A Safe System for Heavy Lifting After a Disc

Bulge

Andrew Lock
Coach

Ive had a mountain of enquiries from people all over the world asking the same
question:

What is the best exercise for my low back problem?

This question shows a lack of insight from injured athletes and their practitioners.
There is no universal best back exercise. There is, however, a best system of
assessment and method of choosing the best exercise for the right time.

Every case is different and needs to be evaluated on an individual basis. In fact, as you
will see in the following case study, the exercises I recommend for back pain change
every two weeks. The best exercise at one point is replaced by a better exercise
when the factors are re-evaluated. To give you an idea of what goes into the planning
and execution of a successful low back rehab program, Ill present a case where
successful return to maximal lifting has been achieved without any significant change in
the MRI-demonstrated disc injury.

A Successful Case Study

In April 2015, this person had experienced severe low back pain after squatting,
and was subsequently stuck in bed for the following week with low back and right leg
pain. The MRI on the left was taken at the two-week mark post injury. The report
described a 9mm retrolisthesis (posterior displacement of one vertebral body with
respect to the adjacent vertebrae) and associated disc extrusion fragment
10x12x18mm. This was compressing the right S1 nerve root and, to a lesser extent, the
right exiting L5 nerve root.
 Compare the MRI on the left to the MRI on the right. You will see there's little change in the disc bulge.

Compare the MRI on the left to the MRI on the right, taken six months afterwards. You
will see there is little change in the bulging disc from the first image to the
second one. What does this tell you? Not a lot, until you understand the rest of the
patients story. Read on, and you will understand why you treat the person, not the MRI.

Initial Subjective and Objective Examination

The patient came to me for evaluation six weeks after the initial incident. He had
just returned to training and was lifting 110kg in both the deadlift and squat with some
resultant aggravation. His hope was to achieve a 220kg deadlift and squat by the years
end.

My subjective and objective examinations are thorough. I use an in-depth subjective

examination that can lead me to a hypothesis I can test further in the objective
examination. I actually dont look at MRIs or read the reports until after both the
subjective and objective examinations are complete. So they never influence my
evaluation of the person.
In this case, my examinations showed lumbar flexion aggravators - postures
involving either static flexion (driving/sitting) or dynamic flexion (bending forward).
Extension movements, such as walking, were pain free. Examination of further lumbar
extension showed some limitation, and also abolition of symptoms and improved
flexion/bending post-extension treatment. A moderate inflammatory component existed.

"There is no universal 'best back exercise.' There is, however, a best system of
assessment and method of choosing the best exercise for the right time."

To look at the MRI, it might have appeared that extension would have produced
exacerbation, due to the size of the fragment and the retrolisthesis. Yet it did not.
Further physical examination showed weak gluteal extension activation, but
excellent hip socket range. So he was prescribed home exercise with an extension
focus and told to cease squatting and deadlifting until his technique was refined. He was
also prescribed glute activation in hip extension and, as he progressed, single leg
bridges focusing on pelvic control.

After a Week
After a week of approximately daily 100 extension exercises (both standing and lying)
and 100 daily glute activations, I reviewed him and evaluated his squat and deadlift
techniques. Here I was mindful of the flexion aggravators and set out to maximise
his neutral spine control. If you have read my previous article on rehabilitation for the
lumbar spine, you will know how it will focus on the pars thoracis components of the
erector spinae as the most effective controllers of this posture.

There was a butt wink at above 90 degrees in the squat evaluation. Structurally I
had tested his hips and found them to be able to get him much lower without that
lumbar flexion. To work on this, I utilised a two-pronged approach:

I started him with face-the-wall squats with toes against the wall to prevent
lumbar flexion and encourage the hip hinge, while using the pars thoracis group
to keep neutral spine.

I then used a counterbalance squat, whereby he held a 12kg kettlebell as far out
in front of his body as he could with his heels chocked (raised). This causes
 abdominal bracing and total core stiffening that translates directly to a functional
squat pattern.

