From Crutches to Deadlifts: Back Rehab 101 From Crutches to Deadlifts: Back Rehab 101

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Thread: From Crutches to Deadlifts: Back Rehab 101

  1. #1
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    Default From Crutches to Deadlifts: Back Rehab 101

    by Emily and Diego Socolinsky

    Would you believe us if we told you that one of our clients went from barely being able to walk without crutches or drugs to squatting in the low 200s, deadlifting in the mid 200s, pressing and benching in just 6 weeks? Maybe not. But this is exactly what happened. And it is not as rare as you may think.

    Read article

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    Second, we showed him a handful of exercises to do that would help depressurize the posterior lumbar discs and the surrounding nerve roots.
    I'm interested in knowing what those exercises were, are you talking about some positions to maintain to "relieve" pressure from the nerve roots' foramen?

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    Kudos to both Scott and the coaches. That's some pretty good work. As an aside, could someone refer me to the articles about back pain talked about in the article (other than those on the SS site)?

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    Quote Originally Posted by eustass92 View Post
    I'm interested in knowing what those exercises were, are you talking about some positions to maintain to "relieve" pressure from the nerve roots' foramen?
    Thanks for reading! Scott was in pretty bad shape when he was able to get back to the gym and before we did any Barbell work or anything remotely like hinging or squatting, we simply did some good ole fashioned “PT” work. I had him do glute bridges and checked with his pain tolerance. Good. So we did clams (lying on one side with his legs together, bent and I told him to open and close his legs as if his legs were a clam shell.)All was good. He got on his belly and did a few cobras (yoga move where you push yourself up from the floor with slightly bent arms and stretch). I had Scott squeeze the crap out of his glutes. Then we got to all fours, hands and knees and did a few Cat/Cows (again, a yoga move.) Very easily and gently, nothing quick or even full range if he could not do it. We transitioned to Rock Backs, sitting the hips back to the heels and opening the hips. Scott did these exercises each time he came in to the gym for the first couple weeks and then when he was able to squat with a little weight and hinge better, he slowly eased up on these beginning exercises and then stopped doing them altogether once he was squatting and deadlifting with weight. We also had him simply hinge while sliding his hands down his thighs as part of these drills. This was the most difficult part for him.

    He never ever saw a physical therapist. My husband and I have been to enough in our lifetime to have picked up a few things here and there due to our own history of back incidents.

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    It's good to see that Scott ignored the bad advice from his orthopedic surgeon.

    However (and this is a big however):

    It seems that Scott possibly tweaked his back training, and this should receive substantial discussion in the article, but didn't. First of all, Scott has already presented as someone who is at least somewhat injury-prone with lifting. That comes down to a lot of things, and not all of them are technique. Next, he was one month into a program that involved technique adjustments from the way he had been doing it for a very long time. So he's strong enough to lift heavy, but is doing it in a new way, possibly relying on supporting muscles and nervous system cues that aren't quite there yet.

    But the problem showed up two days after a uneventful training session. Well, a back tweak doesn't always show up immediately, and you don't always recall the precise moment the tweak happened. A lot of times you notice in in the morning when you wake up and can't get out of bed (for Scott, as described, the pain was obviously progressive over a period of a day or two from initial discomfort to wheelchair urgent care admission).

    So maybe Scott hurt himself lifting. Or maybe he did it to himself moving the living room couch for his wife, and forget. Regardless, the article needs some discussion of it.

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    Quote Originally Posted by thras View Post
    It's good to see that Scott ignored the bad advice from his orthopedic surgeon.

    However (and this is a big however):

    It seems that Scott possibly tweaked his back training, and this should receive substantial discussion in the article, but didn't. First of all, Scott has already presented as someone who is at least somewhat injury-prone with lifting. That comes down to a lot of things, and not all of them are technique. Next, he was one month into a program that involved technique adjustments from the way he had been doing it for a very long time. So he's strong enough to lift heavy, but is doing it in a new way, possibly relying on supporting muscles and nervous system cues that aren't quite there yet.

    But the problem showed up two days after a uneventful training session. Well, a back tweak doesn't always show up immediately, and you don't always recall the precise moment the tweak happened. A lot of times you notice in in the morning when you wake up and can't get out of bed (for Scott, as described, the pain was obviously progressive over a period of a day or two from initial discomfort to wheelchair urgent care admission).

    So maybe Scott hurt himself lifting. Or maybe he did it to himself moving the living room couch for his wife, and forget. Regardless, the article needs some discussion of it.
    As we stated in the article,
    “The Facts About Back Pain
    A number of medical studies (see references) have reported poor correlation between back pain and findings in magnetic resonance imaging of the spine. Most people walk around pain-free not knowing that they have one or more herniated discs in their spine. While it is impossible to know this with certainty, given Scott’s history of lifting with poor form over many years, and previous episodes of back pain, it is likely that his L4-L5 herniation was from an old injury or degeneration. There was no obvious trigger to his pain on this occasion, and the onset did not correlate with a traumatic event but rather occurred two days after his last training session.“

    We don’t know what could have happened/did happen/might have happened. But we do know what worked and we know where he is today with his training and he is training well beyond where he was even before coming to us. Discussing this further was not the point of the article. Back pain is a subject discussed with great detail on many many sites. We wanted to highlight one of our clients who was able to get back to training despite this unfortunate set back that could have occurred at anytime, anywhere. Thanks for reading.

