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A Guide to Training with Low Back Pain for Personal Trainers & Strength Coaches

March 15, 2020

General Guidelines for Training with ANY Injury

1.    Refer out!

We are strength coaches and personal trainers, NOT doctors. We do not make medical diagnoses. Anything that is painful, please refer out to a doctor or specialist in your area. Do your best to make this person a part of your network as it’s about helping the individual, not about egos. In the end, everybody should win: you, the doctor, the therapist, and most importantly the client/athlete.

2.    Ask them: Does it hurt?

Only a yes or no answer will suffice. “Kind of,” “not really,” and “only when I…” are a yes. Refer out, and then regress or eliminate any exercise that causes pain. Read Coach Boyle’s “Does it hurt?” article for more information.

3.    Use an assessment.

At MBSC, we use systems from Functional Movement Screen like the FMS and SFMA. We find these to be the best systems currently available to look at gross movement quality and identify entry points for improvement in training.

When using the FMS, specifically for pain-free clients, the simplified scoring system allows our coaches to put clients into buckets based on their movement quality. Scores of 2 or 3, don’t raise any red flags meaning they can continue training the associated pattern normally. A score of 1, would signify a limitation in gross movement quality, warranting a regression to an simpler movement and further investigation into local joint movement quality. A score of 0 means there is pain associated with the movement, meaning we refer the client to a medical professional for treatment and continue to train the non-painful patterns. Generally speaking, non-specific back pain clients could use more mobility in their hips and thoracic spine and improved motor control of their hips and core musculature.

If you are not familiar with the Functional Movement Screen, you can employ the “Does it hurt?” method above and set up your programming from there. *Note: There are always exceptions to the rule. Think young pliable athletes and yogis. Usually, they’re a case for getting stronger, not more mobile!

4.    Manage your expectations.

Training age, chronological age, previous injuries, joint replacements, and surgeries are all variables that could negatively effect training outcomes, although they’re not an excuses for in-action. Braces, sleeves, ice, heat, taping, compression, NSAIDs, and passive care are just band-aids. Their purpose is to minimize inflammation, stabilize the injury, and help the healing process. Once a cut (injury) heals, you wouldn’t keep wearing a band aid (modalities & passive care) would you? These modalities are meant to be used sparingly, not relied on. 

5.    There is always something…

we can be doing while an injury heals. If your right arm is broken, you have three other limbs and a core to train. The positive systemic benefits of exercise on the human body will aid in the rehabilitation of (X) body part or segment even if you are not training it directly. Movement is Medicine. 

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Contraindicated Exercises for Clients or Athletes with Back Pain

1.    Compression of the spine 

• a.    Barbell on the Back
• b.    Prolonged use of a heavy weighted vest

2.    Explosive Lower Body Plyometric Work 

• a.    High Box Jumps & Hurdles
• b.    Single Leg Plyometrics 
• c.     Cleans, Snatches, & Kettlebell Swings

3.    Explosive Rotational & Heavy or Difficult Anti-Rotational Work 

• a.    Rotational Medicine Ball Work
• b.    Side planks (use short lever instead)
• c.     Landmines (substitute anti-rotation press) 
• d.    Staggered Deadlifts & Single Arm Kettlebell Swings 
• e.    Offset Squats, Deadlifts, Carries
• f.     Suitcase Carries 
• g.    Push Up Taps or Plank (Renegade) Rows

4.    Excessive Rotational Stretching or Core Work

• a.    Russian Twists
• b.    Windshield Wipers
• c.     Scorpions
• d.    Sidelying 90/90 thoracic mobility work is to be avoided as there can be a lot of lumbar rotation involved. You can easily get your thoracic spine moving with the lumbar locked in a better position (see #9 in troubleshooting).
• e.    Remember, there are always exceptions. Someone might actually need more lumbar mobility – refer to your network for help. 

5.    Heavy Bilateral or Single Leg Work 

• a.    Deadlifts & Single Leg Deadlifts
• b.    Squats & Single Leg Squats
• c.     Rear Foot Elevated Split Squats 

6.    Most Overhead Work (where the client or athlete who lacks thoracic mobility compensates through the lumbar spine)

• a.    Overhead Pressing 
• b.    Overhead Throws
• c.     Overhead Squats
• d.    Overhead Carries
• e.    Snatches

7.    High Impact Conditioning 

• a.    Sprinting, Treadmill & Long-Distance Running 
• b.    Heavy Sled Work
• c.     Slideboard due to the explosive lateral nature of the exercise & chance of falling.
• d.    Stay away from most Met-con work. It leads to serious fatigue where the client is usually trying to beat the clock or focusing on quantity, not quality. 
• e. Avoid using the rower for conditioning. You must have a toe touch, a hip hinge, and proper deadlift mechanics to successfully row. Also, when fatigue sets in, clients and athletes use spinal flexion to finish the set, when they should be using their legs.