An instant pattern changer. He was compression tolerant but shear provocative to

manual testing. So this also encouraged our pursuit of neutral spine control. He was to
perform the face-the-wall squats frequently each day and the counterbalance squat
every training session.

After 3 Weeks
Two weeks later, his flexion tolerances improved in time, range, and frequency.
He was still advised to minimize these and we began his deadlift and squat technique
alteration. He had been lifting conventional style at the time of injury, but my
examination showed a clear biomechanical advantage to sumo stance in both deadlift
and squat for his anthropometrics. Read my article on sumo prescription to understand
more about this concept. We began with a sumo kettlebell deadlift and a sumo box
squat using a high bar position. The sumo kettlebell deadlift brings the bells mass
closer to your own centre of gravity and minimises anterior shear forces. These were
done daily.

After 5 Weeks
Another two weeks on, all the improvement had continued. He was now pain free and
unrestricted in any movement direction. Changes to his training were still focused
upon creating neutral spine control, but in more fundamental movements. I
prescribed him front squats with heels chocked to maintain the neutral spine, and
overhead bar box squats to continue to strengthen his erector spinae and abdominal
control. He began regular bar sumo deadlifts in place of the kettlebell. All exercises
previously prescribed were now decreased in frequency to accommodate the increasing
variety of movements and loading.

After 7 Weeks
At the next two-week review we worked on a variety of core work. I added exercises
done in kneeling with his eyes shut to enhance proprioception. These included
kettlebell halo movements and some kettlebell core exercises that I have created but
not named yet - hard core control work with loaded changing masses. We used a
double kettlebell seated suitcase lift for glute strength progression. He continued his
previous technique work.

Exercise prescription depends on an evaluation of many factors.

After 9 Weeks
At two weeks again, he was no longer provocative to shear testing manually, and we
instigated kettlebell swings with 16-20kg for sets of five reps. The low numbers were
prescribed to keep his technique perfect. I use a swing that is more glute- and
hamstring-driven than the regular swing technique. My swing approach for rehab is
all about rehab, not just getting numbers done. We also planned for him to perform
squat variations every day during training, and he could now integrate low bar
positioning.

Lifting 200kg at 6 Months Post-Injury

His loads were increasing throughout the entire process. I continued to review him
monthly, making technique modifications where necessary. At the six-month post-
injury mark, he achieved both a 200kg squat and a 200kg deadlift.
So lets look at the list of best exercises for his back:

Passive lumbar extension in prone

Lumbar extension in standing

Face the wall squats

Isolated glute hip extension in prone (knee bent to minimize hamstring)

Single leg glute and abdominal focused bridges

Counterbalance kettlebell squats (heels chocked and heels flat)

Kettlebell deadlifts

Overhead bar box squats

Kettlebell halo and associated core challenges

Double suitcase deadlift from seated

Front squat (heels chocked and heels flat)

Sumo deadlift

Back squat no wink (lumbar control and abs)

High bar squat - avoided low bar for almost 4 months

Low bar squat

Squatting variations

Kettlebell swings

200Kg squat and deadlift by 6-month mark post injury

The point of note here is that exercise prescription depends upon specific
evaluation of many factors, and these change through time as the patients condition
changes.

A Safe System for Unrestricted Training

This case study is an example of my unique strength training system. It is based on
creating a hypothesis from the subjective patient examination and then testing it
repeatedly with objective markers during the resolution process. It is important to
understand spinal anatomy and human biomechanics in detail in order to be able
to safely work with these disc injuries.

Look again at those MRI scans. You can see that the disc injury exists unchanged
(that is another article Ill write), yet the patient is totally asymptomatic and capable of
unrestricted training. This is possible through knowing how to apply the correct hurdle
requirements. The science behind this approach is in depth and spans many experts
work, including Maitland, McKenzie, Janda, and McGill, to name just four. This does not
even include the strength and neurological science works.

It has taken me more than twenty years of unrelenting work and research to produce a
system that does this safely. But lucky for you, Ill be running two-day courses on my
methods during 2016. The first one being a 2-day event in March that Ill co-present in
Melbourne with Andrew Read and Greg Dea. Click here to book your tickets.