Walk like a monster for glute activation.

Glute training is the de-jour training of the last few years.

If anything has defined the recent fitness zeitgeist its glutes.

There are now approximately 40 zillion glute exercise variation videos available on instagram. But are they all worth it and effective?

And what if you want to progress a client from bodyweight side lying clamshells? Which exercise is the next step? . Of course, there are a 1000 next steps, but the ones I like are the side mini band walk (aka sumo walk, x-band walk) and monster walk. (Also band resisted clamshells, but I will post them in a separate video/blog).

I do see quite a few people in the gym these days with their own mini bands (mainly women - thanks Insta coaches). Butt (see what I did there) nearly all of them places the band around the knees for doing band walks and various squat exercises.

Is this the best placement?

Well no, the research shows (see Cambridge et al 2012) that to get more glute medius activation and less Tensor fascia latae the band should be lower down around the ankles or feet.

And the most glute max activation is when the band is around the forefoot. I am assuming that most of the women in the gym (and guys) are looking for more glute max activation for either injury rehab purposes, athletic purposes or lets face it aesthetic reasons. Therefore the optimal placing of the band would be around the forefoot and then next best would be around the ankles.

Why do it?

• can help as part of a programme for lower back pain.
• can help as part of a hip programme (my hips always feel better after it).
• get more toned glutes!
• athletic purposes, in which case always go in different directions.
• warm up, activation and mobility either for a leg workout or sport.

In the 2 videos below my colleague Nick is demonstrating the side walk and monster walk. Now you may be asking why is the band around his ankles and not his forefoot, if forefoot is better? The answer is you can do both, but from a practical point of view the band around the foot can end up getting caught the floor depending on the surface you have, and the friction of the band on the floor can wear your band out quicker. But hey, try both.





Or the monster walk, I don't see too many people doing this one, but I find it hits the glutes just as much, all you have to do is pretend you are a zombie or Frankensteins monster!



  How to do it:

1. Place band around the ankles or foot!
2. Get into a quarter squat/ athletic position.
3. Don't step too narrow, you will lose tension on the band.
4. Don't step too wide, you will end up using your back and not your glutes. In fact, a common thing I see when looking at peoples lower backs while doing this, is their spine bending to the side and doing the movement and their hips are not really doing anything. Especially if someone is not used to using their glutes or activating them you will see this compensation.
5. To stop the above happening, get some light core bracing. Also, getting the client/patient to put their hand on their waist and lower back, try and breathe diaphragmatically into that whole core region and be cognizant of not moving through the lower back.
6. Also look out for the knees collapsing inwards, they don't have to be excessively forced out but you don't want to see knee collapse.
7. Keep a good neck and shoulder position too.
8. Top tip: a band around the ankle with bare skin can cause chaffing and pinching. Either wear longer socks or trousers/leggings. Or try the band around the foot position.

I like to do this exercise before a leg workout, just one or two sets of 10 in each direction. Or put it into your leg workout and superset with something like walking lunges or glutes thrusts.

For people with back pain, it might be one of the exercises you give them as part of their programme.

And as always, even though someone might be doing it on instagram there is no need to make this exercise more complicated by doing it sideways or backwards on an inclined treadmill or by jumping up the steps on a stairmill - yes I have seen people doing this in the gym!

If you want to feel a glute burn give these variations a go!

References:

Cambridge E, Sidorkewicz N, Ikeda D, McGill SM (2012). Progressive hip
rehabilitation: The effects of resistance band placement on gluteal activation during two
common exercises. Clin. Biomech. 27:719-724

Anterior Pelvic Tilt (A Paradox, A Question, Some Possible Answers)

In this post I will cover anterior pelvic tilt, back pain, why your tight hamstrings may be trying to save you, why trying to counteract pelvic tilt with strength exercises may not work, open scissor posture and how the diaphragm could be the culprit. But first, the question.

Why do some people have excessive anterior pelvic tilt and lordosis when standing but when then go into 4-point kneeling quadruped they are able to get their spine into neutral, and sometimes when they lay on their back the spine is nearly flat? But when you return to standing they can't tilt their pelvis, they can't achieve a neutral position, they are locked in anterior tilt and hyper-lordosis.

If it was a structural issue they wouldn't be able to tilt their pelvis in 4-point kneeling and the back wouldn't go flat in supine. If it is a 'tight' muscle, why is that muscle not tight when they are on the floor?

I have observed this over and over again. As a background, I deal with a lot of people with lower back pain, but not all the people I have observed this in have back pain, but most do. I also see this mainly in women, again, mainly because I probably see more women with back pain and in classes, but also I just don't see this anterior pelvic tilt in many men.

But first things first.

What is anterior pelvic tilt?

Pelvis rotates down and forward, lower back becomes 'excessively' curved

If we consider a level pelvis to be neutral, then if it tilts down and forward it is no longer neutral, anterior pelvic tilt (APT), if it tilts the other way the pelvis has gone posteriorly and the lower back can end up flat. You can also get a paradoxical lumbar curve without the pelvis moving, the curve goes the wrong way, I have observed this in men, according to Pavel Kolar (prague school, www.rehabps.com, Dynamic Neuromuscular Stablization -DNS) this is caused by hip dysplasia. (I will say no more about this).

A couple of things to consider:

1. If the anterior pelvic tilt isn't accompanied by any back pain or movement restriction is it really a problem?
2. Some people have genetics that pre-dispose them to APT, this is most commonly seen in sprinters, therefore it may have an advantage for certain movements. Also be careful when looking at sprinters and some people, it may look like they have excessive APT or lumbar curve due to the size of their glutes. The glutes give the illusion of a large lumbar curve, but when you look at the lumbar spine in isolation it is  'neutral'.

What causes APT & hyper-lordosis?

As stated above it could genetics. Two other obvious scenarios: if someone is 8 months pregnant or is carrying an extra 2 stone on their gut then the reason for the APT are obvious and no amount of 'corrective' movement or breathing will make a difference.

