This is an excerpt from Low Back Disorders 3rd Edition With Web Resource by Stuart McGill.
Neurophysiological mechanisms of pain are highly modulated by movement and exercise. Endorphin release has long been known to occur with exercise, but the molecular basis for these links is not well understood. However, many more exercise-induced analgesic pathways are coming to light. One example is that exercise increases neurotrophin-3 production, which appears to have an analgesic role in cutaneous and deep tissue pan (Sharma et al., 2010).
Psychological components are important for some patients and influence the approach used to introduce and program exercise. For example, some patients obsess over their pain and what is going on in their bodies. Patients with high fear avoidance do better with physical therapy, which de-emphasizes anatomical findings (George et al., 2003). For these types of patients, I suggest not using daily pain charts, but directing their focus to achieving good exercise form. Some patients have back pain because they overload themselves with daily regimens at the gym. For the type A personality, we ensure that exercise is not overexecuted (for people who believe that 25 repetitions of an exercise will do them more good than the 10 that were prescribed). For the type B personality who may bargain with the clinician about doing less exercise, performing the exercise dose as prescribed should be encouraged. These two personality types require different approaches to prescribing exercise.
Some people have pain as a result of tissues that are inappropriately weak for the applied demands. In such cases the goal of exercise is to strengthen tissue, which requires a certain kind of programming. Athletes I have worked with who have recovered well from compression fractures have incorporated sufficient rest intervals to allow the injury to adapt between loading sessions. This appears to not work with collagenous disc injuries given the time required (years) for migrated nucleus material to gristle and form a plug (Adams and Dolan, 2005). Thus, the type of tissue that is the target for strengthening should determine the exercise approach.
Imbalances in joint and muscle function create odd stress patterns and more pain. For example, hip and back pain can cause gluteal muscle inhibition (Freeman, Mascia, and McGill, 2013), which makes the hamstring muscles dominant in creating hip extension moment. Because of the lines of action of these muscles, this causes more load on the anterior acetabulum and labrum of the hip (Lewis, Sahrmann, and Moran, 2009), resulting in associated hip pain.
There is also substantial support for the notion of the existence of a psychological profile associated with fitness - that is, that fitter people ignore small discomforts. As discussed in the section Why and How You Should Read This Book, fitness reduces the tendency to catastrophize pain.
How is the most appropriate exercise determined to reduce each of these pain mechanisms? Although the assessment will reveal the pain mechanism, many challenging patients must be considered experiments in progress. Tweaking the exercise form and the dosage helps you to hone in on the optimal.
Five-Stage Back Training Program
We have developed a five-stage approach to back training that begins with identifying faulty movement patterns and ends with pain-free performance readiness. Consider this the big picture, because only athletes and people who perform demanding tasks will complete all five stages. However, it is important to understand the components and objectives of each stage, as well as their order. For example, patients may be unknowingly following a strengthening regimen (stage 4) without having addressed perturbed motion patterns (stage 1). Doing so will delay their recovery, or make them worse. So when approaching the program, you must first ask, Is the objective pain reduction and rehabilitation or athletic performance? Health objectives demand a focus on motion and motor patterns, stability, and endurance to achieve low tissue loads and a low-risk environment. Performance requires more overload, which naturally results in an elevated risk. The trick in the case of performance is to stay within the lowest risk possible.
Although all five major stages are listed here, only the first three are appropriate for rehabilitation and addressed in this book. Rigorous strength, speed, and power training are only for those interested in enhancing these attributes. The average person does not need them to have good back health. I address more advanced athletic training in detail in my book Ultimate Back Fitness and Performance (McGill, 2014). Begin with an assessment to understand the pain mechanisms. Then use the appropriate approach to address the mechanisms and build the person's tolerance and work capacity. Here is a summary of all five training stages:
- Stage 1: Establish quality movement engrams (motion patterns, motor patterns, and corrective exercise).
- Identify perturbed patterns and develop appropriate corrective exercise.
- Address basic movement patterns through to complex activity patterns.
- Address basic balance challenges through to complex and specific balance challenges.
- Stage 2: Build whole-body and joint stability (focus on spine stability here).
- Build stability while sparing the joints.
- Ensure sufficient stability commensurate with the demands of the task.
- Apply these patterns to the performance of daily activities.
- Stage 3: Increase endurance.
- Address basic endurance training to ensure the capacity needed for stabilization.
- Address activity-specific endurance (duration, intensity).
- Increase the ability to repeat pristine movement patterns without fatigue-induced compromise.
- Build the base for eventual performance training (only in those with this goal).
- Stage 4: Build strength.
- Spare the joints while maximizing the neuromuscular compartment challenge.
- Progress to skill movements.
- Stage 5: Develop speed, power, and agility.
- Develop ultimate performance based on the foundation laid in stages 1 through 4.
- Focus on optimizing elastic energy storage and recovery.
- Employ the techniques of superstiffness.
If you master the first three stages, which are discussed in this chapter, you will understand how to get bad backs to respond and how to develop better rehabilitation programs.
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