Weight lifter/Body builder with LBP

Weight lifter/Body builder with LBP (Full Version)

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Shane Steimel -> Weight lifter/Body builder with LBP (October 1, 2004 8:09:00 AM)
I'm working with a 25 yo male who has been involved with weight training and body building for ~ 7 years. He reports intermittent periods of low back pain that make it difficult to get out of bed for several consecutive days. MRI demonstrates central disc protrusions @ L4-5, L5-S1 and a posterior annular tear @ the L5-S1 level (no central canal compromise or foraminal compromise present and mild bilateral facet joint DJD throughout the lower lumbar levels. The patient is being educated about posture/body mechanics, understanding of the anatomy of the spine and reduction of activities that peripherialize his symptoms, but are there specific exercise modifications you would ask this type of patient to "hold" while recieving therapy or even in the future? Are there common mistakes/risks that the stereotype bodybuilder/weightlifter makes that compromises the integrity of their lumbar?

Shill -> Re: Weight lifter/Body builder with LBP (October 1, 2004 8:43:00 AM)
Shane, Well, for starters, he shouldnt be doing the "Good Morning" exercise. (Stiff legged deadlifts). He should never do these, noone should. Whoever named this exercise obviously has NO idea of spine mechanics under load. It should be called "Good Morning, and welcome to the ER". Secondly, he will likely need to be careful with squatting, as even squatting to thighs parallel to the ground posteriorly tilts the pelvis, thus flexing L4/5, L5/S1, despite best efforts to maintain lordosis. Its actually impossible to maintain lordosis at these lower levels with squats. Watch his pelvis from the side, and stop him before the flexion (post. pelvic rotation) occurs. NO crunches, (B) leg lifts for now. Why? These are likely to make his pain worse. You could try it and see, but with the injuries you describe, repeated flexion under load is not likely to help. You could teach prone bridge, sidelying bridge, if he feels he must work his abdominals while convalescing. If he has a lifting partner, getting the dumbbells handed to him would help decrease strain, such as when he is supine doing chest work, becasue if he sits, bends to grab the weights, then needs to flex (under load again) to get down to the bench, he is likey to regret it. Sitting on the floor for cable rows is also not such a hot idea. For the same reasons noted above. As far as the stereotypical "muscleheads" go, you have to convince him that he is now injured, the rules are now different, if he wants to get better in a reasonable amount of time. (No pain, no gain mentality will result in no gain, no gain.) Is that what you had in mind for your question, or did I just tell you what you already know? Steve

Shane Steimel -> Re: Weight lifter/Body builder with LBP (October 1, 2004 8:52:00 AM)
Yes, thanks for the reply...that's the type of discussion I am hoping to read. I asked him to hold the dead lifts, squats and overhead press (in order to reduce that amount of extra compressive load onto the spine).

Brian Schiff, PT, CSCS -> Re: Weight lifter/Body builder with LBP (October 1, 2004 12:17:00 PM)
I wanted to make one clarification. The good morning and stiff legged deadlift (aka Romanian deadlift) are not the same exercise. The good morning involves holding a bar behind the head and loads the spine much differently than holding a bar or dumbbells in front of the body and performing the stiff legged deadlift (SDL). This is a much different lever compared to the good morning. I am not a big fan of good mornings, however I use stiff legged deadlifts quite often when training athletes to develop power in the hamstrings, reduce hamstring pulls and improve dynamic flexibility. Form is everything, and especially with this exercise. As far as back patients, it probably is wise to avoid them. depending on the person and their symptoms, I might return to SDL's later. One other thought - I once heard Jim Porterfield suggest SDL's as a great way to strengthen the low back, and he in fact evenb used it with his discogenic patients depending on their state and symptoms.

Shill -> Re: Weight lifter/Body builder with LBP (October 1, 2004 1:25:00 PM)
Brian, Either way, either name, its a horrendous amount of force. Take a peek at a study by Alf Nachemson from the early 70s, which discusses intradiscal pressure. SDL's may actually be worse than good mornings. You might get away with these in the athletic, non injured population, for performance training, but using it with an injured patient is a lawsuit waiting to happen. I am a firm believer in the overload principle for strengthening, but to me this is waaaaaay to risky.

