Saturday, June 25, 2011

Wrapping It Up!

The Desk Warriors Guide To Building A Healthy Back

We've learned that we need to sit less, sit better, use a lumbar support, take frequent breaks from sitting, walk more, stabilize our lower backs, mobilize our mid-backs, improve our posture, gain core muscular endurance and provide our backs the proper stimulus. But, what stones have we left unturned on our quest for a healthy spine? What myths, have we left unbusted.

Stones Unturned

1.) We need to improve diet. If we can change our nutritional environment into an anti-inflammatory one via diet we may be able to modulate pain. Pain sensitivity seems to increase in the presence of chronic inflammation. So how can we turn off chronic inflammation?

A.) Nutritionally, we can eat a proper ratio of PUFA (poly-unsaturated fats) which is estimated to be between a 1:1 and 3:1 ratio of Omega 6 to Omega 3 fats. Sadly, some estimate our SAD (Standard American Diets) provide upwards of 20:1 Omega6:3. This creates a pro-inflammatory nightmare as omega 6 fats promote pro-inflammatory processes while omega 3's do the opposite. Eat more omega 3 and less omega 6. Consider supplementing with fish oil. Getting this ratio in check decreases inflammation and should help reduce pain, specifically LBP.

B.) Sleep. We need to focus on getting QUALITY sleep and QUANTITY sleep. Inadequate sleep can be pro-inflammatory. Short sleep times are associated with poor glucose metabolism (hyperglycemia) which is pro-inflammatory. Furthermore, there are many links between short sleep times and hypertension, increased obesity, and other poor health outcomes. On average we slept 9 hours per night in 1910. Now we sleep less than 7.5 on average. Sleep more.
C. Lose weight. You all know that being obese places huge strain on your joints. This is obvious for the knee and the ankle, but obesity also effects the spine. If you have significant body fat, focus on losing it to alleviate compression of the spine.

D.) Lose body fat. Body fat gives off pro-inflammatory cytokines. Losing body fat can decrease inflammation. If you're fat, you're inflamed.

"Old Wives Tales"
What you've heard wrong about back health

We've already dispelled the myths that sitting "rests" the back and that having a "strong" back protects from LBP. We tore down the sit-up as a pro-phylactic exercise for the back. But what other myths are still lurking.

1.) Tight hamstrings cause back pain. A longitudinal study of men in the military did not reveal any significance in regards to LBP and tight hammies (Hellsing, 1988). Future LBP also was not able to be predicted based on tight hammies (Biering-Sorenson 1984). Personally, i've done all the hamstring stretching in the world to relieve my LBP and at best I found it to do nothing. Furthermore, many of the prescribed hamstring stretches place the low back in flexion and as you know from reading this, flexion can often exacerbate LBP.

2.) Leg length discrepancies cause LBP. This is certainly true of large leg length discrepancies. But studies show that even leg length differences up to 5cm rarely develop chronic pain (Grundy and Roberts, 1984). Further, lumbar scoliosis and leg length differences of less than 1cm were not found to be associated (Hoikka, 1989). Don't let your orthopedist/chiropractor install that shoe lift before reading the whole Desk Warriors Guide to Building A healthy Back.

3.) Lifting/moving on the job: bend the knees, not the back. This advice forms the foundation of every job-safety ergonomics guidelines. However, sometimes it is too physiologically costly to always head this advice. Sometimes it's just downright impossible. Also, no conclusion has been made as to its efficacy. I will say this advice needs to be adhered to when lifting set loads in the gym, such as a squat or deadlift. But as for how to perform some light repetitive task on the job bending, the back may not be so bad.

4.) Leg presses are safer than squats. This is false and a huge mistake. Maybe 225 pound leg presses are safer than 225 pound squats for someone who is far too weak to squat the weight. Leg presses force lumbar flexion regardless of load. They are also generally terrible for the knees. They allow larger loads to be moved and thus people feel cool when under the numerous 45 pound plates. Long story short. They are not better for your back. Not even close.

5.) Back Extension machines are safe & effective: McGill and colleagues use commercial gym back extension machines to herniate discs in lab. These are the machines where you sit down & strap in with a seatbelt. A padded bar digs into your back and pushes you forward as you resist it and then extend backwards. Basically it pushes you into full flexion, loads your spine, compresses it greatly and herniates your lumbar discs. Don't use these machines.

