This is a back pain 101 for lifters – taken from our Weightlifters Connect group discussion on Clubhouse, with Back fitpro Dinneen Viggiano on 11/02/21
For those in the session – a booking link for our 60 minute individual movement screen is below – to check your red flags and explore an action plan to improve your lifting. Early bird offer expires midnight 13/02/21 GMT
As an athlete, and having suffered two herniated discs, I’m fascinated by back pain disorders. It was the work of Stuart McGill that allowed me to get to the bottom of my issues & return to competing (using the Big 3 movements & spine hygiene – see his book ‘Back Mechanic’)
As a coach I focus on good technique, optimal movement, and self-care in training, allowing you to continue enjoying lifting for many years without back pain. I love learning about the bio/psycho/social aspects of pain, especially fostering the mindset needed to fully recover into sport again, so I am excited to introduce Dinneeen – a Back-fit Pro based in NYC who founded the Retrain back pain’ – a holistic, integrated, and empowered plan of care and coaching for back pain.
What is your story and how did you end up becoming a backfit pro?
I have been active most of my life, and I’m now 50, I got into yoga pretty heavily in the ‘90s, whilst working at a stressful job. I was the little fresh faced kid on the block then! The theory on yoga then was ‘go deep, find a studio, and method that you like to practice, wake up at four am and practice for two hours’ – it was it was pretty hardcore.
I soon noticed that after a ski weekend or playing soccer, when I returned to my classes, my practice would suffer. I’d go into my yoga class, and I couldn’t do it anymore, so silly me, I stopped doing other things so that I could be better at yoga! Really what I was experiencing because I didn’t know any better, was the push and pull between strength/ stability, and flexibility / instability. At that time I was stable and strong, yet I was choosing to swap it for flexible and unstable eeeew.
I was coming into my 30s, I got married and had a kid. We all know, having and carrying babies, is also destabilising for women due to the changes and ligaments, and all the changes that go through a woman’s body when she carries a baby human inside of her.
With the combination of these things between 1998 to 2003, and the stress of both my parents passing, I was starting to have some back pain. I then moved a piece of furniture and something went in my back. I tried to fix it myself for eight months by stretching. The stretching felt good, because of the Myotatic stretch reflex, offering short term relief, but the pain would always return. I was seeing clinicians from all over New York City, I got scans and chased all the diagnoses. Looking back, the things that were causing me pain were actually not my diagnosis. There were other things happening in my spine, which as a non-radiologist, a non-medical professional, I can see clear as day. I simply couldn’t find the care that I needed.
There was nothing I could do to help myself, no basic practical, integrated, advice or physical exercise, bar one physical therapist who prescribed five, standard, canned physical therapy exercises. The other therapist’s strategy seemed to be, come see me, I’ll tell you how messed up you are, do something to you, then send you home; rinse; repeat.
This does work for some but I am a health-seeking, go-getter kind of person. I really wanted to know how to help myself.
How am I supposed to sleep? How am I supposed to stand? What shoes do I wear? How can I tie my laces without pain? Should I lift? Should I do yoga? What’s safe, or not safe? Should I take supplements? Should I……
By this point, frustrated and unable to play with my kid or lead my life, I had stopped exercising and everything was crumbling in front of me because of the back pain. The diagnosis was spondylolisthesis, herniated disk, disk degenerations, pars fractures, scoliosis, stenosis, and there were other things going on, that I now know about, changes in my vertebra, inflammation, facet joint syndrome and SI joint compression.
I eventually found practitioners I respected and began studying with their mentors, leading me on a five-year process of travelling the world, whilst delivering courses to train other movement professionals. Whilst travelling I went to many workshops, and met or trained with anybody that was doing ground-breaking work on back rehabilitation, as well as those in the field of movement, nutrition, breathing, Pilates, and orthopaedic manual therapy.
I now work with people one to one and have spent five years developing a process that works to help people become their own back rehab boss. It’s a basic three- tiered system giving people what they deserve to know, to move forward, prevent, relieve or manage many back conditions. The program is now being developed online to reach more people.