In the women I mainly observe this in it could due to several reasons

1. Cultural: stick out your bum, push out your chest and suck your abs in to exaggerate your attributes!
2. Lifestyle: women wearing high heels, changes the whole kinetic chain, weight is shifted forward at the foot and everything above compensates. To be fair to the women I have observed this in aren't always big high heel wearers.
3. A compensation or protective mechanism: If flexion is painful then the body compensates by going into extension to spare the spine and avoid the pain. But why does it go so far into extension, if neutral is also pain free?

All these can result in the classic Janda lower crossed syndrome - tight erector spinae, weak abdominals, weak glutes and tight hip flexors. However, why aren't the erector spinae tight when laying down, they can easily do a knee hug stretch, and some clients can even do core work in supine with a neutral spine, but in the plank or press up position they typically drop back into hyper-lordosis.

In standing, the pelvis tilting down can also be accompanied by the ribs going up or flaring. This results in something that the DNS folks call open scissor posture, and the point where the scissors are pivoting and where the most pressure is occurring is typically in the lumbar spine.

Open scissors posture: the front of the scissors is the pelvis and ribs moving away from each other. The pivot point is in the lumbar spine - ouch!

Toe Touches and Hip Hinging

Using the SFMA there are four scenarios, they can touch their toes (multi segmental flexion in the SFMA parlance) and it is either painful or not, they cannot touch their toes and it is painful or not painful.

The painful scenario is most obvious, flexion causes pain, they are forward flexion intolerant and are avoiding flexion because it hurts. I don't actually see the painful scenario that much in the APT clients, more typical is they can't touch their toes and it is not painful or you ask them to touch their toes and they put their hands on the floor - they are mobile...too mobile.

To the hip hinge, there are three scenarios I see

1. They do the hip hinge, and the APT corrects itself into a normal lordosis, this doesn't happened that often, however much you coach
2. They go into even more hyper-lordosis, with the lordosis extending up into their thoracic spine. Typically see this with the mobile Yoga types
3. As soon as they hinge, their lumbar spine goes into flexion and rounds. They have the hip mobility of a breeze block. Therefore, they need to increase hip mobility, but not in the hip hinge position standing, because they just don't get it in this position. In this case taking them to the floor and doing a rocking squat could be a starting point, with the hips unloaded, and in this position their body doesn't have to worry about the ankle and all the other joints trying to keep them upright.

Glutes

You can try to get the person with APT to squeeze their glutes. I normally demonstrate this, as when I squeeze my glutes my pelvis tilts in quite a big way. Normally 2 things happen when they try to squeeze their glutes

1. Nothing happens, they squeeze but there is no glute contraction. If they have back pain or hip pain the glute may be inhibited, they have glute amnesia (listen to audio lecture with McGill and Liebenson where McGill states they have now proved this in the lab, www.movementlectures.com )
2. The glutes contract but the pelvis doesn't move, the APT is not being caused by the glutes not working.

All the standing glute work in the world trying to strengthen these muscles doesn't work in these cases. RDLs and Good Mornings and all that don't do anything,the glutes don't fire, or they do fire and the APT remains. And the client still has APT, excessive lordosis and is still moving through their lumbar spine.

Take the person into a supine 2 leg bridge, but be careful, at the top of extension you can see their lumbar spine actually going into more lordosis with no glute involvement. And at the start of the movement, watch, their lumbar spine flattens, they have gone into posterior pelvic tilt, but check, the glutes may still not be working. They can get into PPT in supine with no glute activation.

To really isolate the glute action here, try the one leg glute bridge aka cook hip lift. This is humbling for many people, hug one knee in and then bridge up, see how far they get with no lumbar spine help.

There are quite a few videos on youtube showing the cook hip lift, here is one 

Tight Hamstrings?

Typically if the person can't touch their toes they tend to think they have tight hamstrings.

However, in nearly every client I can think of, as soon as you lay them on their back and get them to do a straight leg raise (ASLR in the FMS) they can easily achieve 70 degrees, and most women are getting 90 degrees. And if they have 70 degrees or less, they nearly always get more range of movement with simple passive help. This shows two things, when their hamstrings are unloaded in a supine position they show normal range of movement, and if it can be passively increased immediately could it be something on the front of the thigh that doesn't have the strength to life the leg up.

I find people want to stretch their hamstrings for 4 reasons

1. Someone told them their hamstrings were tight, like a physio
2. They can't touch their toes - see above why in most cases the hamstrings are not short
3. They actually feel tight all the time
4. They want to stretch because they like it, they are good at it, and everyone has always told them more flexibility is a good thing

In the back pain client the tight hamstrings may actually be protecting them. If someone has lower back pain and finds forward flexion painful then

"If the hamstrings are tight and short they effectively prevent pelvic tilting." (Chaitow et al, 2002)

 and

"In this respect, an increase in hamstring tension might well be part of a defensive arthrokinematic reflex mechanism of the body to diminish spinal load." (Vleeming et al, 1997 quoted in Chaitow, 2002)

 So the tight hamstrings are preventing movement that may cause pain. I would personally say that the hamstrings are actually contracting all the time rather than being 'tight'. And if they have normal ROM supine then they definitely aren't tight, your body is doing what it can to protect your spine when you stand up, if it has no other option it uses the hamstrings. These people also typically get hamstring cramping in a glute bridge.

Extension, Centration and The Mind

Normally when I ask a person with APT to lean back in standing (multi segmental extension) they can do it and there is no pain, and all sorts of McKenzie extension positions don't make any difference to pain in those with back pain (pain could stay the same, go away, get worse, or not be a problem on that particular day). On that note, it is surprising the amount of back pain patients who have had facet joint injections when extension doesn't hurt but flexion does.

If we take the person to half kneeling hip flexor stretch position we have taken out any influence from the ankle and knee joint. In this position, it is quite normal to see the hip not extending properly, the glute not firing and the lower back going into more lordosis and increasing APT, as well as the person feeling a big stretch on the front of the thigh. Is the lower back compensating for lack of hip extension?

