Rehab Templates - Chronic and Acute

[David_Oswald]

The way the descriptions for the rehab templates are worded, it seems like they are “a return from injury”. And maybe I am just reading things wrong, but do they work for chronic symptoms as well?

I had three lower back injuries in the span of like two years. Two were from moderate rep (8-10) deadlift sessions where my back just locked up and I dropped the weight and took a couple weeks to walk normally. The third was me bending down to pickup a pair of pliers where I fell over and couldn’t get up for about ten minutes, and it took several weeks to walk normally.

About 18 months after the last injury everything kind of hurts my back. It hurts when I wake up in the morning, it hurts when I sit a bit weird in a chair, it hurts to do dead hangs, chinups, any kind of squats, and any kind of hinge. An RDL with 25# dumbbells hurts. It’s a pretty low level of pain I can push through and all of these exercises relieve symptoms for basically the rest of the day and my back feels great.

Specifically it feels like the pain is centered on my SI joint on my left side. But I recognize that might not be the cause or origin of the pain/injury.

I have gotten to the point where I am OK with just having chronic low level back pain for the rest of my life because it isn’t that bad, but I don’t want it to get worse.

Is there any hope that doing a structured rehab program would actually “fix” the problem long term? I have read the articles on how to go about finding an entry point, but really any exercise that loads the spine (any squat or deadlift), or unloads the spine (pullups or dead hangs), hurts. One of the worst is benching. Getting into a good position with shoulders squeezed, back arched, and legs flexed is about the worst.

I would be open to rehab counseling after the new year when my FSA resets, but for now it’s either trying the low back template or pushing through the pain, which isn’t a lot of pain.

The two things that feel the best for my back are rowing and walking. But almost any strength training hurts.

[Jordan_Feigenbaum]

Howdy,

To your question, yes, the rehab templates work for chronic symptoms too, as most injuries in training are (chronic) overuse injuries that often turn up all of a sudden. The method underneath is similar for truly acute and chronic injuries either way.

On whether it can improve things rather than just manage them, I would be optimistic about your situation. The tell is that movement makes it better. That’s a great sign and is the kind of picture that often responds well to consistent graded loading.

To me, it seems like you may be stuck on finding an entry point that doesn’t hurt. You may need to go even further “back”, e.g. isometric work, partial ROM exercises, hip thrusts over deadlifts, blood flow restriction training for the lower limbs while loading is down, and so on. Additionally, it’s okay if the exercise hurts a little bit when you do it, provided it doesn’t spike, get worse, and/or linger afterward.

So the template is a reasonable place to start now. I’d start lighter than feels necessary, using exercises you haven’t done yet/in a while, and address sneaky potential sources of sensitivity, e.g. bench with feet down (do feet up, larsen, or incline), squatting (do split squats, step ups, leg press), etc.

That all being said, and recognizing that we all want to save money, I’d do the low back pain rehab template now. Then, on black friday/cyber monday, I’d sign up with our pain and rehab team if you can swing it. We can be flexible with timing on payment for FSA/HSA stuff. Only reason I say that is because I suspect full resolution may take a bit longer and a bit more of an individualized approach given the duration.

-Jordan

[David_Oswald]

Thank your for your response.

So after posting this I went to the gym and did a low bar squat with just the bar. Then two plates for 135. Normally a set of 12 at 135 is like an RPE 5. And it hurt to just walk it out. I think I did four reps and then decided I needed to buy the program, and I did. So Monday I plan on starting. A few questions.

• The cardio recommended is less than I am currently doing. For example last week I did two rowing sessions, one 30 minute and one for an hour, and another session incline walking for 30 minutes for 120 minutes of LISS. I would have done another incline walking session Friday but life got in the way. Should I reduce my cardio for this program or get away from rowing?
• If I understand the Phase one session. The exercises are sort of ranked by what loads the back the least. Do I start, for both recovery exercises and main lifts, with a super light weight on the first exercise and if it doesn’t hurt progress to the next exercise with a super light weight to find my entry point? In other words, A goblet Sumo Deadlift at 25# doesn’t hurt, so I move on to hip thrusts with maybe just the bar, and if that doesn’t hurt move to hip thrusts with just the bar, and if that doesn’t hurt try a sumo RDL at like 95 pounds to find my entry point?
• For a 3-0-0 tempo for squats and bench I would go slow on the way down, and normal on the way up. For a hip thrust where you start on the bottom, do you do normal speed going up and then slow going down?

