Why do we need to train this particular movement pattern? Even with our sedentary lifestyles we're all required to bend many times through out the day - life still exists below desk level! However bending with poor technique i.e. from the waist without use of the lower extremities, places significantly increased pressure on the lumbar disks.

A retrospective analysis in Spine of 1000 women with herniated disks found straight-legged lifting to be the number one correlating factor! Therefore understanding and learning to bend with correct technique is essential.

Bending to pick up objects is not a bad thing, if it is done correctly with respect to the load.   When should you bend from the waist with straight knees and when should you bend using the legs? The key factor determining your bending technique is the magnitude of the load you are lifting. If the weight being lifted is 60% or more of your 1RM load (in weightlifting terms) or in lay terms; a weight you could lift 20x or more this load needs to be treated with respect. During our days there are many situations where you lift a weight that you could not lift 20x or more - this is when you need to perform a bend that includes the pelvis, hips, knees and ankles contributing to the lift. Therefore learning to perform a deadlift correctly and increasing the strength in this pattern can help keep recurrent back pain episodes at bay.

Your abdominal and back musculature must work in a synergistic manner with the stabilizer muscles of your hips and shoulder girdle to perform nearly all free weight exercises (note that the same can't be said for seated machine-based exercises). The nervous system will never allow the muscular system to reach its maximum output unless the outer (global) and inner unit (local) muscles learn to work together in synergy and effectively dissipate forces away from your spine. The best way to teach your muscles to work together is by performing unsupported compound exercises with perfect form, for example the deadlift. Because the free bar deadlift (bend pattern) requires the body to balance the centre of gravity over the base of support at all times, a high degree of stabilizer requirement and neurological demand is required for this exercise. Since the deadlift is a relatively advanced exercise, many clients will require a programme with precise progressions toward the goal of performing a deadlift.

Lets look at one way that you might rehab and progress a client through an episode of non-specific localized lumbar pain. Let's assume that there is segmental instability after suffering a lumbar disc derangement years past. The client frequently presents with pain inhibition and inflammation from too much unguarded motion and poor motor control at the unstable segment.  I am going to use unloaded non-weightbearing exercise initially and progress them through to a pain free deadlift (i.e. a standing bend pattern).  While some therapists may be uncomfortable in prescribing a deadlift, in my clinical experience I have had many clients completely recover from back pain upon implementation of deadlifts into their program and continue to use the deadlift as the one exercise of choice that can relieve an exacerbation of the same issue.  The initial rehab program also needs to address all length tension issues and assess postural faults that may have a negative influence on your results and limit your ability to load the spine. In conjunction you need to start teaching local stabilization and then co-contraction around the unstable segment. The example program below gives some ideas.

EXAMPLE PROGRAMME

Symptoms: Client presents with pain in prolonged standing worsened with flexion and extensions in prone and in standing positions:

In order to address the pain inhibition the client should be placed in a position of least spinal compression – this will also limit the amount of shear forces that arise whenever uncontrolled compression may place a rotation or torsion an unstable segment. In this situation the positions of choice to exercise are supine, prone, side lying, 4 point kneeling, and Swiss ball - supine, -prone or -side lying.  Removing your client from the vertical position will remove the compressive nature of gravity on the spine.

During this time you can exercise the client on a Swiss ball and still maintain the non- vertical positioning. This allows muscles that create pain in standing, and are therefore inhibited, to start to function and strengthen. Also the stabilizer system will be working with the prime movers and you do not run the risk of creating prime mover dominance and a relative stabilizer weakness, which can occur with use of machines for strength training.

The exact exercise variables in terms of reps, rest times, sets and tempo and time under tension will be addressed in the practical programming session at the workshop.

Examples of initial exercises used to address strength deficits in the hip extensor mechanism and the core are detailed below.

