If you looked at my blog stats, you’d pick up on a few trends. People break their ribs a lot over the weekend, hence why my blog post about broken ribs is looked at 4 times as much on Mondays as all my other blog posts combined. Also, people search the internets a lot for back pain information.
Years ago, I thought that this “Back pain: What (not) to do” post was informative, evidence based, and just long enough to be taken seriously. It was even shared by Mike Reinhold. Believe me, I thought I did something pretty good here. And over the years it has been my most viewed post.
However, every time I see that this post is being read, I gag a little. I am almost embarrassed by it. I thought I knew so much back then, and I am sure in 5 years when I read this post I will be embarrassed by this one too. It’s not really a problem with the old post, but more like a change in my own view point and that of pain science.
Things I hate about this post include:
- Don’t touch your toes in the morning – Yes, your discs are hydrophilic (they love fluid and fill with water as you are non-weight bearing in your sleep) and this is a likely reason your back is more sore in the morning than at night, but this does not mean you should never touch your toes in the morning. There are plenty of people that do this and never experience back pain because of it. If you are CURRENTLY having back pain due to a flexion-intolerance I’d suggest finding alternative ways to do whatever activity you are doing, such as putting the dog’s food on the floor, or tying your shoes. If this is the case, this movement will gradually be safely re-introduced to your treatment protocol. But recommending that people never touch their toes or produce spinal flexion in the morning is just a fear-inducing recommendation that I would cringe at if I heard another physical therapist make. Making you fearful of any movement is a particularly terrible idea, considering some peoples’ low back pain responds positively to spinal flexion.
- Don’t exercise into lumbar rotation – I hate this recommendation because of the same reasons above. I think this recommendation might make you think if you ever rotate your spine you will have back pain, or if you have back pain and you rotate you will continue to have back pain. You will see a kurt exchange between me and a much more senior PT than myself in the comments section of the original post in which I am told that not training rotation is a bad idea and I just act like a young and ignorant PT (which I was). Nowadays, I work primarily with golfers. Golf is a rotational sport. Golfers are usually addicted to golf and therefore will not give up spinal rotation, and if at all possible, I do not want them to stop rotating their spines! Also, we know that for non-specific low back pain, general exercise is the best tool we have. [Now, you need to know that there are actually very few cases of “non-specific low back pain”. This simply means that your specific cause has not been found yet, and general exercise can be more specific if we can get you into a certain sub-group of patients. However, most of these exercise programs need to include or progress to some form of rotation down the line.] We cannot demonize any movement. Your back is capable of producing and controlling rotation, therefore you should express it to the best of your abilities, and if you struggle with it, we should improve it if we can as practitioners.
- Don’t do Crunches, Roman chair, or superman exercises – There is a time and a place for crunches, and supermans, and MAYBE even Russian twists. Training goals, training experience, and performance goals all need to be taken into account when selecting training tools/exercises for you. Non-discriminatively throwing out an exercise for everyone is foolish. If you are actively hurting, I would probably avoid these three because of the stresses they put on your spine, but saying to never do these or you will likely hurt is irresponsible. Even Dr. McGill who is one of the world’s authorities on low back pain, says that there is a time and place for the crunch/sit-ups (found at the end of article, appropriately named, The Death of the Sit-up), but he can think of better ways to achieve these goals.
Anyone notice a theme with these three things listed above? They are basically fear inducing to someone in pain. As a practitioner, I have learned that helping people alter their way of doing things, and educating them is much more valuable than scaring them into not doing something. The reality of the situation is that you need to produce certain movements because you have certain recreational, daily, or occupational activities that require rotation, or touching your toes, or extension, or picking things up off the floor, etc. As a physical therapy patient, you should be asking your rehabilitation professional what you can still be doing, and how to alter things you need to do, like getting into the car, or putting your pants on.
Making sure that you, the patient, have a good understanding that most pain is temporary and can be influenced with conservative measures is crucial to recovery. Yes, spinal sparing measures need to be taken into account with the actively painful back, but this should include reducing the threat of certain movements, and not demonize swaths of needed human kinematics. I often lead patients to resources like:
- Lorimer Moseley’s Painful Yarns
- Greg Lehman’s Pain Fundamentals (free)
- Adrian Louw’s Why do I hurt?
- Stuart McGill Low Back Disorders (not an easy read)
These are relatively quick reads, besides the McGill book, and provide information to help empower you to move with more confidence and less pain. Physical therapy plays a large role in helping people with back pain continue to be active and reduce your pain through activity modification and pain modification. Patients sometimes need help altering their pain experience so you can move out of the pain-catastophizing-fear/avoidance-more pain cycle, and into the pain-confrontation-recovery pathway.