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Back Rehab Protocol

Essential Back Rehab Strategies -Part 1

Jim Smith, CSCS, RKC
Out of the 50-75 emails I receive everyday, I would estimate that 85%+ are injury related. That is why I wasn’t surprised with the overwhelming positive response when I asked the Diesel community if they were interested in some progressive back rehab strategies.

In this series we will define the most important focus areas when working your way back from a back injury. We will further categorize these means for ease of reference and implementation.

As with any progressive strategy, we will start by re-establishing a baseline of stability and strength before advancing forward. My goal is to keep it very simple and provide video demonstrations to drill technique and use as a reference.

Before we lay out our strategies, we must state our most important point.

Step 1: Consult Your Doctor | Get Out of Pain

The first thing you have to do before you start any rehab program is to get the “OK” from your primary care physician (PCP). They probably referred you to an orthopedic specialist or physical therapist. You must get a diagnosis to understand what the injury is. The treatment for a muscle strain is different than the treatment for a bulged disc. You can’t begin to recover if you are in pain and if you don’t know the extent of the injury. After they diagnose your issue, you will begin their prescribed program for recovery.

Some common treatments hey might prescribe immediately following a back injury could include; rest, cold therapy, pain medications, chiropractor, TENS or physical therapy. After you have followed their plan and got clearance, then you can begin again in the weightroom.

In this series, we will focus on how to get stronger from a base strength level of “0″ and AFTER your prescribed treatment from your doctor has been successfully completed. We will categorize the exercises at each level with the goal of being able to build many different back rehab / strengthening programs at the completion of the series.

DISCLAIMER: You must get your physician’s approval before beginning this exercise program. These recommendations are not medical guidelines but are for educational purposes only. You must consult your physician prior to starting this program or if you have any medical condition or injury that contraindicates physical activity.

Essential Back Rehab Strategies

Category A

Essentially, the muscle (groups) that stabilize the torso and protect our spine encompass all of the musculature from the armpits to the knees. In Phase 1 of our back rehab strategies we will be trying to re-establish our ability to brace our torso effectively. This will be a difficult task because after a back injury you will be in pain. And when your body senses pain, it shuts down and inhibits muscle contraction. You will find it very hard to tense the muscles close to and surrounding the injury. This means we are even more susceptible to injury in an injured state. Makes sense, right?

After the doctor clears you to engage in physical activity again, you need to start at the very basic level of recovery. For our back rehab protocol, this means we need to understand what neutral posture is and how to brace effectively in this position. Once we do this, we can begin to activate and strengthen again. Not only strengthen, but build muscular endurance. That is how we are going to lay the foundation and get back to normal movement; which ultimately means getting back into the gym.

As you will see with our simple strategy, the application will be progressive.

Progressive Strategy

1. Find and Understand Neutral Posture

2. Feel Bracing and Understand Tension

3. Build Static Strength Endurance While Utilizing Neutral Posture and Bracing

Neutral Posture

Neutral posture affects everything we do in an out of the gym. When trying to develop our ability to load correctly for strength training movements, absorb impact or transfer forces, a neutral posture is essential. It means the alignment of the “back of our head, the upper back/t-spine and the sacrum/buttocks.” (1) If you can consciously=>sub-consciously (from drilling and patterned reinforcement) move into this position when lifting weights or anything you do during the day, you will be at your strongest and you will be less likely to get injured.

I teach a neutral posture a few different ways. One of which is in the quadruped (all fours) position. This allows the lifter/athlete to adjust their positioning until they “feel” where neutral is. I cue them until they reach the posture and have them stay there for a timed period.

Another way I cue a neutral posture is taking advantage of how our body moves. Movement (and tension) is coordinated diagonally across the posterior chain from the hip to the opposite shoulder (called the serape effect). If we can understand this position and pull the lifter into a compensation (with the elastic band), when they resist movement they will reinforce a neutral posture. Heavier bands can be used as proficiency grows. The lifter should attempt to stay in this posture for approximately 60-90 seconds or throughout a workout.

Side Note: Notice the athlete is contracting his quads, glutes, lats and squeezing his fist, i.e. bracing.

