At some point, every adult over 40 experiences back pain, arthritis or some form of disk injury. When it happened to me, I first sought help from my doctor who told me to focus on mild forms of yoga and Pilates to build up my core. After 2 weeks and no pain relief, I went to a spine specialist who told me that the multifidus muscle (aka muscle that fills up the grooves on either side of the vertebrae) had atrophied. That came as a surprise given that I was an advanced weightlifter. So, I asked him, “Is that what caused my back injury (aka my programming was somehow deficient), and how do I prevent it from happening again?” Here’s what he said.
Now, I’m a visual learner, so he showed me 2 MRI pictures. The first scan was from a person who’d been doing Pilates 3-4x times a week for several years but was still having low back pain. You could see there was no disc injury, just fat deposits where the deeper layers of the multifidus muscle should be. If you’ve never heard of the multifidus muscle, it’s a small muscle that runs the length of the spine and is critical for:
- Stabilizing the joints at each segment level of the spine’s vertebrae
- Helping each vertebra work more effectively and thereby reducing the degeneration of joint structures
- Supporting key hinge movement patterns such as bi-lateral backward extension, unilateral side-bending and rotation to the contralateral side
In other words, without a well-developed multifidus muscle, you’re going to have back problems.
Then, he showed me a second scan. There was muscle everywhere!Everything that should be hypertrophied is. The doctor explained that this scan is from a man with a disc injury and that his healthy back was achieved through a protocol that focused on weight-bearing exercises that encouraged para-spinal and multifidus hypertrophy. In other words, the specific adaptation the body learns from yoga or Pilates is specific only to those modalities. Whereas, the way to correct muscle atrophy is by producing hypertrophy… or in this case “phased loading” of the lumbar multifidus muscle.
The Phased Rehabilitation Approach
So, what’s a good back rehabilitation approach? First, it’s always best to consult with a specialist who can develop the exact protocol that addresses your particular back issues. The key is finding someone who is well-versed in both non-surgical and surgical methods, is an expert at developing a progressive program that helps fitness-minded adults and athletes return to their sport and bases their functional assessment and recommendations based on “how” your body moves. If they’re simply giving you a list of exercises without watching how you move, you need to find a different therapist.
Having said that, I’ve been to some good physical therapists and some “not-so-good” ones, and the ones that rise to the top, in my opinion, have a well-crafted template that they follow and can explain to their patients. It’s not just understanding “why” you need do something. You need to know what signs to look for that indicate your body is healing. One of the best I've found is by VanGelder, Hoogenboom and Vaughn . Granted, while their approach focuses on helping athletes heal from herniated disc issues, I've found their approach carries over to back muscle strains, bruised ligaments...even issues with poor posture. So, I highly recommend you read and print their article. (Note: the accompanying rationale and research for method selection during each phase is also detailed in the article.) Briefly, their phased approach includes:
Phase 1: Non-Rotational/Non-Flexion Phase (Acute Inflammatory Phase/Days 0-6) – The focus here is to reduce inflammation and to eliminate mechanical stress on the spine by practicing stabilizing exercises through a full range of motion. While many often feel these are “rest” days, the key is to practice creating a protective posture (aka “optimal” neutral spine for your activity or sport) while improving hip mobility and back extension without pain. Some beneficial exercises during this phase include:
- With Foam Roller Adduction and Pelvic Floor Recruitment
- Hip Hinge (Standing With Bodyweight)
- Glute or Hip Bridge Progressions, (Bodyweight, Single-Leg to Weighted)
- Weighted Hip Thrust (on Bench)
- Planks (Floor, Ball, Suspended)
- Push-ups (Kneeling, Floor, Suspended)
- Lunges and Split Squats (Bodyweight to Weighted)
- Barbell Lunge/Split Squat
- Lat Pull-Down
- Suspension Inverted Row
- Chin-up/Pull-ups (Hanging Position, Resistance Bands, With Bodyweight)
Phase 2: Counter-Rotation/Flexion Phase (Repair Phase/Days 3-20) – The next phase is about gradually introducing compound movements under tension while simultaneously resisting rotation. This includes practicing hip hinging exercises versus flexing the spine and utilizing isometric contractions to resist twisting movements. Examples:
- Suspension-Assisted Squat
- Bodyweight Squat
- Kettlebell Goblet Squat
- Kettlebell Turkish Getup
- Kettlebell Suitcase Deadlift to Unilateral Suitcase Deadlift
- Abdominal Curl Up and Stability Ball Curl-Up
- Kettlebell Deadlift
- Trap Bar or Hex Bar Deadlift (Floor or on Box)
- Single Leg Deadlift
- Single Leg Squat (Suspension or Bodyweight)
- Bottoms Up Kettlebell Carry
Phase 3: Rotational Phase/Power Development (Remodeling Phase/Days/Days 9 – to Full Resolution) – The ability to return to full fitness or sports participation requires integration of transverse movements (aka twisting, turning, stopping/changing direction, swinging a bat or throwing a ball, etc.). Hence, this phase continues to emphasize lifting, carrying and pushing loads while simultaneously practicing good spinal bracing, glute activation, hip hinging and powerful hip extensions. It also adds in exercises that require full dynamic rotation such as:
- Stability Ball Twist (Without and With Weight)
- Lunge With a Twist (Without and With Weight)
- Banded or Cable Woodchop (Top to Bottom; Bottom to Top)
- Kettlebell Swing (2-Hands and 1-Handed)
- Kettlebell or Dumbbell Snatch
- Kettlebell or Dumbbell Snatch Press
- Kettlebell Snatch Pull
- Hang Clean
Phase 4: Full Return to Sport or Activity – Although most doctors will allow some sports-specific skills during phase 3, it’s not until a person can move correctly in all three planes of motion while controlling lumbar lordosis (aka rounding of the back) under load that determines when an individual can be released to play their activity or sport full-time.
So, what’s the best way to restore a weak or injured back? It’s not by lying on your back or being on your hands and knees. Good functional rehabilitation follows the SAID principle (aka Specific Adaptation to Imposed Demand), which means you need to learn to walk and lift/carry loads with weight. The exercises that significantly restored my back were practicing deadlifts, the turkish getup and kettlebell swings early, and then progressing to the kettlebell snatch pull and hang clean at the end. Within a few weeks, I was not only pain-free, I had significant back stability and strength. Now, all of these exercises are a regular part of my programming to maintain back health. I’m not saying it’s the silver bullet to every back problem, but if you haven’t tried these sorts of weight-bearing exercises, it’s something to explore and talk about with your doctor or therapist.
Anyway, make sure you're taking care of your back…and until next time, seek strength!
1] VanGelder, L.H, Hoogenboom, B.J., and Vaughn, D.W., A Phased Rehabilitation Protocol for Athletes with Lumbar Intervertebral Disc Herniation. International Journal of Sports Rehabilitation Therapy, August, 2013: Volume 8(4): pages 482-516.