Also, it is important to note that the person in APT doesn't feel like they are in APT, they feel normal. In the case of forward flexion back pain, has the body gone into extension to avoid pain and over compensated. Even with or without pain, has the body decided this is the default postural position, it believes it is centred. It could be compensating for head forward posture or ankle restriction or a whole host of things in the chain, but it thinks this is normal. To use Weingroff core pendulum analogy, the pendulum had swung into flexion, so the body overreacted and swung the pendulum too far into extension.

But this is only happening in a loaded position, note that when the spine isn't being loaded by gravity in standing it can go back to neutral. The brain is in control. The person has what Kolar and the DNS guys would call 'body blindness'. In the movement system Feldenkrais they talk about a Homunculus in your mind, a little version of you in space, your body has an image of where you are in space, and it may not match reality, you need to reset the system.

In the standing loaded position.

"internal forces developed by our own muscle are often more detrimental than external forces..external forces are decisive in what way external forces apply on our system." (DNS course notes)

You get told to strengthen your core or back or posterior chain, but strengthen what? In standing we're making the position worse, we need to take the person into unloaded positions or more 'primitive' postures if you will. If we change the function we may be able to change the structure (Lewit, Kolar) with the right exercise.

Its not a strength issue or a muscle issue, its a motor control issue. Having said that, there might be one muscle you need to work on first.

The Diaphragm and a possible answer

  
Breathing is the fitness concept de-jour at the moment, and I will cover it in more detail in another post. However, I think we need to explain exactly why breathing and the diaphragm is so important, especially when it comes to back pain. Firstly the diaphragm actually attaches to the lumbar spine and ribs, as well as many other structures and muscles in the abdomen and thorax (Chaitow, 2002), so it would seem we should train it like the other core muscles. Secondly, "the lower back is stabilised via intra abdominal pressure" (DNS notes). The diaphragm pushing down when you breathe in and helps to stabilise the spine. And in people with lower back pain this may be lost.

Nearly all the people who I have seen with APT and/or lower back pain demonstrate paradoxical breathing, which means their diaphragm and ribs move up when they breath in during normal relaxed breathing. When it should move down when they breathe in.


In a study by Kolar et al (2012, JOSPT) they scanned the diaphragms of people without back pain and compare them with those who had had chronic back pain for 6 months. In the MRI scanner, they did three things, 1) lay down normal breathing 2) then got the person to do isometric flexion of an arm 2) then isometric flexion of a leg.


(I have taken the image below from the paper, before anyone sues me, it is available on the internet for free). On the left is the diaphragm movement during normal breathing of a non painful subject, image B is the movement of the diaphragm in a person with chronic back pain.

Source: Kolar et al, JOSPT, vol 42, no.4, rehabps.com

But the key point is shown in the graph below, when the person is relaxed there isn't much difference between the back pain and non pain people, but as soon as the back pain people have to apply resistance the diaphragm shoots up, it becomes higher in the thorax and the amount it is moving is a lot less than in the non painful subjects.

Source: Kolar et al, 2012, JOSPT, vol 42 no 4. rehabps.com for full article

During strenous activity the breathing pattern in a person with back pain is altered. In a cross sectional view the front and middle of the diaphragm doesn't get recruited but the back part does, this basically pulls the spinal column up and forward causing shear forces which may make back pain worse. Also with the diaphragm higher you can surmise that intra abdominal pressure is lower and the spine is not as stable.

And this may cause the back to be unstable. Of course, there is always the possibility that the back pain caused this dysfunction and not the other way around.

"One possibility is the lack of postural diaphragmatic activation is substituted by excessive activation of the superficial lumbar paraspinal muscles, which may lead to hypertrophy and, eventually, result in lumbar hyperlordosis and/or anterior pelvic tilt. Future research should study this mechanism as possibly contributing to or even underlying the etiology of low back pain symptoms." (Kolar et al 2012:360)

Breathing incorrectly may cause the muscles in the back to become over-developed, until you addres the breathing issue those erector spinae may continue to be rock hard and switched on.

So the first port of call to resolve APT and back pain may well be breathing correctly. See the video below from Evan Osar (though he doesn't mention it all in the video this is essentially the DNS method, he does mention DNS and Kolar a fair amount in his book). This video basically covers what I woudl consider the first thing to do with someone who had APT and back pain. Note the three dimensional nature of the breathing. You will find that many Yoga disciples can easily breathe forward into their abdomen, but they will find it difficult to breathe into their back, which can really help stabilise the spine, relax the lower back and get the area into a more neutral position; all with nothing more than breathing. Simple, but easily missed in our rush to load up with weights.





In Summary

Hopefully this post has raised a few questions and given a few answers.

• Firstly, trying to correct posture in standing with standard strength exercises may never work. You need to unload the system and reset it. And ask yourself why you are correcting it in the first place

• The muscles just do what the brain tells them to do. The movements don't have to be complicated, they should be simple and slow to begin with, and can be quite high repetitions (15-20 reps, re-learn the motor pattern) This could be the DNS approach or a movement system like Feldenkrais or whatever exercises you find work best for you.

• Start with breathing, the diaphragm influences spine position and stability
• Free up muscles that are over- working, for example, 6-10 repetitions of the cat camel are proven to reduce viscosity of the muscles either side of the spine. Then progress to endurance and strength exercises like the bird dog.
• You could then move onto more strength type moves, but stay in these more primitive positions to begin with, could be kneeling rocking squats, then cook hip lifts as well.
• Half kneeling hip flexor stretch with core braced and back in neutral may be appropriate if your movement assessment highlights an issue.
• The hamstrings are probably not tight and don't need stretching, they need to switch off, but they will only do that once other muscles are doing the job for them
• The details matter
• Breathing exercises can even be done in between sets of strength exercises, integrate into the training program
• If somethings worth doing, do it everyday, I think Dan John said that.

The End at last

References

Chaitow L et al (2002) Multidisciplinary Approaches to Breathing Pattern Disorders. Churchill Livingstone
Kolar et at (2012) Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. Journal of Orthopaedic and Sports Physical Therapy. Vol 42, no 4
McGill & Liebenson From the Lab to the Trenches www.movementlectures.com
www.rehabps.com

Is Pilates Good For Your Back? Or Will It Make Your Back Pain Worse?

