Back pain

Lift and Twist; Moving beyond back pain

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Lift and Twist; Moving Beyond Back Pain

Back pain is widely accepted to affect up to 80% of Australians, which makes it almost as common as death and taxes (terrible language! More on the power of language in the next newsletter….). Following a back injury, people often experience flare up episodes in the form of muscle spasms, change of feeling, or heat and swelling. Everyone is unique and manages these episodes in different ways, but typical coping strategies may include medication, heat and ice packs, gentle stretching and light movement. I believe people are too willing to accept flare-ups as a normal part of life following a back injury. Within one year of an episode of back pain, 54-90% of people will likely experience a remission episode (Hoy et al, 2010). What if it was possible to move beyond the cycle of back pain, flare ups, management, repeat? There is a wealth of research demonstrating the long term benefits of a progressive structured strengthening program, focusing on postural strength, quality of movement, postural awareness, and core stability. In this newsletter we will have a look at the 2013 article by VanGelder et al; A phased rehabilitation protocol for athletes with lumbar intervertebral disc herniation. This is not intended as a generic template for exercise prescription, but to demonstrate the high level exercises people with disc herniation are not only capable of, but benefit from when working towards full recovery.

Phase 1: Protective Phase (Acute Inflammatory Phase)

Goals: Focus on how to achieve and maintain a neutral spine in a wide variety of challenging positions. This incorporates abdominal bracing, gluteal activation, and latissimus dorsi activation to promote recruitment of voluntary and involuntary spinal stabilisers.
Physiology: Eliminate mechanical stresses imparted upon the disc by focusing on correct positioning in static and moving postures.
Precautions: Aggressive repeated movements performed during the inflammatory phase may delay healing.
Panjabi Model: Training the active and neural control subsystems through hip extensor and stabilisation exercises in the sagittal plane.
phase 1

Phase 2: Counter Rotation / Flexion Phase (Repair Phase)

Goals: Rotation and counter rotation exercises can aid in the production of collagen and glycosaminoglycan, both of which play a big role in the tissue healing response. Also, controlled rotation is believed to play a role in the reduction of excessive scar tissue formation.
Physiology: Controlled movements that positively affect the healing tissues to stimulate fibroblast repair of the collagen matrix.
Precautions: Isometric resistance to lateral flexion is used to challenge the disc (oblique orientation) instead of full rotation.
Spinal Stability: Multi-directional movements are introduced to coordinate communication between the active and neural control subsystems.
phase 2

Phase 3: Rotational Phase / Power Development (Remodelling Phase)

Goals: Full integration of transverse plane movement (lift and twist!).
  • Progressing exercises to full range with suitable loads will aid in the alignment, organisation, and cross-linking of collagen fibers.
  • Rotation may also assist with nutrient delivery to the nucleus and annulus.
  • Again, controlled rotation may aid in reducing excessive scar tissue, which may prevent annular cell death and allow cell reorientation of the annulus to occur.
Precautions: The introduction of dynamic rotation may result in exacerbation of symptoms, therefore slow and careful progression is required.
Spinal Stability: Finally, all three aspects of the Panjabi model (neural feedback, ligamentous stability, & muscular control) are fully integrated to work together to provide feedback and create spinal stabilisation.
phase 3

Phase 4: Full Return to Life

Goals: Activity specific exercises to ensure that the individual is best prepared for life and all of the challenges that are placed on the spine. This is essentially an extension of phase 3 with modifications of exercises to best represent daily demands and tasks.


As you can see, thorough rehabilitation of lumbar disc injury requires a progressive personalised approach. Unfortunately many individuals cease their recovery beyond early rehabilitation treatment, resulting in the exceedingly high rates of remission. By encouraging patients to pursue full rehabilitation they will not only improve their self-management skills, but will be stronger, more resilient, have increased body awareness and increased confidence in their ability to move well. Lots more information on exercise and back pain can be found here.

Hoy et al, (2010). The epidemiology of back pain.
VanGelder et al, (2013). A phased rehabilitation protocol for athletes with lumbar intervertebral disc herniation. 

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