Thanks for tuning in. Post questions or comments! Share with your friends or that guy with the bad back!

Biering-Sorenson, F. (1984) Physical measurements as risk indicators for low-back troubles over a one-year period. Spine 9: 106-119

Hellsing, A.L. (1988) Tightness of hamstring and psoas major muscles. Upsala Journal of Medical Science, 93: 267-276.

Hoikka, V., Ylikoski, M., and Tallroth, K. (1989) Leg-length inequality has poor correlation with lumbar scoliosis: A radiological study of 100 patients with chronic low back pain. Archives of Orthopaedic Trauma Surgery, 108: 173-175

Grundy, P.F., and Roberts, C.J. (1984) Does unequal leg length cause bain pain? A case control study. Lancet, August 4: 256-258.

Step 10: Provide the Proper Stimulus

The Desk Warriors Guide to Building a Healthy Back 10/10!

This brings us to talk about 'dosing' our workload for the back. You see, every tissue has a tolerance zone. You go above the zone and you introduce injury. Conversely, you never approach that tissues tolerance zone, and you get atrophy and demineralization of the associated tissue that results over time in less capacity for work. What we need to do is apply the proper stimulus or workload so that our tolerance zone gradually improves.

You see in a “bad back” we have very little margin of safety. Too much work, heavy exertions, and faulty motion patterns will cause further injury or pain in this individual. On the completely opposite end of the spectrum, in our elite athlete we have a very high amount of tolerance to both heavy exertions or a high work load. However, if this capacity is not continually challenged, the athlete will lose the capacity that makes them elite. Conversely, if we do have one faulty lift or heavy collison we may go over the amount of tolerated load and induce injury. To sum it up. It is a very critical to prescribe the proper amount of loading in both the “bad back” and the elite athlete, as well as eliminating faulty movement patterns such as poor sitting or standing posture. A bad back will remain bad if we overload it or continually underload it and an elite back will not remain elite for long if we overload it. Conversely, chronically underloading it will eventually reduce its elite work capacity.

The point of the above picture is to help you realize the importance of maintaining your days workload in the margin of safety. The first way to do this is to eliminate faulty motion patterns. Previous injury may make this a difficult task but working with a qualified personal trainer, chiropractor or sports medicine professional may help. Sitting less will surely help as will sitting better.

Assuming our movement is solid and our posture is strong, we can worry about achieving the proper workload. Let’s think of our spinal capacity as a smart phone battery. When we wake up it’s fully charged (assuming we got enough quality sleep). Our goal is to make it to the end of the day with a fair amount of battery left. Then to retire into bed and recharge our battery. We don't want to never unplug our battery (challenge our back), because over time the battery will still lose life (a non-challenged back losing work capacity). Yet, we don't want to drain our battery to 0% and not be able to use our expensive smart phone. When we approach losing battery power, we are approaching the upper margin of safety/tolerance in our back. Do this consistently and we are asking for injury (battery off).

Instead we want to use our phones just the right amount. We want to preserve the battery and not risk having our expensive smart phone shut down before the day is done. Not playing too many games, making too many calls, or leaving 55 apps running will ensure that we preserve our battery. We also want to get the most of our expensive smart phone with its unlimited everything plan and huge monthly bill. Metaphorically, applying these principles to our backs we aim to keep our spinal capacity high by providing the proper stimulus to maintain capacity while not inducing injury. In many cases consistently achieving this will increase the battery life over time so that we may exert more energy into life without depleting our back battery.

So lets take a look at two scenarios

In scenario one. Forty year old 5'9'' 175 pound Bob wakes up after a crummy night sleep with a 75% charged battery. He then hunches over a bowl of whole grains and slurps down a 20 ounces of french roast while sitting through traffic on the way to work. Bob is already down to 51% of his spinal battery. This is because the intervetebral discs are fully hydrated upon rising from bed. Therefore the annular layer is subject to much higher stresses during bending, flexion, and compressive situations (sitting) in the morning. Performing spine bending maneuvers during the first hour of the day is unwise in the unhealthy back as 90% of the fluids have drained by the first hour of our day. Snook and colleagues (1998) proved that conscious avoidance of forward spine flexion in the morning improved low back symptoms.

