There\u2019s not many days that go by where I don\u2019t see someone with back pain, and in more cases, than I\u2019d like \u2013 the opening conversation tends to go like this;<\/p>\n\n\n\n
Me<\/strong>: \u201cSo what brings you in today and how can I help you?\u201d<\/em><\/p>\n\n\n\n Client:<\/strong> \u201cMy doctor\/chiro\/shamanic healer said I\u2019ve got a disc out, a trapped nerve and my MRI proves it. It hurts and I need you to put it back in.\u201d<\/em><\/p>\n\n\n\n Me:<\/strong><\/p>\n\n\n\n The intervertebral disc has become the scapegoat for a lot of back pain and disability. When the word \u2018disc\u2019 is used, it tends to create a cascade of fear, anxiety and worry for the future.<\/p>\n\n\n\n Do I need surgery? Am I going to have problems later in life? Can I still lift and get jacked? Will Dr. Dre ever release Detox<\/em>?<\/p>\n\n\n\n I don\u2019t know if we\u2019ll ever hear Detox, but the answer to the other stuff is more promising.<\/p>\n\n\n\n I had a great follow-up question from my webinar on Flexion & Extension based back pain as part of The Complete Trainer\u2019s Toolbox<\/a><\/strong>, and it gives us a great opportunity to discuss this and think critically about this topic:<\/p>\n\n\n\n \u201cDo you consider exercises with reasonably high compressive and shear load to be risky for someone with disc herniations?\u201d<\/em><\/p><\/blockquote>\n\n\n\n Short Answer<\/strong>: No.<\/p>\n\n\n\n Long(er) Answer:<\/strong> It depends. We know that only Sith\u2019s deal in absolutes \u2013 particularly on Tony\u2019s site, because six other articles have made this gag. Lucky number seven for me.<\/p>\n\n\n\n Let\u2019s break this question down into two smaller questions:<\/p>\n\n\n\n 1) Are disc herniations always bad or problematic?<\/em><\/p>\n\n\n\n 2) Will exercising under high levels of shear or compression increase the risk of pain, injury or further problems?<\/em><\/p>\n\n\n\n No.<\/p>\n\n\n\n Many of us jump to the conclusion that when told we have a bulging or herniated disc, we\u2019re doomed.<\/p>\n\n\n\n It\u2019s normal to worry \u2013 our back hurts and we\u2019re told there might be a problem with it that could threaten what we enjoy doing and how we earn money.<\/p>\n\n\n\n This is actually what happens when someone flippantly tells their client they have a disc problem.<\/em><\/p>\n\n\n\n Whilst disc herniations can<\/em><\/strong> contribute to back pain, it doesn\u2019t mean they absolutely will<\/em><\/strong> contribute to back pain.<\/p>\n\n\n\n One of the best things here is to look at research investigating the low back in pain-free populations. This study from 2015<\/a><\/strong> pooled over three thousand<\/u><\/strong> pain-free people, and at least 30% of people had either a disc bulge or protrusion with no pain<\/strong>.<\/p>\n\n\n\n Nada.<\/strong><\/p>\n\n\n\n Zilch.<\/strong><\/p>\n\n\n\n The other biggie here is a steady increase in pain-free findings as we age.<\/p>\n\n\n\n The older we get \u2013 the more likely it is to find \u2018stuff\u2019 on MRI, that doesn\u2019t have to be a straight up cause of a client\u2019s back pain.<\/p>\n\n\n\n So again, no, disc herniations <\/strong>are not a death sentence for your quest for jacktitude.<\/p>\n\n\n\n Pathology can still contribute to pain.<\/p>\n\n\n\n This research is great, but sometimes the pendulum swings a little too far, and these findings can be dismissed without proper assessment. Want to piss off your client who believes their back is due to a disc problem? Tell them outright it\u2019s not a problem with no real justification other than \u2018the research says MRI findings don\u2019t matter\u2019.<\/p>\n\n\n\n Rapport = gone.<\/p>\n\n\n\n But how do we know when to take notice of an MRI report or not?<\/p>\n\n\n\n Consider the concept of an active wound<\/strong> or healed scar<\/strong> to weigh up how relevant pathology is to pain. I picked these terms up from Dr. Stuart McGill, who knows a thing or two about spines.<\/p>\n\n\n\n He also knows a thing or two about awesome mustaches.<\/em><\/p>\n\n\n\n An active wound<\/strong> is where symptoms, assessment findings, and imaging reports all match up enough to connect the dots.<\/p>\n\n\n\n A healed scar<\/strong> is the presence of pathology on imaging, but without<\/strong> clear correlation to assessment findings. The dots are there, but not clearly connected at this point time.<\/p>\n\n\n\n Remember that an MRI is a single snapshot in time of your client laying on their back, doing nothing. It might look \u2018bad\u2019, but they might also be in no pain and crushing their training without fear or worrying about it.<\/p>\n\n\n\n How do you figure out whether you\u2019re dealing with a wound or a scar?<\/p>\n\n\n\n Work with a healthcare professional who knows how to lift and help come to a clear understanding of your client\u2019s back pain. Trainers are one million percent qualified to work with clients with back pain and disc herniations, when<\/strong> they have been screened and assessed properly.