The three pillars of our work are…
1 Mindset, how you think about pain and injury.
2 How you live, encompassing recovery, rest, nutrition and hydration,
3 How you move, including dynamic stretching, strengthening, breathing and therapeutic rollouts and fascia treatment.
There are many causes/types of back pain and ways to treat it, can you touch on some common conditions you see e.g Disk problems, Spondylosis, Scoliosis, Stenosis & SIJ
Disclaimer I’m not a medical professional, or a physical therapist – but I can help people from a non-medical viewpoint. I am big on working with a rich referral network directing people to the correct therapy for their needs.
Traditionally the back pain industry and many of the practitioners in it, are stuck in the mechanistic model of back pain, whereby the thinking is something is broken inside of you and has to be fixed or repaired. The new word model, which I adopt is the biological, psychological, and social model, incorporating the fact that you’re a whole person with other things happening in your body and environment that contribute to back pain along with the psychological and emotional elements such as how you understand trauma, pain, or illness, which can also be huge factors having hurt your back, affecting the rate of your recovery.
So physical therapists are really kinesio, mechanistic doctors, they will test you and see what is not working well, to see if they can fix anything, this does work for many people. But the relationship of the person to their body, the root cause of the issue and how they’re moving their body on a daily basis has a huge positive or negative impact on recovery too.
I work with a lot of therapists and I don’t tend to see people who have back pain, because they’re stiff or they’ve been driving a truck too long etc occasionally people come because they sit at their desk too long, but in reality, there are many different mechanisms of pain for people who lead different lifestyles. For weightlifters moving gigantic barbells, the mechanism of pain is not usually because their back is stiff, weak, or because they are sedentary – it usually comes down to a mechanistic injury.
The most common mechanistic injuries I see are disc injuries, either herniations or extrusions. A herniation is where the nucleus pulposus inside your disk starts to break through the annular fibres like the rings on a tree, the annular fibres of the disk start to break down and this happens through repeated compression, or repeated torsion or shear compression and torsion to the discs. Extrusions are a worse injury overall but actually heal better than a protrusion which often continues to affect the nerves surrounding it that are pressed upon.
Extrusions tend to heal quicker because when the disc material seeps out of the disc, macrophages in your body come by and remove this foreign material from the spinal canal, and the acute pain will start to subside; whereas a disc protrusion/bulge in the annulus may take a little longer to heal and continue pressing the nerves surrounding. A bulging disk is mis-shaped and probably a little compressed so there is a process of fibrous re-calibrating to heal them. Eventually, the disc will toughen itself up, just like a callus on your hands. It doesn’t reverse completely or heal but the body starts to ameliorate the situation.
McGill likes to say the ‘disks gristle over like gristle on a chicken’!Stuart McGill
Disc herniations will not show up on an x-ray so you will need an MRI from a referral from your GP. To see where they are and if they are aggravating a nerve bundle which causes the discomfort. People can have disc issues, for years and not have any pain because it’s not leaning on a nerve. For more info on these types of injuries try Stuart Mcgill – Back Mechanic
I also deal with Spondylolisthesis where one vertebra shifts over the other due to part of the bony protrusions on the side of a vertebra becoming fractured (a common condition seen in soccer players and gymnasts). Then there is scoliosis, a sort of a squirrelly shifting of the spine out of its traditional curvatures. There are also inflammatory conditions called ankylosing spondylitis, which is not that dissimilar to osteo-arthritis, a kind of autoimmune condition which hardens up the spine. Stenosis, common in people over the age of 55, is a calcification within the spine which creates a smaller area through which the spinal canal and the nerves can move. The treatment of spondylolisthesis and stenosis is slightly set apart from other back pain issues and best dealt with in conjunction with a doctor.
Sacroiliac Joint dysfunction (SIJ) is a different sort of beast right there! It’s helped by all of the spine hygiene (how to sit, stand, sleep, lift, carry, walk) but can be a big trigger for many pain issues. When I had a diagnosis for my back, I think most of my discomfort was actually stemming from SIJ compression. When I look at my X-ray, you can see my SIJ has a big gap in my left side and is jammed up on the right side. But, again, that was never looked at on the diagnostics of a radiology report!