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    Awesome for Scott! Thanks for taking the time to write up the article. I've been fighting lower back issue with similar symptoms expressing in right leg for several years. I can continue to train, but walking, or standing still expresses numbness and alters my gait in my right leg and right foot. NO issues when lifting though I do avoid cleans...

    (Back issues -- sorry another spondylolisthesis thread)

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    I meant the above post to be friendly, and I hope that I brought it up in a friendly way, because I appreciate what you guys are doing, and I hope that you continue. And I hope that this post is friendly as well. But as the article remains unfortunate as written, and your comment did not address this, I'm going to go into more detail in this second post. No hard feelings, I hope. I think that you have a good story to tell about Scott, once shed of some of the less likely statements.

    Your article makes two basic claims: 1) That we don't know enough about back pain to say were the pain came from, and shouldn't speculate. 2) We know enough about back pain to say that your rehab protocol worked.

    We'll come back to the basic contradiction here, but let's first look at the claims in detail.

    First, what do we know about back pain?

    Quote Originally Posted by Back Rehab 101
    A number of medical studies (see references) have reported poor correlation between back pain and findings in magnetic resonance imaging of the spine. Most people walk around pain-free not knowing that they have one or more herniated discs in their spine.
    This seems to stick closely to your referenced studies. For example, see especially the conclusion to Jensen et al.:

    Quote Originally Posted by Jensen et al.
    Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.
    And the other two cited studies seem to back this up, especially Savage et al., who is appropriately savage on MRI diagnoses. I don't know if MRI has become a better diagnostic in the last two decades since these articles appeared, but I'm willing to bet not. Let's go on:

    Quote Originally Posted by Back Rehab 101
    While it is impossible to know this with certainty, given Scott's history of lifting with poor form over many years, and previous episodes of back pain, it is likely that his L4-L5 herniation was from an old injury or degeneration.
    Wait just a moment. This does not follow. I feel that you have misunderstood something. What your cited studies say is that the herniation may be unrelated to current pain (or it may not). The studies suggest that there is no way to tell. Your speculation on where the herniation came from is unwarranted. A correct statement, following your studies and not derailing the thrust of your article, would be to replace this with something like the following: "the herniation may or may not have had anything to do with the pain, and it is impossible to tell whether it is new or old without a previous MRI." (Also, this is only a nitpick, but you have slightly misunderstood the meaning of "degeneration" in this context. It's state descriptive, and not meant by the authors to describe a cause or to preclude trauma or injury.)

    Quote Originally Posted by Back Rehab 101
    There was no obvious trigger to his pain on this occasion, and the onset did not correlate with a traumatic event but rather occurred two days after his last training session.
    In fact, back tweaks in training always take time to lay you out. People don't go from squat to wheelchair in 5 seconds. There is a process of response and inflammation, etc., after an injury, that takes time. Two days is not at all strange or uncommon. As trainers, you should have your eyes wide open to this. I wrote about the particular warning signs for this lifter in my first post, so I won't retread.

    Now for point number 2. Although you call Starting Strength "rehabilitation" in the article, he had already recovered from wheelchair and hospitalization to "pronounced limp" before showing up in the gym again. I am happy for Scott that he got back into the gym as soon as possible. But whatever caused this problem problem in the first place, it seems to have resolved idiopathically before Scott started lifting again.

    To sum up, medical science knows very little about the human back and why it hurts. (Other than that bipedalism was probably a bad idea for our species.) In Scott's case, while there are many possible origins for his back pain, it's not sane for his trainers to ignore his new program as a possible, or even likely, culprit. Similarly, back pain goes away for many reasons that we don't understand. While we can't say for sure why Scott's pain went away, it's an incredibly positive story to hear that he could get back into lifting so soon, and is making new PRs without feeling new pain. Lower back pain can often become a long-term issue, and it says something very good about Starting Strength that it didn't turn out that way in Scott's case.

    Also, sudden onset back pain + MRI is a terrible reason to recommend back surgery. It's a crime that doctors don't police their profession far better than they do.

  9. #9
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    I meant the above post to be friendly, and I hope that I brought it up in a friendly way, because I appreciate what you guys are doing, and I hope that you continue. And I hope that this post is friendly as well. But as the article remains unfortunate as written, and your comment did not address this, I'm going to go into more detail in this second post. No hard feelings, I hope. I think that you have a good story to tell about Scott, once shed of some of the less likely statements.
    Thank you so much for a thoughtful post. It is rare to see this level of attention with no concomitant intention get into an argument. About as rare as me replying to a post on this forum.

