It's the sound you never want to hear when weight training. Sometimes you feel it immediately; sometimes you sense something happen but it takes a few hours for the full impact to hit you. Either way you've injured your back. The big question is, what do you do?
I'm going to share with you what I've done from a personal and coaching perspective. Hopefully this will help you make smart decisions following a training-related back injury.
When the word "back" is used in relation to injury, most people think immediately of the lower back. That's understandable; a lower back injury can be serious. However, in lifting, any area of the spine is susceptible. Whilst lower back injuries may be more severe, I suspect middle and upper spine injuries to be just as common.
I'm not going to neglect the rest of the spine. Rather, I'll break this discussion into three segments – lower, middle and upper. Then I'm going to generalize for simplicity's sake and divide back injuries into three categories – acute or severe, medium and minor. I know, no physical therapy text has these categories, but remember, I'm "just" a coach. I keep it simple and real.
Before we get into the specifics, I want to cover some key topics that'll enhance your ability to endorse my approach and apply the guidance I provide. In essence, I want to teach you how to fish, not just give you the fish.
Natural Protective Mechanisms
The spine has the crucial job of protecting the spinal column and nerve bundles that shoot out to different segments of the body. You only realize how much the body seeks automatically to protect this most vital area once you've had a serious injury! The natural protective mechanisms of the body are great, however, in our fast paced lives, if we left the healing just to the natural mechanisms of the body, we'd need a lot of patience.
You can heal yourself faster than the body's natural response, provided you work with the body. Part of working with the body is knowing when to use its protective mechanisms and when to "override" them. Don't get me wrong, I'm not critical of the body's natural healing powers. After all, it's my underlying belief that rehabilitation is simply a matter of helping the body heal itself. However, the protective mechanisms can in some instances slow the healing relative to the rate possible when we add the finest therapy/rehab methods.
To give a simple illustration, one of these protective mechanisms is to prevent further trauma by restricting movement around the site of the injury. If you focus solely on the injured site and neglect the surrounding soft tissue, you won't heal as fast as you could. If you help the connective tissue that's in spasm to "let go" at an appropriate rate consistent with the ability of the injured area to cope with more range, you'll accelerate the healing process.
Whilst I know this may take some higher level, professional judgment, be mindful in the therapy you receive that attention is given to reducing the natural protective mechanism of soft-tissue tension or spasm around the injured site.
Intuition vs. Emotion: Injury and Decision Making
Any discussion of injury also benefits from a discussion of the psychology of injury. One of the most critical aspects of injury management is the decisions you make. In making decisions, we're faced with emotion and logic, and in this case, I'm including intuition in logic.
We all have intuitive powers, but some people refuse to recognize them. They're not "in touch with their bodies." Even my three year old son prefaces many of his requests with "My belly tells me..." This reinforces my belief that intuition can be felt in our "gut" or abdomen. But some people just don't listen to their bodies.
The people that concern me (and I've been guilty of this so many times!) are those who allow the emotional drive to overcome the intuition. Emotional drive can come in two forms: overly fearful or wishfully optimistic. In the case of overly fearful, as a coach I'd tell the athlete, "Shut-up and keep lifting."
But that's relatively uncommon. Most lifters go the other way: they're wishfully optimistic. They think, "The workout is going great, and if I don't get that next set in I won't feel complete. I may even shrink or suddenly get weak. I'm going to ignore that shooting pain and do the rest of the sets as planned! I'm sure it'll go away any moment..."
That's where a coach or trainer comes in. A coach, assuming he's in control of his emotions and respects your intuition, ideally makes a wise and objective decision. As most of you won't have the benefit of a coach's objective perspective, I'll teach you a technique to balance your decision.
In your mind, place clearly your intuition on one side and your emotion on the other. Now, ask yourself objectively, which has the more powerful case? As the judge and jury, you'll have to live with the decision. But the great news is that you can learn even if you make a poor decision.
I'm an optimist myself, so don't misinterpret the use of that word above. I'm referring to when a person unwisely uses optimism to override intuition. And I'm in no position to judge anyone, as I've been guilty of this more times tha I'd want you to know. But like I said above, sooner or late, I learn. Don't beat yourself up after the first bad decision. The pursuit of wisdom is a journey.
If in doubt, don't do it. There are few side effects to be felt from being conservative in your decision making. Conversely, there's a lot of downside in being bullish.
Categories of Injury
1. Acute or Severe
Acute injuries are the ones that'll likely terminate your training there and then. This is where you immediately know there's something really wrong. Only a fool or a very brave person might be optimistic and keep going. With an acute injury, you may even be on the ground at this point. The full effects of this condition won't be known to you now – it could get worse.