Jon Newman -> Re: Weight lifter/Body builder with LBP (October 1, 2004 3:57:00 PM)
Isn't the Biering-Sorensen test essentially a "Good morning" type exercise (except for the isometric hold required by the test)? jon

Brian Schiff, PT, CSCS -> Re: Weight lifter/Body builder with LBP (October 1, 2004 7:15:00 PM)
Steve, Thanks for your reply. I am not suggesting these exercises as part of my rehab plan. But, I think it is also important to look at how the body functions in real life. We certainly function in such a manner in real life (ever bend forward to get groceries out of the trunk of your car?)Is study you are referring to was in Spine 1981? I think this is a passage from the text. "Measurement of intradiscal pressure is instrumental in explaining, from a mechanical point, the occurrence of posterior ruptures in the lumbar discs, and provides a basis for the rational treatment of patients with low-back pain in so far as these exhibit increase of pain on increased mechanical loads." I don't disagree with you that forward leaning increases load and by that virtue may bring some risk. But according to the statement above from Nachemson, the rationale is based upon pain with such increased loads. So, my question for you is do you think people and athletes move functionally in such a manner in their daily life or with sport? Do you ever have patients do single leg balance with anterior reaching of the hands to a lower object (like a running back might have to lean down to scoop up a fumble)? If you are opposed to squats and SDL's, what methods do you use to develop strength and power in the glutes and hamstrings that functionally simulate real life movements? Personally, I always weigh risk and reward, but the question is how much load was the disc really designed to withstand? 50% more than normal? 100%? 150%? Out of curiosity, what is your view on plyometric training for athletes with prior disc pathology? Are you opposed to Olympic lifts? Do you know of studies citing that these specific exercises when done properly cause disc rupture? I look forward to your reply and insight. This is a good discussion. Brian

Dr.Wagner -> Re: Weight lifter/Body builder with LBP (October 3, 2004 3:04:00 PM)
As a former bodybuilder(quite proud of 2 competitions) and now a skinny girlie man doctor...my feelings are quite strict on "bodybuilding type" exercises with known pathology...DON'T DO THEM! "Good Mornings" are the work of the devil and Straight Leg Deadlifts and simply a no no in this case. Many of the traditional exercises of the past (specific to old school bodybuilders) are simply no good. These types of exercises, earned many in the body building world into an early retirement or early joint replacement or debilitating pain and loss of function. I firmly believe exercise variation (high to low reps, pyramiding, "21's", eccentrics, and plyometrics) is the absolute key. A 25 year old young man has no place for discogenic pathology...no place. Change the scheme now or deal with some serious problems later. Change is good.

Shill -> Re: Weight lifter/Body builder with LBP (October 3, 2004 6:18:00 PM)
Brian, Other than the SDL's, I agree with you on all aspects. When injured, protection is the key to allow rapid rehab without deconditioning. Some movements (SDL's, full squats, those other things noted above in my first post) while healing is going on are likely to perpetuate the healing process. In the healthy state, go nuts. I agree we need to move in functional ways too, but many patients start these movements before they are healed, get loads of pain, repeated (relative) re-injuries, and thus it takes longer. Lunges are great for the hams and glut strength, and the spine gets a chance to stay relatively neutral to lordotic. I think plyometrics are fine....once healed.(once daily routines dont cause any significant pain for a few weeks) As far as studies showing injury during olympic lifts, I have no idea when it was done, but Stuart McGill looked at lifters under fluoroscopy, and one lifter actually got injured during the testing, and they caught it on the fluoro. I think it was a heavy deadlift. Its mentioned in his book on Low Back Disorders -Evidence Based Treatment and Prevention The point you mentioned about pain with loading versus no pain with loading is a good one. The only problem is that sometimes the injury isnt noticed until the next day. Ahhh, the challenge with what we do. If applied at a rate, duration and amount that makes good sense, usually things go well. You are right, this is a good discussion. Like Dr Wagner, I too used to (try to) body build. I was never any good at it, but I still did it. I also am the not so proud owner of an L4/5 disc protrusion/extrusion which greatly effects my ability to stay active, and not feel like Im 60. (I'm 34!)