Note: I originally wrote this for the general public, so tried to make it as non technical and clear as possible. In doing this I have not put in any references, as this may interrupt the flow, but as always, everything can be referenced.

Is Pilates Good For My Back?

Pilates popularity does not seem to be waning. In fact it seems to have become the ‘go to’ class for anyone with any type of injury. (Full disclosure: I qualified to teach mat based pilates about 6-7 years ago, so am aware of what the training consists of and why people are told to go and do Pilates). I have noticed more and more people being recommended to do Pilates for a range of conditions. Doctors, Physiotherapists, Osteopaths, Chiropractors and Consultants have all suggested their patients and clients do Pilates to help them with a whole host of injuries and problems. I’ve had people referred for knee injury, hip replacement, whiplash, shoulder problems, chronic fatigue and most commonly lower back pain. Some of these people were unable to get down onto a mat or kneel down or lie flat, but had been recommended to do mat based exercise. One person came to me after sciatica, back surgery and hip surgery and the only exercise advice she had received was 'to do Pilates'. Pilates has become the universal panacea!

The fact that medical and health professionals are recommending anyone to do exercise should be seen as a good thing. It could also be a sign of an over burdened physiotherapy service, where patients are being told to do classes because the one-to-one physiotherapy they need is not available. In my experience, most people recommended to do Pilates due to some type of injury, are following the advice of their GP. Having said that many physiotherapists are now promoting their own back pain classes and are jumping on the Pilates bandwagon, they are advertising the fact that these exercises are specifically based on the Pilates method. Despite no evidence for its benefits. As we shall see, Pilates methodology may not be the wisest choice for those with lower back pain; and as for those with knee pain and neck pain, it's not clear why it's being recommended at all.

It is a positive that physios and osteopaths are trusting fitness professionals and their knowledge, it would also seem curious that they are passing on patients and clients that they could and should be rehabilitating themselves. However, it seems mostly there is a lack of understanding among medical professionals and the general public as to what Pilates actually is.

For those of you who are unfamiliar with the history of Pilates and how it came to be the universal panacea, here is a brief history. Joseph Pilates was born in Germany in late 1800’s, in the early 20th Century he came to England and while interned on the Isle of Man during the first world war was working in a hospital. Around this time he started to develop a series of mat based exercises and novel equipment like the Reformer ( a cable, pulley, sled type machine ) and the Cadillac and other equipment. His choice of exercises and the equipment he developed was very much informed by his gymnastic background and possibly even the circus, where he had performed. It is also likely that many of the exercises would have been influenced by other disciplines and fitness ‘gurus’ at the time. Although, we think of fitness crazes as a modern phenomenon, they are not, and there were a number of fitness ‘gurus’ around at the time and before, like Arthur Saxon, Eugene Sandow and many more who had their own fitness systems and equipment. Joseph Pilates later moved to America where his studio obtained a steady following amongst dancers especially. Joseph Pilates carried on teaching until the 1960’s.

Jospeh Pilates teaching someone on one of his many pieces of apparatus

Pilates stayed more or less as a fitness footnote until ten or fifteen years ago, when various individuals and schools of Pilates started to emerge and expound its virtues, especially in the UK. This also coincided with an explosion in so called ‘functional fitness’, the use of swiss balls and the concept of ‘abdominal hollowing’ (more on this later). This did help the fitness industry out of a rut, which had become stuck using static machines. Suddenly the public and instructors had a whole new range of concepts and exercises to use.

Over recent years Pilates has grown and grown to become more of a brand than a clear cut exercise system. Go to any Pilates class today and it unlikely you will see any instructor doing Joseph Pilates original sequence of mat work exercises, which from a back care point of view may be a good thing. The original exercises can be very challenging and not the gentle exercise for the de-conditioned individual that most people think they are. Pilates has become the class to improve your ‘core’ or ‘posture’ or in Pilates parlance your ‘powerhouse’ and help you get ‘longer muscles' (of course, longer muscles are impossible as the attachments are set). These days, it is very hard to say what Pilates is, even most of the official Pilates courses have modified the original exercises or broken them down into various levels of difficulty. For example, see the pictures below, one of the original ‘swimming’ exercise and the modified 4 point kneeling version, which is a standard rehabilitation exercise called 'Bird Dog'. The original swimming causes massive loads on the lumbar spine, whereas the 4 point kneeling version does not.

Classic Pilates Swimming exercise - causes massive amounts of compression in the lumbar spine. Say goodbye to your facet joints, you'll miss them when they explode. And your cervical spine (neck) wont like you to much either

Modified Pilates Swimming exercise aka The Bird Dog aka quadruped contralateral arm & leg lift aka your facet joints wont explode

And herein, lies the problem with Pilates as an exercise for lower back pain. You may have lower back pain and have been told to do some Pilates because it will help. You may go to one class which is staying true to the original exercises and do an exercise which is possibly going to make your back worse and you may go to another which is using any of the modified exercises and it is going to possibly help your back. And in another class, an instructor may be throwing in some of the original exercises, some modified ones, and then some general core and toning exercise they’ve picked up along the way because after all that’s why most people come to the class, to tone up and if you do have a lower back problem all that abdominal work is going to help, right? Wrong!

One person may go to Pilates and it helps with their back pain, for another person it may make no difference or make it worse. This doesn’t only apply to Pilates, but Yoga and many other general fitness classes. This also applies to a whole host of injuries, your shoulder/ hip/knee injury may get better but then again it might not, you are not doing a set of exercises specifically designed to help. The problem is Pilates is not specifically designed for lower back pain, and the person teaching it may have no background in it. You may go to a class and be able to do 90% of the exercises, but 10% of the exercises may actually make your back pain worse. You may not have access to a specific lower back class or rehabilitation program where you live and this leaves you with a conundrum - should I do the class or not? Of course, your first port of call is the physiotherapist, though I’m sad to say you may end up with nothing more than advice to do some Pilates and an exercise sheet consisting of knee hug stretches and knee side to side mobility. On the other hand you may get a first class rehabilitation program that is specific to your needs, evidence based and progressive. However, the lack of consistency in this area, means you may need to educate yourself.