The above photo demonstrates how intradiscal pressures increase with various amounts of forward bending. This can be exacerbated early in the morning. The meatty steak looking things are your intervertebrael discs. The rings are the annular layers that hold the nucleus in place. Repeated flexion with high intradiscal pressures gradually degrades the annular layer leading to bulging or herniated discs.

Next Barbara arrives at work where she is fortunate enough to have to walk a few hundred yards before she parks her caboose in her less than ergonomic seat at her cubicle. She looks at this walk as drudgery rather than an opportunity to improve her spinal health by walking with proper posture. This desirable activity decompresses the spine and provides necessary blood-flow and motion. At work Bob is seated for most of the day and repeatedly lurches forward to take phone calls, grab things and sometimes bends down to the lower desk drawers to retrieve items. These repetitive tasks require full spinal flexion under compression (sitting and hunching over) and further drain his battery so that by lunch time, he is at 25% battery life.

Bob finishes his day in a similar manner. Painfully he sits through the rush hour commute home. His fury grows with each tapping of the brakes and each witnessed incompetent driver. Finally he arrives home, stressed, angry, STARVED. He throws a frozen P.F. Changs meal in the microwave and impatiently waits for it to be cooked. Bob scarfs down his processed food garbage in typical hunched over fashion. While leaning forward to do the dishes his battery runs out. He rubs the pain in his lower back, wondering why his back hurts.

Bob had planned on taking the dog for a walk but he is too exhausted and his lower back aches. Rather than being yanked around the block by Fiona, his minature doberman. Bob lets her out back to annoy the neighbors while retiring to his bed where he'll watch some meaningless television programs and ache. Lying down at this point is preferable to Bob because his back battery is out and he can't tolerate any more sitting or intense activities. After watching a few re-runs of Seinfeld Bob falls asleep with the tv on…

Bob awakes to his alarm with a 74% charged battery.

Scenario 2

Ron, 40, 5'9'' 175, wakes up after a revitalizing 8 hours of sleep in a pitch dark room absent of electronic noise. His battery is fully charged, 100%. He puts on his shoes and notices his back is a bit tight (from the disc hydration). Rather than sitting down to breakfast, he throws a bit of coffee on the pot and takes his dog for a walk. Ron has been reading The Desk Warriors Guide to Building a Healthy Back. He realizes the importance of walking and avoiding forward bending postures in the morning. Ron returns from his walk, grabs some healthy paleo leftovers from the fridge and heads to work. He gets in his car and enjoys the leftover chicken satays, while his lower back rests firmly supported by the lumbar support he recently purchased. Ron arrives at work with 96% battery life.

At work Ron is aware of his posture. He uses a lumbar support and moves items on his desk often to avoid repetitive tasks. He recently petitioned his boss to allow him a sit-stand work station and won. He often is able to do his work in a reclined fashion to reduce the compressive load on his back, and when he can’t he’ll rise the desk up and stand. He makes certain to take breaks from sitting and static standing. He'll often pace while on his cell phone, gets up to speak with other colleagues and looks forward to the rare opportunity to walk down the hallway to use the bathroom or deliver some finished work.

Like clockwork Ron does not fail to take breaks from sitting, usually every 30 minutes. His co-workers think he’s weird because he’ll sometimes stretch, foam-roll and do these goofy looking three exercises while he’s in his slacks and dress shirt. But none of them would dare insult Ron as they know they would be demolished in a matter of seconds if it came down to it.

It’s lunch time and Ron’s back battery is at 75%.

Ron finishes out his work day in this manner. He is done at 3pm and hits the gym. Ron doesn’t have much time so he does a quick hip mobility warm-up knowing that hip mobility spares the spine. He then mobilizes the thoracic spine and does some spinal bracing techniques as he prepares for heavy lifts. From working with his personal trainer, Ron confidently executes sets of squats working up to 225 pounds for 10 reps. He doesn’t rest long between sets and finishes with some standing dumbbell presses and pull-ups before promptly exiting the gym drenched in sweat.

His battery is at 45%.

Ron gets home before his wife and starts preparing dinner. His kids are already home from school and his son has a baseball game at 5. Ron quickly enjoys a meal of real foods with his family. At little Joey’s ball game, Ron helps coach and throws the kids fly balls. Ron is bending, twisting and running down bad throws. These activities would have bothered his back in the past, but his spinal capacity seems to have improved since he's practiced what he's read in The Desk Warriors Guide To Building A Healthy Back.