Many times when we coach neutral, the lifter / athlete finds it a very difficult posture to achieve due to tightness or inflexibility. The majority of the time, tight hip flexors (from too much sitting) and a tight upper (thoracic) back (from too much time at the computer or sitting with bad posture), are the issue. Working on hip mobility and opening up the upper back, will be very important. You should make it a priority in every workout to address these restrictions.

Bracing

Not that we’ve obtained a neutral posture, we need to start creating tension. After a back injury, tension without movement (or static/isometric strength) is the first priority. Pain inhibits muscle contraction and once the pain is gone, we need to get everything firing again (motor unit recruitment). Think about the atrophy that occurs when your arm is in a cast for an extended length of time. It becomes much weaker and smaller. This “use it or lose it” analogy is the same after an injury. The worse thing you can do is to remain sedentary for and extended length of time.

For more advanced applications like strength training, bracing plays a significant role in how much strength we can display, how much impact we can absorb, how much power we can transfer and how susceptible we are to injury. Remember our body acts as a single kinetic chain and we must coordinate the muscular contractions across many muscle groups (intermuscular coordination) when we engage in strength training or real-world movements.

When athletes are just starting in the program and begin utilizing compound movements, I use a simple elastic band to teach them bracing. I have them wear the band while performing squats, clean & press, deadlifts (and others). The goal is to not let tension off the band, but to keep it tight throughout the duration of the exercise.

Many fitness professionals coach “bracing” as if you were protecting yourself from a punch. This couldn’t be further from the truth. Remember, the “core” involves everything from the armpits to the knees, and we must brace each kinetic segment across this distance. Radiant tension (or co-contraction) (2) involves the summation of the tension of multiple muscle groups to coordinate movement, resist or prevent movement and / or create more strength / power.

Static Strength Endurance

Remember, for Phase I of our back rehab program, we will start at the beginning. Starting over means we forgot everything we know and work on the basics. The first base we covered was “finding neutral”. The second base was once we found neutral, we created tension. Understanding what it means to create real tension across the torso and into the trunk will carry over into everything we do. It forms the base of the pyramid and without it, we can’t progress.

Once we are able to create tension again, we must develop it over a period of time. This will provide us with static strength endurance.

Exercise selection, much like our rehab strategy, must be progressive. The following exercises will be introduced (and continue to be used later on) to build our static (without movement) strength endurance proficiency for our (anterior/posterior) torso stabilizers.

Level 1: Bridges

Level 2: Supermans

Level 3: Birddogs

Level 4: Planks

Exercise Index

Bridges

Supermans

Birddogs

Planks

Summary Back Rehab Protocol – Category A

Task 1. Drill a neutral posture

Task 2. In a neutral posture, brace and create tension

Task 3. Build static strength endurance of our torso stabilizers while utilizing a neutral posture and becoming proficient at bracing

Task 4. In the initial stages of a back rehab protocol, bridges, planks, supermans and birddogs can be used to accomplish Task #3

As we move into Category B, movement will be introduced and our strength levels will start to increase. The first step is to start slowly incorporating these Category A movements into your daily recovery. Here is the back rehab protocol as we know it so far.

Phase 1: Neutral | Bracing | Static Strength Endurance

Exercises: Pick 2-3 exercises; bridges, supermans, birddogs, planks, elastic band bracing

Volume: 3-5 sets of 30-60 seconds holds (at each posture)

Duration: 2 Weeks (or until you feel comfortable and strong)

References

1. Robertson, Mike. Coaching Neutral Spine, robertsontrainingsystems.com, 2011.

2. Verkhoshansky, Yuri and Siff, Mel. Supertraining - 6th ed., Ultimate Athlete Concepts, 2009.


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Essential Back Rehab Strategies

Category B

Strengthen Hip Specific Movement Patterns and Glute Activation

As a refresher, in Phase I of our Back Rehab Protocol, we established:

- What neutral is and why it is important to try and achieve this posture. Also, what some of the common issues are and why many people can’t achieve this ideal alignment, i.e. immobile hips and upper back (Special Note: We will address these limitations further in Phase 3)

- Why bracing is important and how and why it can be optimized.

- Why building static strength endurance is important to get muscles working again after an injury

Essential Back Rehab Strategies

In Phase 2 of the protocol, we will now introduce movement. Not only introduce movement, but strengthen in these movement patterns.