Medium level injuries refer to injuries you know have occurred, but you're unsure about what to do. This is because you probably can train, but should you? This is the danger associated with the medium level of injury: the fact you could still do the set, but aren't sure if it's wise to do it. You can learn by trial and error, as most do, or you can benefit from the experience I share in this section.
Minor injuries are those you didn't realize occurred during the workout. Once you realize you've had an injury, you probably won't know when or how it first occurred. Having said that, you become aware of minor injuries at some stage post-training, but because they're so minimal, you're tempted to brush them under the carpet and keep going.
This gamble sometimes works... and sometimes it doesn't. The insidious nature of these injuries is based on the old jungle saying, "Little leopards become big leopards and big leopards kill." These injuries can grow over time. If you neglect them, they can become serious injuries that'll keep you out of the gym. Or worse still, they can lead to more serious traumatic injuries.
I have a saying that relates to this situation: Allow half the time you've had the injury for it to be removed in full. The implication is the longer you allow this chronic injury to hang around and possibly get worse, the longer it'll take to get rid of it. The solution is to act fast!
Chronological Steps in Injury
I'll be addressing the injury chronologically in five steps:
Step 1: Initial response
Step 2: Medical and physical therapy support
Step 3: Personal management of the injury
Step 4: Exercise selection during the rehab period
Step 5: Avoiding future reoccurrence (Or ideally, preventing it from happening in the first place!)
Let's break those down.
Step 1: Initial Response
The initial response is what you do when you first become aware of the injury. For most people, this is a decision they make alone. For the elite athlete, there may be a number of professional people around them to assist. For those with a trainer, there may be one person they can turn to.
But you need to ensure that the coach or advisor is in control of his emotions and respects your intuition enough to make a wise and objective decision. This may sound like a very basic point, but I've seen too often where a coach wants an athlete on the field, and a physical therapist is only too willing to oblige (which in many cases is why he got his job if the coach is the decision maker!), and so they "help" the athlete decide that it's okay to train or compete when, ethically and in the interests of the athlete, it isn't likely to be.
The implications of decision making in injury, especially severe injuries, can be greater closer to the original incident than further in time from it.
Step 2: Medical and Physical Therapy
As soon as possible after the initial response, I recommend seeking medical guidance. Note I said "guidance." The historic forte of the medical profession is drug prescription and surgery – and this may not be suited to your needs.
The medical consultant will conduct some type of scan or X-ray (or both). This would then be followed by therapy in light of what you learn from the medical investigations. Few MD's will have a clue about injury rehab. Just hope that they recognize their limitations and refer you to a great injury treatment specialist. If the MD doesn't, you may need to go on a search via others to get a referral for someone in your area.
Treatment specialists will come from diverse backgrounds, belief systems and titles.
You're probably going to benefit from seeing more than one type of injury therapist. Three things I recommend:
1) Working with therapists that are comfortable with the fact that you don't intend on having a monogamous relationship with them.
2) Being honest with them about all the treatments you have.
3) Having one person in the treatment field helping you make management decisions or coordinate the game plan.
I'd like to think the days of one type of treatment specialist having an agenda against a different discipline are long gone. If someone does discourage you to seek a different or specific type of treatment, review any possible bias in his recommendation and take that into account.
If you're not honest with each different type of treatment specialist about who else you've seen, what they've done or recommended, you're not helping yourself. That's a bit like the patients who seek various doctors so they can gain multiples of the same prescription drugs.
Whilst I do recommend selecting one of the medical/therapy teams you use to be your dominant guide, I'm going to encourage you to be in charge, take responsibility, and make the final decision. What, you don't have medical training? Think of it like this – to leave injury prevention/rehab decisions in the hands the medical/physical therapy professions is like giving the mafia the keys to the government and asking them to look after it! I haven't met too many from this profession who are dedicated to making themselves redundant and unemployed!
You also need to consider the role of drugs in your rehab. A professional's opinion will be colored by his or her own beliefs. So get clear on what you want. But don't use this as an excuse to become a junkie; understand that many pain killers and muscle relaxants can be addictive.
Now you're off to the physical therapist, or ideally, more than one type of treatment provider. I can't say what's going to work for you, or how good the person you're seeing is as a representative of their discipline, but I can give you this hint: if you're not making progress within two to six weeks, stop contributing to their retirement fund. (They're probably retired in the mind already, but keep turning up in the body anyway!)
Any worthwhile therapist will see the limitations of your relationship (the lack of progress could be caused by either one of you) and resign from the relationship with perhaps a referral to someone considered more effective (or if they thought you were a real pain in the arse kind of client, they may even send you to someone who they perceive is a great match!)