His battery is at 30%

He uses a bit of his back battery lifting the kids and jumping around celebrating their victory! When Ron gets home he finishes up some chores around the house, gets the kids to sleep and uses a bit more of his back battery capacity making his wives toes curl in bed. BIG RON retires with 15% battery life left.

After a solid nights sleep, Ron wakes up the next day with the slightly more capacity than he had in previous days.

I hope the above helps illustrate the proper way to use your back capacity through the day. Preserve it by doing a lot of low-intensity moves like walking and mowing the lawn. Practice proper posture and be aware of reducing repetitive tasks. Sit less and sit better. Give your back some exercise stimulus and preserve your capacity.

When we continually drain our back battery to 0% we end up hurting our backs doing something insignificant like lifting a dropped pencil off the ground or sneezing. Don't be like Bob. Be a Ron.

Snook, S.H., Webster, B.S., McGorry, R.W., Fogleman, M.T., and McCann, K.B., (1998) The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. Spine, 23: 2601-2607.

A special thanks to Dr. Stuart McGill. Buy his books here at

Friday, June 17, 2011

Step 9: Gain Endurance In Your Core Muscle

The Desk Warriors Guide To Building A Healthy Back: 9/10

The commonly held beliefs that a strong low back and strong abdominals are protective of back pain are not entirely true. Several studies have shown that muscular strength does not predict who will suffer from future back pain (Biering-Sorenson, 1984). You see, most people have the requisite muscular strength needed to maintain a neutral lumbar spine during daily activities. However, repetitive tasks seem to tire our musculature, resulting in faulty movement patterns over time. Poor movement patterns put undue strain on tissues in the back that inevitably lead to pain. These findings suggest that it is not insufficient strength, but insufficient muscular endurance that leads to injurious movement patterns associated with low back pain(Cholewicki, 1996). This dispells the myth that strong back or abdominal muscles are prophylactic of the back. Rather it has been shown that core muscular endurance reduces the risk of future back problems (Louto, 1995).

So possessing core strength doesn't appear to protect the spine from CLBP (chronic low back pain)? Does training for core strength? It appears not. One study found that traditional physical therapy treatment modalities coupled with lumbar strengthening exercises were less effective than training for dynamic muscular stabilization techniques. Let's define strength as to not get one confused. Strength refers to maximal muscular contractions, as in moving the heaviest load possible or resisting being moved by large forces. Generally strength is measured in short amounts of time or repetitions (less than 5). Strength is not to be confused with muscular endurance, which is measured by performing many repetitions or by performing over a duration of time.

Another study in which all 3 groups increased trunk strength concluded that,

"No differences in the clinical outcome were observed between the three therapy groups, and the changes in physical performance after therapy did not correlate with the clinical outcome. It is therefore questionable whether strength measurements have any clinical significance in documenting the success of rehabilitation programmes."

Yet another study shows that training trunk balance improved CLBP more significantly than training trunk strength.

So possessing strength or improving ones strength in the core musculature doesn't appear to help reduce CLBP. improving trunk/core balance, muscular endurance and dynamic muscular stabilization do appear to help. Again, this harks back to the fact that repetitive tasks seem to tire our musculature, resulting in faulty movement patterns that over time lead to injury and pain.

So how should I go about gaining endurance in the core musculature? You want to do this in the manner in which the body is meant to move. This means avoiding machines. Anything that trains you in an upright seated posture most likely is not going to benefit your spine. Secondly, sitting in a loaded position or sitting and repeating flexion/extension or rotation only further damage the spine via increased compression in an already precarious position. DON'T DO IT.

Dynamic muscular stabilization techniques (DMST) may be more effective than traditional physical therapy. DMST basically means training yourself to be able to stabilize the spine throughout a variety of 'dynamic' movement patterns. DMST is training muscular endurance in a functional manner. This type of training requires proper movement patterns be taught so that one may maintain optimal spinal positioning during activities of daily living and progressing to more challenging rarely used postures. Including gardening from the knees, picking items off the floor, rising from chairs etc. Teaching proper movement patterns may alleviate CLBP. If the painful stimulus is lessened or eliminated shouldn't the pain go away with it?