[Jordan_Feigenbaum]

David,

Sorry to hear about the gym experience. I do wonder what squatting the empty bar or ~ 65lbs felt like. Perhaps that would’ve been tolerable for an entry point vs. 135. Unfortunately, we often see many stay too heavy for too long in this setting. Either way, we’ve got a plan in place, so let’s sort out some details.

For the cardio, I do think it would be reasonable to reduce the rowing exposure in an effort to get the back to settle down a bit. I would continue your current volume of conditioning though, shifting over what you were doing on the rower to the bicycle, elliptical, stairs, and/or treadmill.

For phase 1, the exercises are listed in ascending order of predicted threat to someone with low back pain. We recommend picking one based on what you think you can do, then sticking with it through phase 1 before changing in phase 2. A trial and error session would help narrow down the entry point, yes, but it’s not really necessary provided the exercise you pick is tolerable. I’d probably pick a 3-0-0 leg press and 3-0-0 tempo mid shin rack pull or hip thrust for your squat and hinge patterns. In this case, the “3” refers to the initial phase of the movement, i.e. the downward phase (eccentric) of the squat and the upward phase (concentric) of the deadlift or hip thrust. I know the instructions say both should be eccentric tempos, but since I have you here, I can tweak it a little bit for your case.

-Jordan

[Paul_Hernandez]

Hello Dr. Feigenbaum,

I really appreciate this this thread, as I have playing with a little bit of experimentation as I also navigate through Phase 1 of the Low Back Rehab template (redicular pain in the low back radiating down my leg). In this particular case, why are you recommending using a 3-0-0 eccentric tempo on squat/leg press and a 3 second concentric tempo on the mid-shin rack pull? Do you feel that the 3-0-0 eccentric tempo would be too much on the low back and/or could lead to a flare up? Also, in what circumstances do you feel this change would be a benefit or non-beneficial? Do you think it could be a benefit in my particular situation? Thank you for your feedback! Have a blessed day.

[Jordan_Feigenbaum]

I think the slower concentric in the deadlift is what would limit the load the most, which I think is the problem most people have: not taking enough weight off the bar.

Hoping for a speedy recovery!

[David_Oswald]

I started week one three weeks ago. For the phase one rehab exercises, anything that unilateral caused quite a bit of pain (the posterior medial taps for example). I went with tempo safety squats and tempo rack Pulls. I’m terrible at estimating a 12 rep RPE and honestly I was probably undershooting which is probably for the best.

After the first week, my back felt phenomenal. No pain. Hasn’t felt better on years.

Week two I added ten pounds to both the squat and hinge and my lower back flared up again after squatting. It still hurts eight days later.

I decided to restart week one with different exercises for the squat pattern. I decided to drop down to doing leg presses and that was about the worst thing I could have tried. Honesty I think it’s the specific leg press machine, it’s precor and I hate it. It somehow puts all the pressure on the lower back.

So I’m using this “squat machine” from Arsenal. What the heck do I call this in the drop down menu? A back squat, a leg press? I suppose it doesn’t matter but it feels way better while still loading the back. Any issues with using this for tempo squat patterns? Pictures attached.

[Jordan_Feigenbaum]

Looks like a v-squat machine to me. You can also do them turned around the other way like a hack squat. I would recommend slowing down and cutting the depth off here in an effort to reduce sensitivity. I also

I also think it’s a good thing that we took a step back from the traditional barbell work. I would’ve likely done that for you, as well as explored if tempo or partial ROM unilateral work was tolerated. I’d really like to see that in there.

For the leg press, I’d be wondering if stance width and/or foot position altered how it felt on your back, as well as ROM. The main thing we’re trying to do here in phase 1 is to get you a couple weeks of exercise where we don’t get a flare up, but are still moving. Adding weight or ROM is all “bonus”, though I’d generally be cautious to do so. The weight just doesn’t matter right now.

[David_Oswald]

Thank you for the help.

And despite needing a reset, my back feels better than when I started. I’m not able to do the unilateral rehab work so this is a reset but I also feel like I am making progress.

I did play around with foot placement on the leg press. I think what gets me is the molded back pad. The gym also has a Precor hack press and it’s the same thing, molded back pad and a ton of pressure on the lower back. But there is also another hack squat where it’s just a flat pad which feels fine. Both the Precor molded seats just don’t fit me well.