You should consider the full range of injury treatment professionals, including but not limited to:
ART (Active Release Technique)
Step 3: Personal Management
I'm not referring simply to things like getting out of bed safely – although you should! Here's my take on the relationship between medical/physical therapist contribution and your personal management.
Assuming you're genuinely committed to be injury free (don't laugh, this isn't always the case!), you're the person most committed to the prevention and rehabilitation of injury. If you get sucked into the mainstream reliance on others, you give them a warm feeling of being wanted, contribute to the gross revenues of that profession, and slow down your injury rehab! The role of the medical/physical therapy profession is to give you guidance as required, and to apply drugs or treatment methods to advance or breakthrough sticking points in the injury rehab process.
So how did I figure this out? Well, apart from watching many doctors and physical therapists wishing to play God with their injured patients (have you heard the "Don't do this activity until I tell you that you're ready to do this activity..." line yet?) – consider the following.
The three main factors that contribute to injury rehab and prevention include:
1) Connective tissue tension
2) Connective tissue length
3) Joint stability
I know, there are many different philosophies and many won't confer with me. For example, a chiropractor may tell you a bone is out of alignment and needs manual adjustment. I might say a bone is out of alignment because (unless you were subject to a blow or similar) the muscle tension, length or stability affecting the joint in question isn't appropriate. Now this doesn't mean I don't recommend or personally use chiros. This is just an example of divergence in injury theory.
But work with me; humor me for now. If you know of the ability of stretching to contribute to lower connective tissue tension, then who has the most power to effectively lower connective tissue tension – you or another person/drug?
If you know that stretching can contribute to increased connective tissue length, then who has the most power to effectively increase connective tissue length – you or another person/drug? And if you know of the power of selected exercises to increase joint stability, then who has the most power to effectively increase joint stability – you or another person/drug?
I understand that I've raised the subject of stretching and assumed some alignment with my thinking on that topic. Perhaps optimistic. An activity that so few bothered to do or talk about a decade ago has now become an activity that's still not done, but now everyone has a "scientific" reason for not doing it! But perhaps that's a rant for another day.
The relative contribution to each of these three key injury rehab and prevention issues is as follows:
|Variable||Medical/Therapist Potential Contribution||Your Potential Contribution|
|Connective tissue tension||60%||40%|
|Connective tissue length||40%||60%|
Now you're seeing the first reason I believe you should be in charge and take a key role in your injury management. This is generalized and simplistic, but you get my message.
The second reason I have for believing you should be the final decision maker is this – chances are, you received the injury chronically. This means over time. Even if the injury was traumatic or suddenly apparent during training, chances are there was a significant chronic or "over time" contribution. The gym is a reasonably predictable environment – you aren't about to be tackled from behind. For this reason, most gym injuries aren't acceptable because they could've been avoided.
Most injuries build up over time as a result of inferior decision making – decision making about volume, load, frequency, density, exercise sequence and selection, and so on. Want to prevent them? Make better decisions!
If you get another person or drug to help you overcome the injury, the cause of the injury remains. You have to learn to take charge! The great news is I'll share with you some very effective personal management techniques for back injury in this article series!
Step 4: Exercise Selection
There's a lot of focus in literature on "contraindicated" exercises – exercises that some professional or group believes shouldn't be done by anyone or anyone with specific conditions. Now if you have a back injury, you're a prime candidate to fit into one of these lists. But if you're reading this, I doubt you want to be subjected to that kind of limited thinking.
There's no such thing as a contraindicated exercise. There may be exercises that are inappropriate for a certain person, at least until they change their condition and then it'll be less of a risk. More importantly, there are inappropriate techniques and loads for some people.
Take the deadlift for example. I guess that would be high on the hit list of contraindicated exercises. It's a great and very safe exercise if you know what you're doing, or more specifically, do it the way I recommend.
What you'll benefit from and want, I believe, is guidance that's less fear-based and more specific to the reality of your needs. That's what I aim to provide you with! You'll need to make adjustments in your training, and I'll offer some direction there.
Step 5: Avoiding Future Reoccurrence
In this section I'll talk about the most common contributors to the spinal segment injury. As I've said above, most injuries that occur in strength training are built up over a period of time because of what you do or omit to do.
Now, you might not like what I have to say about this topic in later articles in this series, especially if it challenges dominant dogma or paradigms, but give my ideas a go and you may be pleasantly surprised! You're more likely to be receptive to new ideas when you're in the hole of injury, especially if you're struggling to get out of the hole.
I've concluded that I have been in my training life a test pilot for injury rehab – that's a positive spin on my personal injury list! Seriously though, many have benefited from my journey here, and you can too. But it begins with trust.
I said from the outset that this is a coach's perspective, yet I believe you may find power in what I share. In the next installment of this series, I'll get more specific with information on how to deal with back injuries once they've occurred.