prescription of surgery and injections to treat the problem even though the success rate is only middling in some patients.

I don't want to give the idea that I'm discouraging surgery. I had back surgery myself and it was an amazing improvement for me. However, I had a severe herniation and it was possible to see on the scan that my disc was actively pressing against the nerve related to my pain. And I had sciatica. These are the kinds of problems for which surgery is clearly indicated.


Non-Surgical Treatment

Strength training and movement training will help correct many kinds of back pain. And I firmly recommend physical therapy referral for minor back pain. (I just wrote an essay for my Simmons application explaining my philosophy on how PT can better deal with back pain)

Joints are primarily stabilized by the muscles and not by the passive bones and ligaments. As such strengthening will improve joint stability and address some kinds of pain. Additionally, strength training will improve range of motion, which helps to address other causes of pain.

Movement patterns need to be fixed in people with pain. A good physical therapist or strength coach will be able to spot these movement errors and fix them. Creating new grooves for correct movement patterns. It takes time, skilled supervision and a lot of conscientious practice. So the 'boot camp' approach discussed in the article makes sense. I would gladly take this kind of approach with patients when I complete my DPT.

Personally, this is what I have done for my back. After the surgery I was back to the ACSM recommended amount of exercise within 2 weeks. I endeavor to place as few limits on my activity as possible. With ongoing back pain I still strength train, do conditioning work and martial arts training. The primary limitation I accept is on sitting. Sitting too much is bad for my back and I know it.



The article poo-poos pain-killers. And I disagree. But I disagree in the context of a complete program to address back pain which includes the above kind of training. If the only thing you are doing about back pain is pain-killers and avoidance then that is a problem. Pain-killers to improve quality of life and facilitate movement and strength training are a positive thing.


The Dubious

There are several specific exercises recommended in the article that I'm dubious about. This comes in part from recently reading Stuart McGill's "Ultimate Back Fitness and Performance", as well as my own personal experiences and martial training.

As I've said before the primary role of the trunk (or core) muscles in most activities is to hold the torso stationary. Not to move it. Our back is well designed from this perspective. It can move but it is not well designed to move under a load. As such we can look at two categories of back movement:
1) Loaded and stiff
2) Unloaded and mobile

The combination of motion and high loads seems to be a primary mechanism of injury for the back. Exercises for the back should instead focus on holding the back stiff and stable while under a load. For instance planks. Weight or other challenges can be added to the basic plank exercise to increase the difficulty as you progress.

But the torso rotation machine that combines twisting with moving weight is probably a bad idea. Same with the back extension machine. Yet both of these exercises are included in the 'boot camp' program.

Stretching is also mentioned. Flexibility in the back is unrelated to back pain and it is mostly useless or even counterproductive to stretch the back. There are a few exceptions but they aren't the norm.

Alternately I could be suffering from a limited point of view based on what I've read and experienced so far. Time and a three year graduate degree program will afford me the opportunity to gain a more complete picture.

That being said I doubt that the kind of program Stuart McGill describes is bad for you. It just may not be the only kind of program that works.


The Bad

Like any popular science article it relies on personal stories and anecdotes instead of good research findings. Well done science reporting would look at literature reviews and meta-analysis as well as positions stands from reputable organizations (like the ACSM and NSCA). This is unfortunately typical and frustrating to me.



Strength training and movement training are more useful for typical back pain than surgery, injections or other invasive procedures. Get thee to a physical therapist!

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