6 Step Guide to Prevent and Fix Extension Based Lower Back Pain (Part 2)

October 10, 2016
/ Injury Prevention Lower Back pain physical therapy rehabilitation return to sport

Welcome back. So in the first installment we broke down:

What extension based lower back pain is
Which movements have the potential to cause it
Compensations that lead to overextension and potential pain
Training errors that can potentially lead to pain

If you haven’t checked out part 1 of this article series then please do prior to reading this. You can find the link to part 1 HERE. It’s about to go down!

1) Get Out of Pain:

Now, with any pain situation one of the very first things to do from a rehabilitation perspective is to get out of pain. This is where a licensed healthcare practitioner will come in handy. I recommend seeing a therapist, physician or other qualified healthcare specialist prior to starting any rehabilitation protocol, including anything you read here. Everyone is an individual and a rehabilitation protocol should reflect that.

My general recommendations to help get out of pain (After seeing a qualified health care professional):

Stop all offending movements – This could be overhead pressing, kipping, etc…
Continue your regular exercise program for all movements that do not cause pain while you’re performing them, the night after performing the exercise and the following day – We want pain free movement if possible and some people don’t hurt until the following day. You’ll have to learn which movements are “OK” to perform and which ones aren’t. A movement that causes more pain the night of or the following day should be kept away from for the time being. Keep in mind this will change over time.
Modify your lifestyle to de-sensitive the area – For the time time being modify your lifestyle to stay out of pain. What I’ve found is that painful backs generally like low levels of movement and don’t like prolonged positions. For example, some painful backs don’t enjoy prolonged sitting. This can make it very difficult for people who have sedentary jobs to get out of pain. Keep in mind that all people are individuals and will require some trial and error to find out what their bodies like and don’t like. Bottom Line: Do more of what your lower back likes and less of what it doesn’t.
Give it time – Many injuries can take months of time to start improving. Patience is a virtue but please see a medical professional if your conditioning is not improving or it is worsening. Lower back pain generally gets better in time and isn’t a life sentence (1)

Keep in mind that pain is a defense mechanism designed to keep you safe from harm. It is also a very valuable teaching tool. Be sure to listen to your body and what it tells you. It will help guide you to success.

Some things that we can work on concurrently while getting out of pain that were discussed in the last article series are:

2) Fix Overhead Mobility Restrictions:

Part of getting out of pain and back to training are removing the root causes of your pain. As described in the prior article, overhead mobility restrictions can lead to lumbar overextension. We definitely want to get rid of this to prevent future problems and optimize performance. Here’s how I screen athletes and improve overhead mobility:

3) Fix Hip Extension Restrictions:

First we need to figure out if you have a hip extension limitation. Remember our hip extension assessment called the thomas test? If you forgot it, I’ve included it below:

If you’re missing hip extension we’ll have to work on it. Keep in mind not everyone with extension based low back pain has this issue going on. Here are a few of my favorite mobilizations below with a few exercises to strengthen and reinforce that new range of motion after mobilizing:

4) Fix Spine and Pelvic Control, Strength and Endurance:

After we’ve improved both hip and overhead mobility we’ll want to learn how to move appropriately and build strength and endurance in these positions. What we’re shooting for is the ability to move from the hips and shoulders while keeping a neutral spine. We’ll want to start with easy, unloaded movements and progress to movements that are loaded and more specific to what we want to get back to (eg: overhead press, kipping and olympic lifts). Here are a few drills I like to get started with this process:

Learning to extend from the hip fully while maintaining a neutral spine:

Core stability – Moving from the hips while maintaining a neutral spine

Learning How to Press Overhead with a Neutral Spine

5) Fix Technique and Slowly Re-introduce Offending Exercises

So we’ve gotten the pain to die down some with time, modification and exercise. We’ve ironed out our mobility restrictions, gotten stronger and we’re moving better and better. Generally this takes several weeks to months. Now it’s time to slowly introduce back in our offending exercises gradually and progressively and fix any technical problems we used to have.