As for gaining muscular endurance in objective measures, you may guess that I am not going to recommend performing 2000 sit-ups per day like Manny Pacquiao claims to perform in his commercial. This is lumbar spine suicide for 99% of humans. Instead, revisit the big three exercises popularized by the leading spinal researcher in the english speaking world, Stuart McGill. As you progress with these movements, try subbing the modified curl-up for front plank progressions. Practice the front and side planks until you can easily hold them with great form for greater than 60 seconds. Next, progress by adding weight, using one/arm for support or rotating the body in a plank fashion into front/side planks, and returning to the initial position. Build your capacity via many sets of shorter holds. For example 8 sets of 6 second holds instead of going all out on 2 sets of 20 second holds. This will limit chance of injury and allow re-oxygenation and recovery of the stressed tissues.

McGill and colleagues (2003) demonstrated that the relationship between the extensor musculature of the back is diminished relative to the flexor and lateral musculature in those with lingering back troubles. Specifically we are talking about the thoracolumbar musculature; erector spinae, the longissimus, iliocostalis and multifidus muscles .The best lifters in the world (Olympic Weightlifters) show hypertrophy in these muscles that act to support the spine from buckling forward when lifting a load. Any time we bend over or flex forward, these muscles act to create posterior shear to counter the anterior shear forces that we may experience from picking a heavy box from the floor.

So how do you know if your extensors are weak relative your flexors/lateral musculature. Check out the table below.

RSB= right side bridge, LSB= left side bridge, the times are listed in seconds.

The above results are from pain free subjects mean age 21 years. As you can see, women had higher times in extension vs. men and lower times in the lateral musculature as measured via side bridges.

Next, we look at older men; mean age 34. Endurance times are down across the board as compared to the younger counterparts from 11.2. Specifically note the ratio between flexors and extensors in the non-back troubled controls vs. those with a history of back troubles. Those with a history of back troubles have much more flexion endurance (84 vs 66 seconds) as well as more lateral muscular endurance. They also have lessened extensor endurance 90 vs 103 seconds).

Extensor Test for thoracolumbar musculature and glutes

Flexion Test for hip flexors and abdominals

Side-Bridge Test for lateral musculature (Obliques)

The tables above were produced by measuring the amount of time folks could hold these positions. Now go through the tests yourself. If you have diminished extensor endurance (you can perform the test of a table with someone holding your legs down) relative to your flexors and have similar endurance ratios as found in the group with a history of back troubles, you know that you need to work on increasing muscular endurance in your extensor muscles. Don't immediately go out performing long static holds. Rather, build capacity with many sets of shorter holds. These sets allow for re-oxygenation of the tissues and rest that will ensure great form and minimize injury risk. For example doing 6-8 sets of 8 second holds in the bird-dog or glute bridge or the above extensor test.

So those with lingering back issues have poor endurance in the lower back extensor musculature as well as the glutes in comparison to the obliques and the abdominals. They also had increased endurance in the obliques and abdominal/hip flexor musculature compared to the pain free controls. This suggests that compensatory movement patterns that neglect lumbar extension and rely more on the anterior musculature of the core are not protective of the back. If you fall into this category, focus on holding bird-dogs then progressing to more demanding moves such as supine planks from the hands, supine planks, supine bridges / glute bridges, hip-thrusts and graduating with glute-ham raises. Again, be smart and build endurance through many bouts of shorter holds or lower reps with numerous sets as you work towards longer holds or more repetitions.

With all of the above movements, focus on limiting motion at the lumbar spine by bracing your ribs to your hips via the abdominal musculature. We want the movement to come from the hips via strong gluteal contractions that extend the hips. SQUEEZE YOUR CHEEKS HARD! When at the top of the movements, picture a quarter between your cheeks and squeeze as hard as possible as to not let it go. Strong glutes may be protective of the back, while muscular endurance of the lumbar extensors (this includes the glutes) certainly appear to be protective.

What are you waiting for assess! Correct! Get started progressing with your exercises! And of course don't start without discussing this with your Dr. Yada yada. Don't sue me! I'm only trying to help.

Biering-Sorenson, F.,(1984) Physical measurements as risk-indicators for low-back trouble over a one-year period. Spine, 9: 106-119.