With this in mind, here are some ways to modify and avoid certain things that may make your back pain worse. These are all evidence based strategies and proven to work. In each example, I will show the most common way an exercise is taught and how you can modify to help spare your spine and strengthen the muscles.

The Spinal Roll

Modified Spinal Roll in Pilates - may not be the best idea if you have lower back pain

The spinal roll is almost universal in Pilates as a warm up exercise and a way to get down to the mat. However, look at the position of the spine, it is fully flexed, it is in a rounded, bent position. Now, evidence shows that repeated spinal flexion can lead to a disc prolapse or injury. The load is not important, it is the amount of times you do it, and the amount of times you do it before it causes injury is purely individual. Imagine a credit card, if you keep bending it back and forward, eventually it will snap in the middle. Also holding a spinal roll position can cause the muscles in the back to switch off and the back is hanging on the ligaments between the vertebrae in the back.

In adults aged 20-50 years old nearly all back pain is forward flexion intolerant and discogenic. In other words, round the back and bending over makes it worse!

Avoid any exercise that may round the lower back and especially if it is rounded under load. So in Pilates terms this also means you need to avoid the Roll Up and Rolling Like a Ball (see below for pictures and video and to be fair on the Pilates course I attended, they did say to avoid rolling like a ball if you have scoliosis).

Pilates Roll Up - avoid if you have lower back pain and also promotes poor posture

An alternative to the spinal roll is the hip hinge. See my article here, for a full explanation of the hip hinge. In this movement you will keep your back in a neutral position and hinge from the hip by pushing the hips back as you fold forward. This movement spares the spine, works the muscles either side of the spine and gets the muscles around the hip working as they are supposed to.

Abdominal Hollowing

This has become almost universal advice in all classes, in the gym and in Pilates. Joseph Pilates original work was also very much about pulling in the stomach muscles, hollowing, engaging the internal corset. Of course, doing this can immediately make your waist look smaller and more sleek. The explosion in popularity of Pilates also coincided with some Australian research that showed people with lower back pain weren’t firing off their transversus muscles (the internal corset). However, this study only measured the transversus, it didn’t measure any of the other core muscles, and it only measured it on one side when people were told to lift their arm over head. With lower back pain we need to get the whole core working to protect the back. Not just focus on one muscle.

Other muscles around the core are just as important, the obliques, quadratus lumborum and rectus abdominis. These are best engaged by bracing the abdominals. Hollowing actually causes the lower back to be less stable. Imagine the difference between a tent where all the guide lines are taught and spread out, and one where the guide lines are loose and close in, which one is going to stand up?

Brace wherever possible, this engages all the core muscles. Brace as if you are going to punched. It is important to not try to pull in or push out your abdominals, keep the circumference the same.

Lateral Breathing

In Pilates you are instructed to breathe laterally or thoracically. This probably stems from a couple of factors. Firstly, Joseph Pilates came from an era when those involved in Physical Culture pulled their stomachs in and puffed out there chests, it is almost a classic Westernised idea of what good posture should look like. The guys and strongmen especially wanted to make their chests look bigger and their waist look smaller. As do women as well I guess!

Joseph Pilates - note, the abs are being pulled in, the ribs are flaring, the diaphragm can't do its job. And I have no idea what that machine is!

Secondly, if you are practicing abdominal hollowing you can't breathe using the diaphragm because you can't push your abdomen out. In fact, Pilates states that abdominal breathing is wrong. However, if you look at breathing anatomy, to breathe properly your diaphragm must push down to let the lungs fill and that will push the abdomen out and also give you a more stable core.

If you breathe laterally, you should breathe laterally using the diaphragm, which means you should feel the area between your lower ribs and hips (your obliques) expanding sideways. But you should also fell the front of your abdominals and lower back pushing out and expanding as you breathe, like a cylinder.

The diaphragm pushes down when you breathe in

This type of abdominal breathing is practiced in yoga, meditation and most Eastern martial arts. They were onto something.

Spine Twists

This is an exercise where the details matter. A lot of classes will finish by lying on your back and rotating the knees from side to side in a windscreen wiper fashion, this exercise is still given out as a rehab exercise for the back. However, the lumbar spine isn’t designed to rotate that much, your back is designed to rotate through the thoracic (middle back) and hips, therefore sparing the spine. Many people with lower back problems think they need to stretch out their lower back and improve the flexibility in this area. In reality, many of these peoples lower backs are already too mobile and unstable, they need to work on having a ‘stiffer’ core and getting mobility in the middle back.

The modified Pilates spine twist is ideal for doing this. In the video below the modified Pilates spine twist is shown, as well as a tall kneeling version. I use this modified spine twist all the time with people; there are elements of Pilates which work well for back pain, it is just knowing which ones.
The classic Pilates spine twist is much harder, as the arms are out straight to the side and the legs are straight to the front. The modified one fixes the head and rotates with a neutral spine, the classic version can end up being flexion and rotation.



Also, there is a Pilates exercise called The Saw which is flexing and twisting to do a toe touch - one of the worst things for those with back pain. We know one of the worst actions for the back and tearing up the discs is the action of bending and twisting. So we can see how one version of this exercise is beneficial whereas another version is not.

The Saw - most people are going to end up twisting and bending through their lower back.

Crunches and back flattening

There are very few crunching movements in Pilates, to its credit much of the time you are trying to keep a neutral spine. In some exercises though, the back is flattened or rounded into the floor or mat. In Pilates this is called 'imprinting' the spine or back. This is just really forward flexion again but with your body on the floor, same as the standing versions. Repeated crunches or imprinting/ flattening of the back can damage the lower back tissue and are not that effective at activating the muscles in the core and can result in poor upper body posture. Try not to flatten or over extend the back, keep it in a neutral position with a natural curve. Your lower back is strongest when it has a natural curve in it, not flat or excessively curved but neutral. This is where the grey area of what is Pilates comes in. Pilates itself doesn’t have many crunching movements, but instructors may be adding these in.