FLAOrthoPT -> Re: Weight lifter/Body builder with LBP (October 3, 2004 6:19:00 PM)
at his age post tear at L5/S1 screams FRS at L5, check out his spine better maybe he has an FRS at L% and a corresponding ERS at the sacrum (sacrum moves opposed to L5) this would cause a shearing loading force, cause low back pain, cause annular tears, maybe he just needs his L5 encouraged into neutral, and then focus on retraining his core stabilizers and neutral training for lifting.

Brian Schiff, PT, CSCS -> Re: Weight lifter/Body builder with LBP (October 4, 2004 8:10:00 AM)
Steve, I too, actually agree that eliminating SDL's in the injured/rehabilitative state is wise. No argument there whatsoever. I just wanted to make it clear that when healthy and with the strictest of form, the SDL is an effective way to strenghten the glutes/hams. I suffered a significant disc injury myself at age 22 (L5/S1). Since that time I perform SDL's and squats periodically (no greater than oncer per week but usually every other week) and I have had no further problems related to the lifting. I always do submax loads and maintain strict form. Now at age 30 myself, I can attest that they have not contributed to further problems for me. Nonetheless, I do agree with you that they are a somewhat "objectionable" exercise when you can not teach or adequately supervise people. In the stable or healthy population I view them as an option, but I do not use them with individuals who are incapable of mastering form. In regard to olympic lifts, I limit the ones I use and typically reserve them for higher level athletes. It always comes back to form and knowing the medical history and demands of the client. Thanks again for the discussion.

JLS_PT_OCS -> Re: Weight lifter/Body builder with LBP (February 2, 2005 4:26:00 AM)
Hmm. I actually think that both the good morning and the SDL can be a great way to strengthen the low back extensors (multifidus and erector spinae) and use it frequently with my back pain patients. I am aware of studies of intradiscal pressure. However, you should know that when you do a good morning, you maintain a natural lordosis in your spine. I'm not sure that position has been studied, one with forward bending at the hips and not lumbar flexion. I know standing and bending forward at your SPINE with a load really increases intradiscal pressure, but that is not what these exercises do. If someone's doing that, form is to blame, not the exercise itself. I feel this is a very good way to teach people the difference between hip motion and lumbar motion. In fact, this is no different than the "waiter's bow" exercise many of us use in spinal stabilization programs. (that is, bending from the hips while keeping your spine in neutral). I think that individual patients may have different needs, and so if hip muscles are tight or patient cannot maintain (or does not have) a lordosis during the exercise, then I would not include it. But I would not reject the exercise as dangerous without a careful study. Given the recruitment of the lumbar extensors, it's a great exercise. If you think this exercise is dangerous by nature, what is your opinion of the Biering-Sorensen test or the so-called "hyperextension" for back patients. They rely on the same principle. Let's not throw the baby out with the bathwater. This reminds me of the "squats are bad for the knees" arguments I have with some of the Ortho Surgeons. Something that seems dangerous and high-level, upon closer inspection (and when done properly) turns out to be a great rehab tool - both for conditioning of the patient and for movement confidence. I feel that early in my career I tended to baby my patients which can perpetuate fear-avoidance behaviors. Regardless of the diagnosis, I now focus on the fact that most activities can be resumed if the proper conditioning and rehab is done. That includes ergonomics/body mechanics training, and these exercises are a great way to do some of that. Thoughts?

JLS_PT_OCS -> Re: Weight lifter/Body builder with LBP (February 10, 2005 5:09:00 AM)
So, if rehabilitating a body builder or weight lifter (or anyone else for that matter), would you include these exercises (straight leg deadlift or good morning) if the patient could maintain proper form? Or do you feel comfortable teaching this movement at all?