The strength training movement pattern we will focus on is hip extension. We will perform hip extension while trying to maintain a neutral posture from our hips to the top of our head and from our hips to our feet. We will also finish each repetition in a neutral posture. Category B will do two things; activate and strengthen the glutes, hamstrings and adductor magnus and reinforce bracing of the torso.

There are 3 different loadings and base of supports we will cover.

Exercise Category 1: Strengthening hip extension – supine on floor (feet and shoulders provide base of support)

Exercise Category 2: Strengthening hip extension – torso loaded (specific)

Exercise Category 3: Strengthening hip extension – trunk loaded (specific)

It is important that once we are able to move pain-free through a full range of motion, we start incorporating exercises that will strengthen and mobilize our movements. Moving straight toward mobilization (and going overboard with hyper-mobility) will be setting you up for trouble. Introducing passively (mobility) or forcibly (flexibility) new ranges of motion without subsequent stability (control) will leave you prone to injury. So as we create and engage in new movement patterns, will will build strength in these movements.

Exercise Index

Category 1: Hip Thrusts, Glute Bridges

Hip Thrust VIDEO

Glute Bridge VIDEO

Category 2: Band Resisted RDL’s, Dumbbell RDL’s, Banded Good Mornings, Back Raises

Band Resisted RDL VIDEO

Back Raises VIDEO

Category 3: Hip Extensions, Hip Extensions on Swiss Ball

Hip Extensions | Hip Extensions on Swiss Ball VIDEO

Note: I like this variation because of the lat engagement and the slight agitation during the movement.

Phase 2: Strengthen Hip Specific Movement Patterns | Glute Activation

Category A Exercises: Pick 2-3 exercises; bridges, supermans, birddogs, planks, elastic band bracing

Category B Exercises: Pick 3-4 exercises; hip extension variation, RDL variation, back raise variation, hip thrust variation, glute bridge variation

Volume: 3-5 sets of 10-15 reps, 60-90 sec REST between sets

Duration: 2-3 Weeks (or until you feel comfortable and strong)


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Essential Back Rehab Strategies

Category C

Hip and Upper Back Mobility | Strength Mobility

Now that we have re-established stability in Part 1 and started strengthening the erectors, hips and hamstrings in Part 2, we will begin to improve our hip mobility and upper back mobility.

It is important for us to focus on hip mobility because immobile hips cause huge issues in the kinetic segments above AND below, i.e. stress on the knees and lower lumbar. Hip mobility means our ability to move our legs into extension, flexion, internal / external rotation, ADDuction and ABDuction; without restriction for a required activity. Many times we can’t do this because we sit too much, we drive too much and after our workouts, we don’t include mobility work to negate the restrictions that are associated with recovery from strength training.

Upper back mobility is also very important. Working our our thoracic mobility will improve our posture, ensure our shoulder health and will develop efficiency (without restriction) of movement by optimizing the structure of the diagonal fascial line running from each shoulder to the opposite hip. This coordinated muscle action determines our ability to move and has a huge impact on how we transfer forces.

The final important piece of the puzzle requires us to strengthen these new movement patterns. It is one thing to be mobile, but we must control and stabilize throughout the movement pattern.

Category C Strategies

For this fourth installment, we will focus on movements we can do in the gym before, during and after training to positively affect the mobility of our hips and upper back. Then we will build strength mobility in these new ranges of motion.

Hip Mobility

Exercises: Side to Side Hip Stretch, Lying Knee-to-Knee Stretch, Rear-Elevated Hip Flexor Stretch, Braced External Hip Rotation Stretch, Abducted Internal Hip Rotation Stretch

Upper Back Mobility

Exercises: Lat Stretch, Band Shoulder Stretches, Thoracic Extension on Foam Roller, Shoulder Flexion | Extension on Foam Roller, Shoulder Flexion | Pec Stretch on Foam Roller, Quadruped Extension | Rotation, Deep Tissue Lacrosse Ball with Shoulder Flexion | Extension

Upper Back Strength Mobility

Exercises: Maxwell Spinal Wave, Band Resisted Back Extensions

Phase 3: Hip and Upper Back Mobility | Strength Mobility

Category A Exercises: Pick 2-3 exercises; bridges, supermans, birddogs, planks, elastic band bracing