Swiss ball glute bridge

This particular exercise is great at helping reduce pain if you wrap a seat belt around the thighs and the client exerts a static hip adbuctor force against the belt. Adding a belt helps to share the load across the lumbar extensors, the hip extensors, the hip abductors, the core and  hamstrings. Many clients have significant pain relief from this technique. The exercise may be performed as a static hold in the bridge or they may move their hips up and down into flexion and extension – thereby mimicking a bend pattern which can then be progressed to a deadlift in standing when ready.

Swiss ball hip extension

The extensor chain is again targeted in this exercise. By placing the feet on the ball as opposed to the floor, the ball magnifies any imbalances in the extensor musculature and the client is forced to use the legs symmetrically so that the ball is kept stable. Again this prepares for a deadlift as the client must learn to drive into hip extension coming out of a bend/deadlift.

Swiss ball hamstring curl

Hamstring strength is vital when utlising the hip extensor function.  Hamstrings are dominant when deadlifting and also coming out of a straight leg bend pattern - an exercise called the “Romanian deadlift” in the gym.  In preparation for a Romanian deadlift, the hamstrings need to be strengthened. Improving hamstring strength will also help to pull an anteriorly rotated pelvis back towards a neutral pelvic position which may unload the lumbar facets and increase passsive ligamentous stability around the lumbar spine.

Kneeling back extension

Once the client is able to move in a a more vertical orientation with minimal discomfort, the “kneeling back extension” may be introduced. This stimulates the bend pattern and activates the gluteals to help lift and lower 60% of the body weight (located in the trunk and arms). This movement pattern can also be performed in standing as the “waiters bow” hamstring stretch.  This exercise teaches hip / pelvis dissassociation teaching the client to move at the hips rather than the spine. The kneeling back extension is an excellent preparatory exercise before taking the client to a standing bend pattern.

N.B: In a normally functioning spine the core musculature contracts at the initiation of and during any movement of the extremity (loaded and unloaded) to stabilize against any loads. All movement patterns emanate from the core outward.  However it is vital to understand that abdominal function is movement specific.  While your client can display core control in one movement pattern and position they may be absolutely deficient in another movement pattern.

Bent Over Row

Bent over row moves your client closer towards the deadlift pattern. In this exercise, loads can be light and postural endurance may be gained by keeping the weight light and performing high reps with slow tempos to stimualte a strength endurance response (training the 2A fibres) to prepare for daily activities that require many bend movement patterns.

The Sumo Deadlift

Finally progress your client to the deadlift. Look at the amount of hip knee and ankle motion required. Here is an example of an effective bend pattern for when you have to lift a heavier than 20 RM. Your deadlift may start from any position and ideally the start position from the floor as seen is a progression from performing the deadlift from the hang position (holding the bar in your hands before you start).

This picture shows a “Sumo Deadlift” which I have found to be particularly safe for clients who have suffered low back pain episodes. The stance is wide which helps facilitate the hip abductors and hip external rotators to help stabilize the pelvis for picking up the weight in the deadlift. The wide stance also allows the trunk to remain more vertical which reduces the load on the discs compared to a horizontal trunk.

As your client bends, pay careful attention to the spine and torso. It is very common to find transverse plane dysfunction coupled with frontal plane dysfunction. This combination can be devastating to the spine under load! A transverse plane dysfunction can be identified as a spinal scoliosis that develops during the deadlift movement and reduces as the client stands erect in the mid position. It may also be seen as a swinging of the bar, one end of the bar being forward of the mid-frontal plane, the other end behind it. Factors driving transverse and frontal plane dysfunctions include joint restricitons at the hip, knees or ankles.

The example of exercise choices listed above are examples of ways to introduce exercises to help stabilise and strengthen clients with a history of low back pain. These examples will be revised and extended upon during the Practical Programming for Exercise Rehabilitation Workshop in August and September of 2010.

Pictures reproduced with permission from The C.H.E.K Institute. 2105 Industrial Court Vista, CA 92081 USA

www.chekinstitute.com