8.    Dynamic & End Range Core Exercises that could lead to excessive flexion or extension moments:

• a.    Flexion based
  • i. Mountain Climbers
  • ii. Sit-ups & Crunches or Bicycles 
  • iii. V-Ups, Pikes, or Inchworms

• b.    Extension based
  • i.  Poorly done Push Ups, Front Planks & Body Saws
  • ii.  Stability Ball Rollouts & Stir the Pot
  • iii. Ab Rollouts or Fallouts
  • iv.  Prone Press Ups or Cobra 
  • v. Burpees

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Things to Troubleshoot with Clients or Athletes with Back Pain

Anything below could be contraindicated depending on the individual. In our experience, the information below has worked well for our back pain clients. Please consult with a good physical therapist, chiropractor, or doctor who understands the importance of quality movement to get a second opinion on your programming. We see this as “best practice” for any injury: everyone working together for the sole purpose of getting the client healthy.

1.    Easy Plyometric Work 

• a.    Ladder drills
• b.    Body Weight Squat Jumps
• c.     Battling Ropes for the upper body
• d.    Medball Chest Pass
• e.    Jump Rope
• f.      Low Box Jumps that don’t require end ranges of hip mobility 

2.    Light Rotational Work (Anti)

• a.    Keep rotational work Tall Kneeling or Half Kneeling, Static and Anti.
• b.    Anti-rotation Holds
• c.     Keiser Push/Pull
• d.    Tall Kneeling Side Plank 

3.    Bodyweight or Assisted Bilateral & Single Leg work

• a.    Ensure a 2/2 Active Straight Leg Raise & Hip Hinge Pattern, then move to Kettlebell Deadlift.
• b.    Bodyweight or Assisted Single Leg Deadlifts
• c.     Bodyweight or Assisted Squats
• d.    Split Squats, Reverse or Slideboard Lunges and Lateral Lunges 
• e.    If you are going to load the pattern with resistance, start in a goblet position. Having the client/athlete load the front of the body, reflexivity activates the core and encourages good posture without having to cue it (external cueing). 

4.    Light Overhead Pressing & Pulling

• a.    Landmine Presses
• b.    Medicine Ball Slams
• c.     Wall or Floor Slides 
• d.    Pull Ups, Chin Ups and Hanging work may be good for the spine as it provides slight distraction of the segments and acts as a good static stretch for the upper body.
• e.    Be careful when doing Heavy Dumbbell Bench Press. The pressing action is usually OK, but picking up the dumbbell to start the exercise and then getting up off of the bench after the exercise can be problematic for the back.

5.    Light-Impact Conditioning 

• a.    Airdyne Bike for time or distance, slowly integrate interval work.
• b.    Walking! Get outside and walk every day, preferably on their own time.
• c.     Light Sled Pushing or Dragging 
• d.    In this situation, an Elliptical is a viable option to get someone moving again without impact. We would still prefer walking.

6.    Core Work 

• a.    Coach diaphragmatic breathing techniques first as they will carry over into everything you do.
  •  i.  90/90 Breathing (feet on a wall or bench)
  •  ii.  Crocodile Breathing 
  • iii. Supine Breathing 
  • iv.  Child’s Pose
  • v.  Quadruped Breathing 
  • vi. 3 Month Position 

• b.    By using the ground as your “core,” you can put your spine in a good position without compensation. 
  • i. Lying Hip Flexion
  • ii. Dying Bug with Core Activation 
  • iii. Supine Anti-Rotation Press 
  • iv. Supine Chops and Lifts
  • v. Leg Lowers (supported or core activated)
  • vi. Segmental Rolling Correctives
  • vii.  ½ Turkish Get Ups 

• c.     Functional glutes on a stable core. The glutes act as a force couple with the deep inner abdominals to create a strong and stable lumbar spine.
  • i.  Hip Lifts (Bilateral & Single Leg)
  • ii. Quadruped Hip Extension progression
  • iii. Mini-Band Walks and Single Leg Holds maintaining spinal position first and foremost.
  • iv.  Clam Shells with back flat against a wall.

• d.    Crawling: Begin on the hands and knees (6-point) and work your way to the more difficult version with knees off of the ground (4-point). Crawling helps integrate the contralateral pattern in a safe and easy progression.
  • i.  Bear Crawl 
  • ii. Lateral Crawl (“bear” position or push up position)
  • iii.  Circles

• e.    Light Carries: Coach how to pick them up and put them down.
  • i. Farmer Carries
  • ii.  Goblet Carries 

7.    The 1/2 kneeling position

The legs in this 90/90 works well to spare the spine. The lumbar spine is locked down by way of having one leg in front. Also, crossing the midline in this way is like candy for the brain.