Louto, S., Heliovaara, M., Hurri, H., et al. (1995) Static back endurance and the risk of low back pain. Clinical Biomechanics, 10: 323-324.

McGill, S.M., Childs A., and Liebenson, C., (1999) Endurance times for stabilization exercises: Clinical targets for testing and training from a normal database. Archives of Physical Medicine and Rehabilitation, 80: 941-944

Thursday, June 16, 2011

Step 8: Take pride in your posture

The Desk Warriors Guide To Building A Healthy Back 8/10

Strong men stand tall. Weak men slouch. Attractive people have good posture. Studies show that good posture is valued by the opposite sex. Good posture is perceived to coincide with self-confidence, youthfullness and general health. It also makes one appear taller which has been shown to correlate with increasing salaries and job opportunities in men.

No sane person prefers a slouch to a more fit healthy posture. Great posture as in a West Point Cadet demands respect. Proper posture exudes self confidence and self confidence will enhance countless areas of ones life.

On the contrary, think of a creep. Really, take a second, close your eyes and picture your textbook definition of a creep. What did their posture look like? I can guarantee they weren't standing tall and proud like our West Point Cadets. The creep on the other hand is characterized by a bent spine, internally rotated shoulders and raptor-arms. The creep does not follow my blog and maintain a healthy spine, rather they develop their hunched posture and shoulder internal rotation via too much facebook creeping and masturbation to internet porn. Don't be a creep; follow my blog.

As we age, we decrease in height. On average we lose .4 inches every 10 years after the age of 40. Women lose more then men due to increased bone loss via osteoporosis. A great deal of this loss of height is attributed to poor posture.

There are a few main reasons for this loss of height. One, the poor posture and resultant kyphosis and or anterior pelvic tilts mechanically shorten us; limiting the vertical heights of our spines. Two, the resultant poor posture coupled with aging accelerates the degeneration of cartilage at the joints (ankle, knee, hip, vertebrae etc...) The resultant cartilage loss will decrease height. Proper posture will limit movement impairment syndromes that accelerate the degradation of cartilage. Three, disc hydration and joint hydration via decreased synovial fluid will decrease joint space and height. Four, vertebral discs may rupture or bulge creating decreased intervertebral disc space and thus decreased height. Five, osteoprosis and osteopenia decrease height by turning our big hard bones into softer spongier; more compressed and less robust bones. Six, loss of muscle mass coincides with a less erect posture and decreased height.

How can we maintain our posture and height?

What can we do to improve our posture and maintain our height, health, and hotness? To improve posture, improve thoracic extension by foam rolling and stretching and also stretch your hip flexors. The hip flexors include your psoas and iliacus as well as rectus femoris. Do these simple stretches to make sure your hip-flexors are not overly tight. Tight hip flexors pull you into a bent over, shortened posture. They increase lumbar extensor activity and can lead to LBP. If you sit more than 2 hours per day, you can pretty much guarantee you would benefit from stretching your hip flexors. Check out the BEST hip flexor stretch below which we call the "couch stretch."

When standing up from the seated posture that molds our tight hip flexors; ensure optimal posture by first pushing your hips forward with your hands and leaning back into elongated extension. Aim to push your rib cage upward off your hips and pushing your hips forward, creating length in the spine. Do this a few times to help return the disc nucleus to equilibrium (remember from the sit less post that prolonged lumbar flexion via sitting pushes the nucleus of the disc posteriorly or backwards) , next externally rotate the arms and lift the chest. Focus on pulling the head backwards and elongating your middle or thoracic spine. Congratulations, you are now in ideal posture. Now go for a walk and take pride in your tall, sexilicious posture.

Simply being conscious of your posture is enough to limit this progression towards hunchback-dom. With hunchback-dom inevitably comes increased orthopedic problems. Loss of thoracic extension results in increased lumbar and cervical flexion. These two things increase the risk of herniation. Lumbar disc herniation is greatest in the 20’s while the spinal vertebrea are their most spry. However, cervical disc herniation is something of a more degenerative nature which increases with age.

In conclusion, focusing on the prior principles illustrated through this back health series will help you maintain your or rehabilitate your posture to pain free, tall and in charge as you age. Make posture a priority; something you take pride in and you will inevitably avoid the many downfalls of a hunched spine. Thanks for reading and stay tuned for part 9!