Classic exercise Neck Pull. Doesn't really get done anymore in classes, but if you think crunches are somehow safer or better then think again

Curl Up - flipped onto its side. Some Pilates courses teach the curl-up. Even if imprinting and flattening the lower back didn't cause problems look at the posture this promotes - head forward, shoulders rounded, hips flexed. Most people spend all day in this posture anyway, they don't need to practice it

Stretches

As mentioned earlier, people with lower back pain often feel the need to stretch out their lower back or are advised to do a knee hug stretch. This is not a Pilates exercises but is often done, as is rolling like a ball, which is one of the original exercises. Stretching the lower back muscles can be detrimental to the spine, as it makes the lower back less stable.  The muscles may have become permanently switched on and in ‘spasm’ but there are other ways of switching these off and helping them to relax that don’t involve stretching. This doesn’t mean stretching in general is bad, other tight muscles in the body may benefit from stretching.

Pilates originally attracted quite a few dancers, this group is naturally very flexible and in many cases way too flexible and unstable. An exercise that may be easy for them may impossible for you. Plus their incidence of back pain is the same as everyone elses, they just end up with different types of back pain.

In summary

Hopefully, this article has cleared up some of the issues surrounding back pain and Pilates. The term Pilates has become so general that really there is no set definition anymore. This article shouldn’t discourage you from taking part in classes, nor does it mean Pilates wont help. Following the guidelines above should help. Remember, this article is aimed at people with lower back pain,

• Avoid forward bending with a rounded back, you should hinge from the hips
• Abdominal bracing is superior to hollowing to strengthen the core
• Avoid lateral or thoracic breathing, breathe using the diaphragm, this will activate your core and  protect your back
• Try to avoid rotating through the lower back, you should rotate through the middle back and hips
• Keep a neutral spine and avoid pressing your back flat or doing traditional crunches
• Avoid stretches like the knee hug stretch, but other muscles like the gluteals & hip flexors may be tight and need stretching.

You may think, that if you do all these things, then you are no longer doing Pilates. The truth is you probably weren't doing classic Pilates in the first place, but a hodge podge of things mixed together. If however, you go to a class, it makes your back feel better and you enjoy it, does it really matter what it was called?

Lastly. Ideally try to attend a specific class for chronic lower back pain or have an individualised program. If you have other injuries like hips and knees, again a specific individualised program specific to your needs will be more beneficial than attending a class where possibly only one or even none of the exercises are going to help you.

*I originally wrote this article over 2 years ago, but never got around to taking the photos for it or publishing it. I have had added a few extra bits, but this is pretty much how I wrote it 2 years ago, the principles in it all hold true. I wasn't going to publish it, as I thought all this information was out there and quite well known. Turns out I was wrong, last weekend I was on a course with Physios, Osteos and Chiros, when the issue of abdominal hollowing and back pain came up it was a revelation to the majority of the people in the room - about 30 - many of whom had been referring patients to Pilates for back pain, as one of the physios/osteos asked at the time 'does this mean Pilates is wrong?' In this case, I'm afraid it is. The mantle of back pain & injury cure-all got projected onto Pilates, and turned it into something it never initially claimed to be. For lower back pain, the evidence is clear and despite over a decade of research showing that many of the Pilates concepts should at least be modified or reversed or in some cases completely replaced, they continue to be taught.

HIP HINGE! Your Body Wants You To

The hip hinge is a fundamental movement pattern. You need it to get out of a chair, squat, pick things up, deadlift, do an Olympic lift and generally spare your spine while moving.

See the video below of how to do a hip hinge.



However, it's surprising how many people can't hip hinge. I've noticed it with a whole host of different populations. When I get a client who has back pain, one of the first things I do is observe them get in and out of a chair. A high proportion of these clients tend to get out of the chair by lifting their hips up high and then unrolling or flexing/ bending  through the lumbar spine. Some can't even get out of the chair without using their hands to push themselves up. A few simple cues and adjustments and then suddenly they can get out of the chair with a neutral spine and without using their hands. Mostly I tell them to bring their feet wider, push their knees out, hinge from the hips, keep the chest up and drive into the floor with their feet - and bingo they get out of the chair with a neutral spine and using their hips.

Chair Squat - start position

Chair Squat - mid point

Why can't people hip hinge then?

If the hip hinge is a fundamental movement pattern, and everyone should be able to do it and use it on a daily basis, why can't people do it. Why do they bend/ flex in the lumbar spine? Why does the thoracic spine round too much?

The body will take the path of least resistance, the least stiff part will move and compensate for the stiff part. In the words of Charlie Weingroff (2010):

"The movement goal is achieved but there is no integrity to the movement."

Which means I asked them to get out of the chair and they got out of the chair, the goal was achieved. The hips and thoracic spine may be stiff so they used the lower back to get out of the chair, they achieved the ultimate aim. Or in the context of weightlifting, one person deadlifts the weight using the hips, while another person uses their lower back - they both got the weight up, and if you're in a competition you can justify it to yourself, but don't train like this, you're going to end up in a world of hurt.

Your body responds and adapts to what you practice most. If you adopt a certain posture 8 hours a day, what does your body do, it adapts to it.

"Prolonged sitting has been cited as a factor in the development of back pain. Cyclists who spend 3 hours riding their bicycles in a position of lumbar flexion have a reduced lumbar curve when compared with control subjects who do not ride bicycles." (Sahrmann,2002:13)

which means

"repeated motions of daily activities, as well as those activities of fitness and sports, may also induce undesirable changes in the movement components." (Sahrmann, 2002:13)

So in most cases the lumbar spine is moving too much. In this context the joint by joint theory espoused by Mike Boyle and Gray Cook makes sense. If the body is a series of joints stacked on top of each other, with some tending to be more mobile and some more stable, a loss of mobility in a joint may affect the ones above or below. So in the case of the hip hinge, if I lose mobility in the hips the lower back will compensate, if I lose mobility in the thoracic spine, the lower back will compensate; the lower back should be stable. In lower back pain rehab we always ended up spending as much time on trying to restore peoples hip mobility and strength and their thoracic spine mobility, as well as lumbar spine stability. When I first read Mike Boyle's joint by joint article in made perfect sense because I was seeing it on a daily basis with people.