<\/p>\n\n\n\n Short Answer:<\/strong> No.<\/em><\/p>\n\n\n\n Longer Answer:<\/strong> You need to \u2018dose\u2019 things appropriately.<\/p>\n\n\n\n As a quick refresher, spinal compression is the force that approximates each vertebrae. Spinal shear is the force that tries to pull one vertebrae forwards or backwards on another (at least in the sagittal plane).<\/p>\n\n\n\n Compression (image via Stronger by Science)<\/em><\/p>\n\n\n\n Shear (image via Stronger by Science)<\/em><\/p>\n\n\n\n The spine is designed to bear load, and the interactions of motions, loads and postures will load the spine in different ways.<\/p>\n\n\n\n What counts as \u2018high\u2019 levels of shear and compression?<\/p>\n\n\n\n If you\u2019re a Sith dealing in absolutes:<\/strong><\/p>\n\n\n\n If you\u2019re a Jedi and want to consider context:<\/strong><\/p>\n\n\n\n This is where the science & art of training and rehab meet.<\/p>\n\n\n\n Science tells us that a conventional deadlift and back squat can probably allow us to lift the most load, but knowing your client would benefit more<\/em> from front squats and trap bar deadlifts whilst their back hurts or if they are learning the ropes of lifting, is the art.<\/p>\n\n\n\n Don\u2019t be this guy.<\/em><\/p>\n\n\n\n So what happens if we apply the appropriate \u2018high\u2019 level of stress with a disc herniation?<\/p>\n\n\n\n Just like everything else \u2013 discs will adapt<\/strong><\/p>\n\n\n\n The body is a wonderfully adaptive organism that will react to the stresses placed upon it. If you get the dose<\/em><\/strong> of \u2018high\u2019 in the right ball-park, you will create positive adaptation. We\u2019ve known about this the 80\u2019s, where this study found<\/a><\/strong> the intervertebral disc positively adapts compressive load, yet it\u2019s often viewed as a fragile structure that, when injured, spells game over.<\/p>\n\n\n\n Seems not.<\/p>\n\n\n\n This can be incredibly empowering for the clients suffering from back pain, whether it\u2019s a diagnosed disc pathology or otherwise, that things can get better. This case study<\/a><\/strong> showed a huge improvement in a patient with an L4\/5 herniation in just 5 months:<\/p>\n\n\n\n Credit \u2013 New England Journal of Medicine<\/em><\/p>\n\n\n\n Not sure if this applies to lifters?<\/p>\n\n\n\n Check out Brian Carroll\u2019s MRI before and after working with Stuart McGill.<\/p>\n\n\n\n He started being disabled by pain with a broken sacrum and pretty banged up lumbar spine, but returned to the Powerlifting platform to set new world records at a lower bodyweight.<\/p>\n\n\n\n Credit \u2013 Brian Carroll<\/em><\/p>\n\n\n\n For me \u2013 this is where we need<\/em><\/strong> load within a low back rehab program.<\/p>\n\n\n\n If back pain stops us from exercising, we will lose some level of fitness and adaptation as a result, which means we need to find a way back to exercising, based on what we can currently manage. I think this is why a lot of rehab programs don\u2019t do well \u2013 it\u2019s either too much load too soon which lead to flare ups and setbacks, or not enough load over time which means symptoms linger for longer than necessary.<\/p>\n\n\n\n So if we can say with confidence that disc herniations are not permanent, can get better and<\/strong> need load to return to our meaningful activities, how do we decide how to push it, when to push it, and how far?<\/p>\n\n\n\n Let\u2019s answer these too.<\/p>\n\n\n\n If you\u2019re working with someone with back pain (or any pain really), your assessment should tell you this by answering this question;<\/p>\n\n\n\n \u201cHow much load can this client currently tolerate right now, and how can I best safely apply this?\u201d<\/em><\/p><\/blockquote>\n\n\n\n Don\u2019t be afraid to use load in your assessments.<\/p>\n\n\n\n In fact, USE LOAD IN YOUR ASSESSMENTS.<\/em><\/strong><\/p>\n\n\n\n A table and movement assessment is the starting point to see what the foundation is like, but how does what you see \u2018at rest\u2019 compare to when you\u2019re at working weights?<\/p>\n\n\n\n Your client might have a perfect air squat, but if it resembles a melting handle at their working weight, you probably want to find that point where it looks good enough<\/em>. Not perfect, not scratch-my-eyes-out terrible, just good enough<\/em>.<\/p>\n\n\n\n Your 3\/3 on the Overhead Squat won\u2019t save you if you look like this under load.<\/em><\/p>\n\n\n\n If you start running into pain or problems under load, be comfortable enough to tweak the load, change the exercise variation, or coach it further. It\u2019s OK if your assessment starts to resemble a training session, because it will give you way more information for your initial program with that client than relying on unloaded tests alone.<\/p>\n\n\n\n This is where you need the nuts and bolts of exercise progressions\/regressions, coaching cues, and loading\/tempo schemes to find the sweet spot for your client at that moment in time<\/em>.