• a.    Chops and Lifts 
• b.    Inline Balancing 
• c.     X Pulldowns & Landmine Presses
• d.    Anti-rotation Holds

8.    Squeeze something between the knees.

This will help activate the deep inner core by way of where the adductors attach to the pelvis and the pelvic floor. You are less likely to flex or extend through the lumbar spine (this is a wonderful teaching tool but don’t rely on this as a crutch. As the client/athlete improves, try to use it less and less).

• a.    Push Ups & Planks
• b.    Hip Lifts & Leg Curls
• c.     TRX Rows 
• d.    Standing Anti-Rotation Holds and Push/Pull

9.    Pack the neck

The neck has a direct link to the lumbar spine and your ability to sit into your hips. On exercises like Planks, Push Ups, Kettlebell Swings, and Deadlifts, it is best to try and keep the head in line (neutral) with the spine. Using a PVC pipe is a wonderful teaching tool to make someone aware of their spine.

10. Hip & Thoracic Spine Mobility

When working from the joint-by-joint approach, the lumbar spine sits between two joints that favor mobility over stability – the hips and the thoracic spine. If either the hips or thoracic spine are lacking mobility, the (more stable) lumbar spine is likely to pick up the slack. This is the problem.

Some of our favorite hip and thoracic spine mobility drills are:

• a.    Thoracic Spine
  •  i. Quadruped T-spine Rotations (external & internal variations)
  •  ii. Peanut or Tennis Ball Extensions 
  • iii. Hanging
  • iv. Lat Band Stretch
  • v. Bench T-spine Stretch
  • vi. V-stance T-spine Rotation
  • vii. Cat/Camel

• b.    Hips
  • i. Box Hip Flexor Stretch 
  • ii. Lateral Adductor Hip Rock
  • iii. Posterior Hip Rock 
  • iv. Spiderman Stretch
  • v. 90/90 Hip Stretch (not a spine rotation)
  • vi. Table Hamstring Stretch
  • vii. Ground/Table Hip Rotator Stretch
  • viii. Wall/Table Quad Stretch 

It’s important to know that these mobility, flexibility, and low-level stability drills are all done for a count of breaths, and not for time. Breathing is the only way we can consciously regulate the autonomic nervous system to relax. Coach breathing during the initial phases of your training and it will carry over into everything else you do.

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Conclusion

As your client progresses, slowly build in explosive and heavy work. There may be exercises your client can never do again; exercises that will always be contraindicated for that individual. That is reality. Set your goals high but have realistic expectations. Trial and error will be a part of the process. Use our Phase 1 Intro Adult Program and regress or eliminate from there. 

Remember, when someone has back pain, spare the spine in training while you work alongside a good doctor, therapist, or both, to restore function. 

If you’re ever at a loss for what to do with clients who have back pain, or there is a fear around starting a strength program, are a very minimum you start with health. Below are a few suggestions to get the ball rolling:

• a.    Hydration
  • i. Your discs are made of water.
  • ii. All of our metabolic processes require water.
  • iii. An estimated 75% of Americans are chronically dehydrated. (1)

• b.    Nutrition
  • i. Losing weight will lead to less compression on the spine and decrease anterior pull on the spine due to adipose tissue around the belly.
  • ii. Food supplies us with all of the nutrients and minerals we need to heal.
  • iii. Inflammation caused by a poor diet can be systemic, and your gut sits directly in front of your lumbar spine.

• c.     Walking
  • i. Helps with weight loss.
  • ii. “Movement is Medicine” There are so many wonderful benefits of moving and exercise.
  • iii. Get outside! Nature is healing.

• d.    Breathing
  • i. Your diaphragm has insertions on your lumbar spine and your rib cage which articulate with your vertebrae. 
  • ii. Being in pain puts us into a sympathetic state (stressful). Breathing is the only conscious way we have to downregulate ourselves into a parasympathetic (relaxation) state. The more time we spend in a parasympathetic state, the more time we give our body the opportunity to use its own resources to heal. 
  •  iii. You take roughly 22,000 breaths per day. If you’re doing it poorly, you could potentially be limiting your ability to heal. (2)

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Program Example 

The accompanying example program is our Intro Phase One Adult Program. The contraindicated exercises have been replaced with exercises that may be a better choice. Remember, each person is different. There is no timeline on when it’s appropriate to progress. The provided program is a great place to start. Regress and progress as needed, with the end goal being to get every client into our Returning Adult Program pain-free and without any compensations.

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Interested in learning more? At our Certified Functional Strength Coach course you will experience 8+ hours of hands-on coaching. We will take you through each of the regressions and progressions mentioned above and share with you the system we use to train large groups of clients and athletes.

This article was written by CFSC Coach Brendon Rearick. He can be contacted at brendonrearick@gmail.com