Now we have to start introducing and loading the movements that bugged as previously slowly over time. If split jerks were previously the offending exercise, I wouldn’t start by introducing push jerks. Start with simpler movements and if you’re pain free when loading, progress to the next level, all of the while with correct form as you go. Here’s an example:

Start with a standing press
Progress to push press
Progress to power jerk
Progress to split jerks

An example for returning to olympic lifts

Start with RDLs
Progress to clean and snatch pulls
Progress to muscle cleans and snatches
Porgress to power variations of cleans and snatches
Porgress to full squat variations of cleans and snatches

Just keep in mind that rehabilitating from an injury is like riding a roller coaster. Some days feel good, some don’t. That’s just the name of the game. Try not to get frustrated. On days where you feel good, push a bit. On days where you don’t feel as good pull back some.

I like to think of pain as the boss of your body. If I come to work every day late, don’t finish my work and do a poor job then my boss is going to be on my ass big time. If I start showing up early, get my work done on time and make my patients happy then my boss leaves me alone. Do what you should and your boss lays off of you over time after you’ve built his/her trust. Pain is pretty similar. With pain, do what you should over time and slowly the pain will die down as well.

6) Manage Load and Volume with Smart Periodization

Remember the discussion on load from the last article. Too much weight can throw off your technique and potentially flair up your symptoms again. Make sure to keep your weights manageable moving forward. I often tell my athletes to use percentages based off on your 1 rep max with good technique. Sure you may be able to snatch 225lbs 1 out of 10 times and do it with god awful technique but 210 can be done cleanly, consistently and with good technique. Use that as your true max to determine lifting percentages moving forward

The other piece of the puzzle is a smart training program. Now this is a complex topic to delve into because everyone is an individual with different goals, injury history, tissue tolerance etc. 3 things that are universally important are:

Changes or spikes in training volume can increase injury risk – Take care when switching programs or adding increased volume. Increase volume and intensity slowly and progressively (2,3,4)
Don’t do too much – Your body can handle a finite amount of volume (quite a bit if slowly progressed over time) but keep in mind there is a ceiling and too much of anything can be too much. Think about taking 2 aspirin for a headache vs. the whole bottle. The full bottle will kill you but the 2 aspirin gets rid of the headache nicely. Think about what your effective dosage is to reach your goals without causing injury. (2,3,4)
Everyone is an individual. Perhaps I can handle more volume of olympic lifting throughout the course of the week and training cycle but historically you know that the same volume would bury you and cause your back to scream. Don’t try to follow someone else’s program. Once you learn what your spine tolerates and what it doesn’t then adapt the program to your body.

Well that’s it! Sorry for the length of the whole series but I really wanted to be thorough. This is a glimpse into how I treat individuals in pain on a regular basis and how I help them get back to what they love, training. If you know someone who could benefit from this series then please share.

That’s enough lower back talk for today,

Dan Pope DPT, OCS, CSCS, CF-L1

Works Cited:

McGill, S. (2007). Low Back Disorders. Champaigne, IL: Human Kinetics.
The Development and Application of an Injury Prediction Model for Noncontact, Soft-Tissue Injuries in Elite Collision Sport Athletes. (n.d.). Retrieved August 01, 2016, from https://www.researchgate.net/publication/46288877_The_Development_and_Application_of_an_Injury_Prediction_Model_for_Noncontact_Soft-Tissue_Injuries_in_Elite_Collision_Sport_Athletes
Relationship Between Training Load and Injury in Professional Rugby League https://www.researchgate.net/profile/Tim_Gabbett/publication/49775412_Relationship_between_training_load_and_injury_in_professional_rugby_league_players/links/551894590cf2d70ee27b41ad.pdf
Training and game loads and injury risk in elite Australian footballers. (n.d.). Retrieved from https://www.researchgate.net/profile/Brent_Rogalski/publication/234699103_Training_and_game_loads_and_injury_risk_in_elite_Australian_footballers/links/53dadd6b0cf2a19eee8b3f9f.pdf