<\/p>\n\n\n\n Adaptation takes time, but it shouldn\u2019t take forever. Your assessment gives you your starting point and how you feel during and after your lifting should guide how you progress. You don\u2019t have to be pain-free, but you shouldn\u2019t be pushing yourself through agony either. Here\u2019s how I tend to work;<\/p>\n\n\n\n Previous injury, pain, surgery or a lot of concern from your client will influence how quickly you choose to reapply the \u2018stress\u2019.<\/p>\n\n\n\n It\u2019s ok to give it a little longer if needed, so know you can be flexible.<\/p>\n\n\n\n If things do go beyond what\u2019s deemed acceptable, it doesn\u2019t put us back to square one, but it might just require a little course-correction from time to time. No return from pain or injury ever moves in a nice linear, expected direction.<\/p>\n\n\n\n Credit \u2013 Sports Physio<\/em><\/p>\n\n\n\n As long as the loads, intensity and your client\u2019s confidence and pain are steadily improving over time, you\u2019re on the right track. Where \u2018how\u2019 is the science, \u2018when\u2019 is the art \u2013 know when to hit the gas, and when to pump the brakes, because it\u2019s rarely a straightforward process.<\/p>\n\n\n\n What\u2019s your client\u2019s endgame?<\/p>\n\n\n\n The greater the demand of what your client is asking their body to deal with, the more time you\u2019ll probably need. The new parent with a month or two of back pain wanting to pick up their kids without hurting and get 2-3 workouts in a week, will have a vastly different course to the powerlifter who\u2019s been beaten up for years and wants to be out of pain and setting new world records.<\/p>\n\n\n\n Not everyone needs to hit soul-crushing, nose-bleeding levels of intensity, but if a client wants to work on their true maximum strength, you better be ready to take them back to working to 90% and above.<\/p>\n\n\n\n The goal of any rehab plan should be to build both physical and mental<\/em><\/strong> robustness that allows us to remain resilient to the stresses we<\/strong> want to place on ourselves<\/strong>, and still have enough in the tank to deal with the stresses we have to put on ourselves. <\/strong>As much as we want ourselves and our clients to crush their training sessions, it shouldn\u2019t come at the expense of living the rest of their life the way they want to.<\/p>\n\n\n\n The biggest challenge when someone is in the depths of an episode of back pain that may or may not have involved the \u2018D\u2019 word, is that they have the opportunity to get better and it\u2019s not game over.<\/p>\n\n\n\n If we can get past this barrier, it becomes a matter of \u2018when\u2019 will they get better, not \u2018if\u2019. The intricacies of getting can be incredibly individual, but with the right approach, there\u2019s no reason why you and your clients can\u2019t get back to crushing it.<\/p>\n\n\n\n If you want to take a deeper dive on this \u2013 check out the Complete Trainer\u2019s Toolbox<\/strong><\/a>, where I spend nearly three hours talking through what influences spinal loading during exercise, and how to plan a way back to beast-mode if back pain is a problem.<\/p>\n\n\n\n Ps \u2013 disc\u2019s don\u2019t \u2018slip\u2019 (courtesy of The Honest Physio).<\/em><\/p>\n\n\n\n![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/bergundy.png\")
<\/figure><\/div>\n\n\n\n![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/Detox.png\")
<\/figure><\/div>\n\n\n\nAre Disc Herniations Always Bad or Problematic?<\/h3>\n\n\n\n
![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/damon.png\")
<\/figure><\/div>\n\n\n\n![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/review.png\")
<\/figure><\/div>\n\n\n\nBut<\/h4>\n\n\n\n
![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/An-Interview-with-Dr-Stuart-McGill-Part-1.jpg\")
<\/figure><\/div>\n\n\n\nWill Exercising Under High Levels of Shear or Compression Increase the Risk of Pain, Injury or Further Problems?<\/h3>\n\n\n\n
![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/compression.png\")
<\/figure><\/div>\n\n\n\n![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/shear.png\")
<\/figure><\/div>\n\n\n\n![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/graph.png\")
<\/figure><\/div>\n\n\n\n![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/guy.png\")
<\/figure><\/div>\n\n\n\n![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/disc.png\")
<\/figure><\/div>\n\n\n\n![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/carroll.png\")
<\/figure><\/div>\n\n\n\nHow Do We Push It?<\/h3>\n\n\n\n
![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/bad-squatr.png\")
<\/figure><\/div>\n\n\n\nWhen Do We Push It?<\/h3>\n\n\n\n
![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/rehab.png\")
<\/figure><\/div>\n\n\n\nHow Far Do We Need to Push It?<\/h3>\n\n\n\n
Remember \u2013 Disc Diagnoses Aren\u2019t Death Sentences<\/h3>\n\n\n\n
![\"\"](\"https:\/\/tonygentilcore.com\/wp-content\/uploads\/2019\/04\/discs-dont-slip.png\")
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