Shill -> Re: Weight lifter/Body builder with LBP (February 11, 2005 6:52:00 AM)
Hey Jason, Let me first say its good to have your contributions to this forum. You and I have similar thoughts on some of the posts and therefore your ideas have to be good. :) I know it seems like people maintain lordosis with the good morning, but it really doesnt occur at ALL of the L spine. The lowest two segments flex, no matter how hard we may try to prevent it. And where do most of the spine pathologies seem to eminate from? L4-S1. Lift one leg, (extending the hip) and its a different story, but it is likely biomechanically impossible to stand on two legs and flex forward while maintaining lordosis at all segments. Or, could it be weak paraspinals and Glutes, etc, that prevent it from occurring "correctly?" I'd like to see fluoroscopy on this, or ask Stuart McGill what he thinks. Have you seen his Low Back Disorders book? Its quite good. I think, and its only a semi educated guess, that from a tissue stress theory standpoint, that it is reasonable to provide graded exercise in the aforementioned movements, but I also think its too risky for me to be the one to suggest it to my patients.

JLS_PT_OCS -> Re: Weight lifter/Body builder with LBP (February 11, 2005 8:20:00 AM)
Steve- Well put, especially the compliment. :) I would agree in general with your statements and definitely can respect your point of view. I do think that it would depend on the ROM of the exercise as well. Certainly when using a good morning or "hyperextension" exercise, 90 degree flexion is not required, at spine (!!) nor at hips. Usually it is about a 60 degree trunk angle that I use, with an isometric hold. I don't really have any solid evidence behind why I rather arbitrarily pick that number, but it seems to do a good job of controlling the flexion while still allowing good muscle recruitment. And my experience in rehab has guided me to the conclusion that in many cases, failure to maintain proper lordosis in a given activity was a strength and motor control issue in the back. With proper, progressive training, they did quite well. I think Brian earlier brought up very good other ways to activate some of these same muscles, so I don't see a need to "die on my sword" about these two exercises. But I do use them often, with the right patients. Especially if it is an existing part of their program...

Shill -> Re: Weight lifter/Body builder with LBP (February 11, 2005 10:28:00 AM)
Jason, Now I get it. Anytime I think of goodmornings, I think of the dorks at the gym that stand on cement blocks and do straight leg dead lifts and good mornings all the way to the ground. I always want to slip one of my cards in their pockets, but they usually dont have pockets. Hey, its 40+ degrees in Wisconsin in February. thats call for celebration.

JLS_PT_OCS -> Re: Weight lifter/Body builder with LBP (February 14, 2005 5:04:00 AM)
I have seen those guys in the gym, too. You should get an adhesive backing for your business cards, just stick them to their shirts! I guess my overall point is that it is all about the proper form. Exercises are not intrinsically good or bad, but form and patient selection can make them so. (To paraphrase Shakespeare). :) J

Nicole Matoushek PT MPH CSHE CEES -> Re: Weight lifter/Body builder with LBP (February 14, 2005 3:47:00 PM)
Very impressive Steve Hill! You would make Janet and Mark E. proud! Nicole

krpowell -> Re: Weight lifter/Body builder with LBP (April 1, 2005 6:15:00 AM)
Hey... Would like to add 2 cents q/clarification; as I understand them, not only are stiff legged deads (sld's) not 'good mornings' (which I agree, is a poor exercise) but SLD's are again differentiated from Romanian SLD's, where the knees are slightly bent. Also - single leg SLD's (various exercises) are seen as effective for the Ham's and easy on the lower lumbar. Form is everything, focus should be on technique at the expense of load - often that's not something you see at the gym. If you take a look at McGill new book "Ultimate Back Fitness & Performance" (http://www.backfitpro.com), you'll find he is a proponent of rational lifting program for the hams, glutes and quads (as well as core strengthening). He seminal work "Lower Back Disorders" not only documented a disc sequestration under load (an enormous load) - but considers many difficult q's about intradiscular pressure and common rehab therapies (Seated, closed chain machines, Pilates, Yoga, etc.). Needless to say, I workout later in the morning now.

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