Editor's note: Part 1 of this article appeared in the Dec. 15, 2014 issue.
Stiffness: Useful in the Right Place and at the Right Time
Stiffness is a word that has a negative connotation, both in life and in our ways of looking at tight fascia and joints.But stiffness, especially temporary stiffness created by activating the right muscles, is an essential component of effective movement. Your core needs to be stable and stiff when you throw or push something. If not, your back will take the brunt of the motion, you'll hurt yourself and your motion will not have the power it needs.
Think of the connection between the legs and the throwing arm of a baseball pitcher. The top-level athlete knows how to stiffen their trunk rapidly and then relax. The person in pain is weak and stiff, but can't focus the stiffness; they can't create stiffness where and when it is needed.
Timing is everything. Instead of holding on for dear life with constant tightness, the healthy body knows how to fire muscles when needed, and let go when not needed. Of course, this is easier said than done or taught.
How does temporary proximal stiffness help the low back pain patient? Stiffness eliminates the micromotion in the joints that can cause pain and contribute to ongoing tissue degeneration. If they feel pain when rolling over in bed, they are unstable. Arrest the micromovement via simple bracing strategies. Teach the patient to brace their abdomen before rolling over. In the bigger picture, the goal is to have bracing occur automatically as movement is initiated. This is the long-term strategy to get the trunk stable in everyday movements.
This does not mean we do not want mobility. We just need to get there differently. Most of you know that trying to beat up the tight iliotibial band (ITB) is not that effective. It is more effective to wake up the gluteus medius to create reciprocal inhibition of the ITB. What about tight lumbar erectors? Get the whole of the extensor chain working as a team so the erectors don't have to stay "on" all of the time. Tight hamstrings? Wake up the glutes and activate the hamstrings.
The Specific Muscle Approach vs. the Integrated Muscle Approach
McGill is skeptical of the Australian model of training small, specific stabilizer muscles. He sees the function of muscles as a composite, as muscles that work together as a team. He showed a slide of activation of the transverse abs, with the external obliques, showing that they both turn on at the same time.
When I think of my most challenging patients, I notice that they are often "motor morons" and have the hardest time learning the subtle stuff. McGill strategies and exercises are practical and teachable. Training to isolate the small muscles is not easy for the average person, let alone the motor moron with long-standing back pain.
Temporary Injury or a Train Wreck Waiting to Happen?
Patients often describe a specific moment of injury. The question is, was that an isolated event or a disaster waiting to happen? When someone drives for 10 hours, and then gets out of the car and lifts a suitcase, what should we blame? The moment of injury or sitting in a lousy posture, with too few breaks? Most injuries are about cumulative loads over time. They represent viscoelastic creep. Over time, tissues fatigue. Think of road cyclists, ski racers, rowers, etc. All of these athletes hold a flexion posture over time.
Think of all the people who sit all day long. When a person sits in a flexion slouch for 20 minutes, their ligaments creep and they become unstable. It takes females 30 minutes to recover their stability. For men, even after 30 minutes, they are still 25 percent more lax.
What are the simple solutions? Sit less. Take frequent breaks. Set up a standing computer station. Don't overtrain to fatigue in the gym.
A Unique Approach to Rehab
I'll quote here from McGill's text, Low Back Disorders, chapter 10.1 McGill describes a five-stage back training program sequence. He notes that only the first three are appropriate for rehab, while the last two only come into play for athletes interested in performance. I think the general public, and most trainers, doctors and therapists, are confused about this.
- Stage 1: Groove motion patterns, motor patterns & corrective exercise.
- Stage 2: Build whole body and joint stability with a focus on spine stability. This may include strategically directed mobility aimed at the ball and socket joints.
- Stage 3: Increase endurance."
He adds two more stages for performance (these are optional for the average person).
- Stage 4: Build strength (spare the joints while maximizing neuromuscular compartment challenge).
- Stage 5: Develop speed, power, and agility."
How many patients ask you, "How can I build core strength?" Is this the right question? How many patients with back pain are focusing on strength in the gym, without awareness of moving correctly? I think McGill has described a much more useful sequence, especially for the patient suffering from chronic or recurrent back pain. The big picture: Teach your patients to move better. To quote Gray Cook: "First move well, then move often."
- McGill S. Low Back Disorders: Evidence-Based Prevention and Rehabilitation, 2nd Edition. Human Kinetics, 2007.
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