I know I know, the title is a cliché but I couldn’t help myself. Dealing with patients with low back pain is our bread and butter as physios. Not that we don’t see other stuff in the office but all of us have seen more clients with low back pain then we can count. For all you physio student that are readers of this blog and have not yet treated patients you still know what lies ahead of you; a lot of sore, achy backs.
For some time now I have introspected on how we treat low back pain and have come to the realization that we are fairly good at treating various causes for low back pain when our patients come see us in the office. We often measure our outcome depending upon how low could we bring the pain down on the pain scale and get our patients back to their ADL’s. However, an aspect we often unintentionally neglect is keeping people pain free and out of our offices. In other words training our patients in lifestyle modifications and on how they should move better. Not all of us though, I have had the pleasure of meeting and working with some physios that hammer the above two points well. For them the whole spectrum of treatment for a person suffering from low back pain does not end at manual therapy/modalities etc to relieve pain and then strengthen back/core etc. This is just half the job done. These physios take multiple visits just to teach lifestyle and behavior modification strategies so their clients stay pain free and learn to move well. We all can learn something from this. This blog post is on one such example. Lets dive right in.
Let me paint a clinical picture we often see- Patient comes in with low back pain, no H/O trauma, pain from repeated bending forward or lifting etc, pain has a gradual onset, no major red flags etc etc. Fairly common scenario. We dig into our tool kits and do a great job in getting the person almost or completely pain free and then prescribe strengthening exercises. We spend a few visits in this. Finally, when its time for discharge, we go over the do’s and don’ts, show them how to maybe lifting things of the floor or bending forward correctly etc and then its goodbye. I have done this in the past and have had lengthy debates with other physio friends about how this seems to be a norm. What we ought to do instead is to spend more time/visits to show them how to bend forward correctly/lift correctly so they can protect their backs.
Enter one of the most underutilized movement pattern that everyone must be able to perform- THE HIP HINGE.
The hip hinge is an excellent movement pattern to disassociate the hip from the rest of the back/torso, an good position to lift heavy things off the floor without stressing the lower back and its associated discs which would otherwise put us at an increase risk of injury (refer to the work of one of the best back research and rehab specialist Stuart McGill to learn more), a great movement to train some of the strongest muscles of the body- the glutes, hamstrings, a very important athletic movement to produce explosive power for movements like jumping, sprinting etc (the glutes muscle is stretched and in a good position to produce great force for athletic performance). The list is quite long. Hence its imperative that we not only master it ourselves, but make sure our patients can execute it well and most importantly, that they utilize this in their day-to-day lives. That only means one thing- practice.
Wrong cuing– Before we proceed, lets talk about what we have been doing incorrect for a while. When we ask our patients to bend forward and lift something off the floor we often say thing like ‘keep your back straight and bend from the knees’ or bend your knees and lift the object of the floor’. There are a few things wrong with this- first this que sounds like a squat and as we all know a squat is one of the most complex movements. Not everybody will be able to perform it well. Secondly, there is no mention of the hips. Moreover, if our patients lack ankle dorsiflexion or/and have knee pain, good luck with having them do this. What ends up happening is that they go back to their default lifting pattern and sooner or later they will be back to see you.
Here’s an example of bad lifting form-
Enter The Hip Hinge-
I’m pretty sure your tired of reading so scroll down for a video on how to hip hinge.
Now go out there and lift heavy things, the right way.
Abhijit Minhas PT
(BPT, MS, CMP, FMT)