And remember, stable doesn't mean static and still

"stability is the ability to control movement in the presence of potential change." (Weingroff, 2010)

So why can't I bend my lumbar spine, it's meant to bend isn't it?

Somewhere in Canada there's a guy called Stuart McGill and if he's not on his yacht or kayaking or cross country skiing or grooming his moustache then he's in his spinal lab at the University of Waterloo. He breaks spines so you don't have to.

It seems the number one mechanism for herniating a disc is fully flexing the spine.

"In fact, herniation of the disc seems almost impossible without full flexion." (McGill, 2002:56)

 And the number of flexion is important, the spine doesn't have to be loaded up, the repeated flexing of the spine with minimal load can cause disc herniation. I like Mike Boyle's analogy of a credit card, if you keep bending it back and forward eventually it will snap, not because you were applying much force but the repetition caused a weakness in the plastic until it snapped.

Imagine this shiny new gym membership card is your spine, eventually it's going to snap

"repeated spine flexion - even in the absence of moderate load - will lead to discogenic troubles." (McGill, 2002:127)

The way to avoid this is to flex at the hips while keep the back in neutral and the abdominals braced for the task at hand. This is the hip hinge. Interestingly,  one group of people who lift some of the heaviest weights are Olympic lifters, they lock their spine into neutral and rotate around the hips (McGill, 2002). Their incidence of back pain is lower than the general population. If you look at the video clip below of the snatch grip romanian deadlift, you can see the spine in neutral and the hips doing the work. The position of the bar below the knee is essentially the same as the start of the second pull in the Olympic lifts. (note: if you ever film yourself doing a lift, then it gives an insight into your technique and will immediately make you lift with better technique).



Hang on, shouldn't I be able to touch my toes?

Toe touch: an assessment not an exercise

Being able to touch your toes is still seen as a measure of flexibility. It appears in Gray Cooks Selective Functional Movement Assessment  as one of the tests you employ if someone is in pain, it's the multi segmental flexion assessment (Cook, 2010).

I think Charlie Weingroffs Core Pendulum theory is a good explanation of this. Charlie explains this in his excellent DVD set Training=Rehab Rehab=Training (go and order it now, it'll change your life for sure! And I don't get any money for saying this). We need to exhibit for flexion and full extension for our spines to know where the middle is, joint centration. If you have a loss of flexion then your neutral spine will be off because your body doesn't know where the middle is, same as if you have a loss of extension. The lumbar spine is meant to flex and extend but going to the end range on a regular basis is not a good idea, its proven to eventually cause disc problems. Remember an assessment is not an exercise you should be doing on a daily basis.

Core Pendulum: If neutral is in the middle(3), then your body only knows its the middle because it can get to the end ranges (1 & 5), if it can't, adopting neutral spontaneously is going to be difficult.

As an example, I never practice touching my toes and I hardly ever stretch my hamstrings passively and my flexibility in this area isn't the greatest and yet I can touch my toes. This is purely from doing hip hinges, kettlebells swings, deadlifts and so on.

Save your spinal flexion for when you need it, on those occasion's when its impossible not to flex, the rest of the time adopt spine sparing strategies such as the hip hinge, squat using the hips or a golfers lift for picking things up.

Golfers Lift: reduce load on lumbar spine when picking up light things

A quick note on the golfers lift: The leg cantilevering behind acts a counter weight, effectively hinging one hip and helps reduce the load on the spine. To train this movement I like to put a kettlebell in the hand opposite to the one on the floor.  For back pain clients who can't balance, it's acceptable to support one hand on a wall or chair or table when picking things up.

Hip hinge common mistakes

In the first video clip below you can see Nick is bending his knees too much and flexing in the thoracic spine. Knees should be about 20 degrees  (if  you happen to carry a protractor or goniometer around with you) this allows the glutes to be engaged more effectively. You should feel a stretch in the hamstrings on every repetition. Cue to keep the chest up but the head neutral.



In the second clip below, you can see the hips hardly move back at all. In fact, Nick had a hard time trying to demonstrate this because he's is so used to hip hinging, his hips are still moving, you'll see some people with no hip movement and all spinal flexion. You can try to get them to push their hips back by standing near a wall and trying to push their glutes (bum) back to the wall and touch, may be a foot length away from the wall at first. The broomstick on the back can also help people feel when the back starts to bend.



Another thing that can happen mainly with women is the lower back has too much curve in it, too much extension. No video of this because neither me or Nick can get that much extension in our backs! Remember neutral is not over extended, it's in the middle of the pendulum swinging.

You can start to weight the movement using a kettlebell once the hip hinge has been grooved in, and some people will naturally start to brace more when they have a weight in their hands, and it helps to get that stretch feeling in the hamstrings, loaded up and ready to contract.




And finally the squat

For most people using a squat that has some kind of hip drive component to it is the way forward. If you're an olympic lifter you are going to drop almost straight down and most probably be in a front squat position. For everyone else, especially the general population, sitting back more is going to be more beneficial.

I've used the bench squat technique (see video below) successfully with back pain clients as well as clients referred to me on GP referral (exercise referral scheme) with knee replacements and hip replacements. It is essentially an unweighted box squat. The client learns to break at the hips first and sit back, keeping a near vertical shin also helps those who have knee pain. The hip hinge is a vital component of this.



When a person can't sit all the way down onto a bench or chair I use a step on risers, and gradually as they get better reduce the number of risers down. Don't think about loading up a squat until someone can do it bodyweight with neutral spine.

In the video below are some common squat mistakes.




On the first repetition - trying to do all the movement at the knees, no hip hinge. A lot of people do this when you ask them to squat. I think it might actually be a misunderstanding, you say squat and they think the knee must bend, they have an image in their head of what a squat is. Sometimes you can correct this immediately with the right cue to use the hips. Thus demonstrating it's not always a muscle or joint issue.

On the second repetition - rounding the thoracic spine and over extending the cervical spine by looking up.

On the third repetition - knees caving in.