Category B Exercises: Pick 3-4 exercises; hip extension variation, RDL variation, back raise variation, hip thrust variation, glute bridge variation

Category C Exercises: Pick 2-3 exercises from each category; hip mobility, upper back mobility and pick 1 exercise from strength mobility

Volume: 2-3 sets of 10-15 reps or 60-90 seconds work for dynamic | static postures, 60-90 sec REST between sets

Duration: 2-3 Weeks (or until you feel comfortable and strong)

Sessions: 3-4 sessions / week


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Essential Back Rehab Strategies

Category D

Anti-Rotation Movements

After we established stability in Part , strengthened the erectors, hips and hamstrings in Part 2, and worked to improve our hip mobility and upper back mobility in Part 3, we will now improve our ability to resist rotation.

Resisting rotation, or anti-rotation movements (in transverse plane), is one of the basic core strength movement patterns. When anti-movements or statics are discussed, we are talking about no movement occurring. When developing strength, we typically do so in linear and fixed movement patterns. But the other essential component involves resisting these exact same movement patterns. This makes us more proficient at absorbing, accumulating and transferring forces, staying solid under load and remaining injury free.

The other core strengthening movement patterns include:

- statics (forces acting perpendicular to midline in sagittal plane, stabilizing in frontal plane)

- hip flexion

- hip extension

- lateral flexion

- rotation

- chaos movements

Category D Strategies

For this fifth installment, we show movements that focus on simple exercises you can do in any commercial gym. I show the Pallof Press with an elastic band, but they can also be done with a cable machine. I also show one arm farmer’s walk which is a anti-lateral flexion movement. I did this because it is a great, simple exercise that promotes static proficiency in a different pattern other than anti-rotation.

Anti-Rotation Movements

Exercises: Pallof Press, Pallof Press into Split Squat, Core Statics (TM) – Lateral Shuffles, One Dumbbell Bent Over Rows, Alternating Dumbbell Rows, 45 Deg Back Raise DB Rows, 45 Deg Back Raise Alternating DB Rows, One Arm Farmers Walk, Anti-Rotation Sled Dragging (for Power)

Anti-Rotation Movements

Anti-Rotation Sled Dragging

Phase 5: Anti-Rotation Movements

Category A Exercises: Pick 2 exercises; bridges, supermans, birddogs, planks, elastic band bracing

Category B Exercises: Pick 2 exercises; hip extension variation, RDL variation, back raise variation, hip thrust variation, glute bridge variation

Category C Exercises: Pick 2 exercises; hip mobility, upper back mobility and pick 1 exercise from strength mobility

Category D Exercises: Pick 2 exercises; anti-rotation, anti-lateral flexion

Volume: 2-3 sets of 10-15 reps or 60-90 seconds work for dynamic | static postures, 60-90 sec REST between sets

Sessions: 3-4 sessions / week

Duration: 2-3 Weeks (or until you feel comfortable and strong)

Essential Back Rehab Strategies

Category E

Compound Movements

By now, you are ready to integrate more compound movements back into your program. You have laid the strength and stability foundation you need to stabilize under load.

But progress slowly.

The goal isn’t to start throwing weight on the bar or using the biggest dumbbells. The goal is to move through a full range of motion and see how you feel. Bodyweight movements are a great way to begin this transition. Exercises like pull-ups, push-ups, lunges will be amazing choices to see how you react to strength training after an injury.

Auto-regulation will be the key to ‘listening’ to your body. You might find that you are having trouble with the compressive forces of typical barbell squats. Unilateral movements and / or goblet squats are excellent substitutions. Just be smart and don’t be misled by what others are doing. Do what is best for you.


Phase 6: Time to Workout AGAIN

Begin whatever workout program you would like. Focus on the warm-up and maintaining a neutral torso (spine) when under load. This will keep you healthy and safe. Incorporate any of the exercises in the back rehab protocol into your program as needed. They can be used in your warm-up or for your core training component.

How to Perform Goblet Squats

How to Perform Zercher Squats

How to Perform Rear Foot Elevated Split Squats (Goblet Rack)

How to Perform Romanian Deadlifts

How to Deadlift

How to Squat


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