    Your article makes two basic claims: 1) That we don't know enough about back pain to say were the pain came from, and shouldn't speculate. 2) We know enough about back pain to say that your rehab protocol worked.

    We'll come back to the basic contradiction here, but let's first look at the claims in detail.

    First, what do we know about back pain?



    This seems to stick closely to your referenced studies. For example, see especially the conclusion to Jensen et al.:



    And the other two cited studies seem to back this up, especially Savage et al., who is appropriately savage on MRI diagnoses. I don't know if MRI has become a better diagnostic in the last two decades since these articles appeared, but I'm willing to bet not. Let's go on:



    Wait just a moment. This does not follow. I feel that you have misunderstood something. What your cited studies say is that the herniation may be unrelated to current pain (or it may not). The studies suggest that there is no way to tell. Your speculation on where the herniation came from is unwarranted. A correct statement, following your studies and not derailing the thrust of your article, would be to replace this with something like the following: "the herniation may or may not have had anything to do with the pain, and it is impossible to tell whether it is new or old without a previous MRI." (Also, this is only a nitpick, but you have slightly misunderstood the meaning of "degeneration" in this context. It's state descriptive, and not meant by the authors to describe a cause or to preclude trauma or injury.)
    I essentially agree with all your points. We may have been unclear in our wording in some passages. It is hard sometimes to step back from your own prose and read it with fresh eyes. It is clear from the literature that the correlation between pain and findings on imaging is tenuous, and we tried to stress that point. We did not mean to speculate too deeply on the origin of the pain beyond the fact that Scott reported a history of various injuries over his lifting career, including back injuries. This made it seem likely that we were looking at a flare up of a previous injury, but really there is no way to know. It is certainly possible that his training aggravated it or caused the injury altogether, although certainly not in an acute fashion. All we can be sure of is that the training Scott was performing leading up to his episode of pain was almost exactly the same as what what he did after, and he remains pain free to this day. Not trying to imply any causal links here, just an observation.

    In fact, back tweaks in training always take time to lay you out. People don't go from squat to wheelchair in 5 seconds. There is a process of response and inflammation, etc., after an injury, that takes time. Two days is not at all strange or uncommon. As trainers, you should have your eyes wide open to this. I wrote about the particular warning signs for this lifter in my first post, so I won't retread.
    While we have a remarkably low rate of injury at our gym, we do see enough of them to understand the development and progression.

    Now for point number 2. Although you call Starting Strength "rehabilitation" in the article, he had already recovered from wheelchair and hospitalization to "pronounced limp" before showing up in the gym again. I am happy for Scott that he got back into the gym as soon as possible. But whatever caused this problem problem in the first place, it seems to have resolved idiopathically before Scott started lifting again.
    It is an indisputable fact that many, if not most, episodes of back pain get better on their own. Scott certainly was feeling better when he started back to lifting than on the day he went to the hospital, although some of that was due to the opioid pain killers he was taking. He was not on a wheelchair, but he walked with great difficulty, could hardly sit and stand and was generally in serious pain. Hardly what I would call full recovery. Perhaps "rehabilitation" is not the right choice of words. I am not attached to it and I am happy to use a different description if necessary. The dictionary definition says something about "returning to good working condition". For a lifter, good working condition means being able to lift and train, so maybe getting Scott back to the point that he could do that is "rehabilitation".

    Regardless of terminology, the article was aimed at people in the Starting Strength community, most of whom are interested in lifting heavy things. We get tons of inquiries from people who have back pain and want to know whether their lifting years are behind them. The emphasis of the article was on showing that even in a pretty acute case of severe back pain, we were able to bring Scott back to full (lifting) function by following the approach described.

    To sum up, medical science knows very little about the human back and why it hurts. (Other than that bipedalism was probably a bad idea for our species.) In Scott's case, while there are many possible origins for his back pain, it's not sane for his trainers to ignore his new program as a possible, or even likely, culprit. Similarly, back pain goes away for many reasons that we don't understand. While we can't say for sure why Scott's pain went away, it's an incredibly positive story to hear that he could get back into lifting so soon, and is making new PRs without feeling new pain. Lower back pain can often become a long-term issue, and it says something very good about Starting Strength that it didn't turn out that way in Scott's case.

    Also, sudden onset back pain + MRI is a terrible reason to recommend back surgery. It's a crime that doctors don't police their profession far better than they do.
    You are absolutely correct. We know very little about the how and why of back pain. However, we have pretty good (anecdotal) evidence from multiple sources that strength training with barbells can be practiced by individuals with back pain under coach supervision, and the results are positive. Back pain resolves and the individual gets stronger. It is possible that the back pain would have gone away on its own anyway, but in most cases the subject would have been discouraged from barbell training in the meantime, or perhaps forever. Given that we know of the benefits of getting stronger with barbells, a point of the article was to highlight that resolution of back pain could happen simultaneously with barbell training. Whether the relationship is causal or incidental is impossible to tell without a controlled study.

    Thanks again for your thoughtful reading of our article.

  10. #10
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    Thank you for the detailed and informative response. Please keep up the good work!

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