To paraphrase Gray Cook (2010) I wouldn't get too caught up trying to analyse why all this is happening, is it because the hips are tight or not working, or the lower back not stable, or thoracic spine being immobile or the ankles being stiff? Possibly all of these, but work on fixing the movement pattern. Sometimes its just because the person just never moves that way, the software isn't in their brain, practice the movement and the nervous remembers it and saves the software for the new improved movement pattern.

And maybe they never challenged themselves before, if you sit in a chair all day you don't need to be very mobile or stable. You only need stability in the presence of mobility (Weingroff, 2010)


In conclusion

You need the hip hinge. You need it to spare your spine and keep your lower back neutral when picking things up at home or in the gym. You need your hips working for you, not against you. Your body remembers what you do most.

Tina Fey: No, don't pick that typewriter up with a flexed spine, hip hinge dammit! Okay, I forgive because you created 30 Rock and you're hot. But if you're ever in England and you have back pain give me a call and I'll see what I can do.

References

Cook G (2010) Movement
McGill (2002) Low Back Disorders
Sahrmann (2002) Diagnosis & Treatment of Movement Impairment Syndromes
Weingroff (2010) Training=rehab rehab=training DVD

The Yoga Up Dog Pose For Mobility (Urdhva Mukha Svanasana, What?!)

I've been meaning to write this for a while. A few months ago Mike Reinold posted on his blog that the Yoga cobra pose may be the best postural stretch. The reasoning was quite sound, using the joint by joint approach this stretch opens up many of the tight areas in the body.

Standard Desk Jockey Position

However, what I wanted to know was how to do this pose correctly, and the best person to ask is a Yoga teacher, so I asked a friend of mine, Janet Kelly, to talk me through it and demonstrate various progressions (see the video below of Janet demonstrating it). The first thing to note is she called it the up dog pose and not the cobra. I'm sure that many Yoga people argue the subtle differences between the cobra and the up dog and where the arm positions differ. All in all I'm looking for the mobility exercise that can be modified, used by the most people and benefit the most people. This is the strength of Janet's progressions and explanations of where you should be feeling this pose and how to do it, and this is why I think these up dog progressions are going to better for most people.

Why You Should Do It

This pose is going to lengthen your anterior chain. In the desk jockey picture above you can see the head is forward, the shoulders rounded, the chest collapsed inwards (Janda Upper Cross Syndrome) the hips flexed and the knees flexed. The up dog pose is really the opposite of this posture.

Who Should Do It

The up dog pose is similar to the McKenzie extension position, one of a series of extension exercises popularised by New Zealand Physiotherapist Robin McKenzie. This extended position is proven to provide back pain relief for some people with discogenic back problems, helping to 'suck' the disc back in. However, like everything, this is an individual thing.See the quote below from Stuart McGill (online article 'Selecting Back Exercises' available at his website)

"The location of the annulus breaches can be predicted by the direction of the bend. Specifically, a left posterior-lateral disc bulge will result if the spine is flexed with some additional right lateral bend (Aultman et al, 2004). Subsequent twisting leads circumferential rents in the annulus that tends to make McKenzie extension approaches for these clients useless, or even exacerbating."

Also, I imagine any type of facet joint problem could be made worse by this position. In short, use your judgement, if it hurts, stop, figure out why and do something else.

If you don't have any of these problems, this is a fantastic mobility exercise that you should make it part of your training routine, especially if you are a desk jockey or do a typical bench press routine or spend a lot of time cycling or driving. This is a great reverse posturing exercise.

As usual the people who should be doing it are the ones who are not doing it. All the guys in the gym spending all their time bench pressing should be in the studio doing some yoga and mobility work, and all the women in the yoga studio working on their flexibility should be in the gym lifting weights. This is the nature of things, resist the urge to only gravitate towards things you are good at, sometimes do the opposite of what you normally do.


How to do it

In Yoga the up dog pose is done as the opposing move to the down dog and is part of the sun salutation (don't ask me, I'm not a Yoga teacher!). In this example we are doing it as a stand alone move. In the video and explanation it is broken down into 5 levels, this is for ease of explanation and progression, these aren't 'official' levels.



Level 1

• Forearms down, elbowed directly beneath shoulders
• Rolling shoulders back and down
• Think of sliding chest forward and up
• Chin tucked & head neutral
• Relax lower back
• Big toes in, all 10 toenails resting on the floor
• Relax glutes

Level 2

• Slide elbows behind shoulders
• Opening middle back but not 'impinging' shoulders
• Imagine back and chest equally open and wide
• Don't retract shoulder blades, think of length

Level 3

• As previous levels but now more pressure through the forearms
• Think of pushing floor away rather than lifting the body up

Level 4

• Hands beneath shoulders, softness in the elbows
• Make sure there is space between your ears and shoulders
• Eyes looking forward
• Hips are now off the floor

Level 5

• Knees off the floor
• Now only the top of your feet and hands are in contact with the ground
• The body is not being driven downards, think relaxing again rather trying to force yourself down
• Stay open and still think of the chest going forward and up

 A note on breathing: Breathe in as you go into the pose, then exhale as you settle into position and soften

How long for

As we are using this as a stand alone mobility exercise, as long as you need to, 15-30 secs would be a good starting point to aim for

Where should you feel it

You should feel this opening out your hips and in the thoracic area. When I first tried this I felt it in my lower back, until Janet coached me to relax my lower back, and relax my glutes and then I could really feel it in the thoracic area. Remember, you are not trying to push your hips into the ground.

If it's painful stop and try something else, there are plenty of other exercises you can try to open out the hips and shoulders, this one just happens to accomplish a lot of things in one go. Using the joint by joint approach the only joint I think that needs to go the other way for most people and especially runners is the ankle. In this pose the ankle is in plantar flexion, I think for a lot of people working on dorsiflexion and calf tightness is the way to go. Of course, that's why in Yoga, they do the down dog pose as well. Who would have thought they knew a thing or two about keeping the body in balance a few thousand years ago.


Thanks to Janet Kelly. Also bear in mind that Janet is your typical flexible yoga teacher, her spine looks like that without her forcing it, don't expect yours to necessarily look the same, mine definitely doesn't!