When somebody has SIJ, I asked them about their ankle injuries. I check their ankle mobility, because really a dysfunction in the ankle whereby the ankle is no longer mobile or strong, starts a chain reaction through the skeletal system; in my opinion, in almost 99% of people who have had ankle injuries, end up having sacroiliac joint dysfunctions, compressions or form and force closure issues at the pelvis. To relieve SJI compressions I suggest rolling a ball around the glute, and glute medius, doing side hip rollouts, and low-level activation torque drills for the SIJ. Backing off squat work and quit wearing your lifters for a while. Add hip adduction work to your training and always stand or sit with your legs uncrossed and equally load-bearing.
When I talk about these painful conditions with someone who has back pain, they tend to feel fear. When I started hearing about my diagnoses, they sounded terrible, like ‘degenerated disc disease’ “and it’s irreversible” what a terrible way to explain it! There should be a different way of speaking to patients about their back conditions; I like to approach people’s diagnosis by teaching them their diagnosis includes “degenerative disc disease’. Taking ownership of their diagnosis leads directly to how you start to identify with the injury in a positive way and move forward. The industry currently does not give us the tools to understand our anatomy, injury, or what pain triggers makes it worse or better, I’m just one woman with a lot of curiosity and motivation to figure shit out! I believe all patients should get a baseline of simple recommendations when they get a diagnosis and everyone should learn about spine hygiene. Both these factors will help with alleviating every kind of back problem yet these things are still not taught.
Having experienced these issues myself this is great advice – as a coach the 1st thing I was taught was ‘do no harm + protect the spine’ I also think of the spine as the highway for the brain & nervous system, and understanding if you block or have potholes in the highway – including in your mind – your movement will suffer or stop without repairs. Lifting is awesome to build strength and resilience in the muscles required to help alleviate and prevent back pain whilst promoting good basic movement patterns, and control of your spine, as long as it is done well. I think it is important that coaches and lifters are aware of the signs of a major back incident, because it can happen: what are your red flags to identify when to take it very seriously and get emergency help to avoid long term damage?
When somebody gets really hurt, the first thing you’re dealing with is that they go limbic, e.g their eyes get real big, they may get they may become uncommunicative or unable to answer questions, as they go into shock. With shock help them stay calm. Their eyes will end up darting around or they’ll be shut, which is normal at the first onset of pain, but within a minute or so you want that person to look at you and connect with your eyeballs, to see your soul, because that’s what’s ultimately going to give them the vagal nervous system reassurance, of human connection to bring them back into their body and lessen them freaking out!
In the following cases call the emergency services:
If you have numbness or tingling in the pelvic floor area? (Called Saddle paraesthesia?) or if you have any difficulty urinating or defecating? Or have been incontinent.
These symptoms should not be ignored and indicate the possibility of Cauda Equina Syndrome. Cauda Equina Syndrome is the result of a problem at the base of the posterior spine putting pressure on the Canada Equina bundle of nerves which control the bowels, bladder and pelvic floor and sex organs. If somebody’s getting a lot of really terrible nerve feedback, not necessarily sciatica, but in some other area where they’re completely losing feeling and a part of their body, get them checked out at the emergency department.
There’s a mnemonic in the back pain world. TUNA FISH to help you remember the red flags for medical attention.
- T is for a trauma
- U unexplained weight loss,
- N neurologic symptoms,
- A age if they are over 50yrs and more likely to have cancers.
- F fever,
- I intravenous drug users
- S’s for steroid use and
- H is for history of cancer
Notably also pain is in the thoracic area. Particularly if it moves around, comments such as “Oh, it was on the left side of my spine under my shoulder blade, and now it’s on the right side of my spine” pain that moves around that doesn’t sound muscular especially if they’re over 55, can occur with malignancies that happen in the upper body, so you get them to visit a doc.
Outside of medical emergencies other back-related nerve issues can be kept in check by following a basic mobility routine to alleviate pain, by moving the muscles around the nerves which may free them up from being trapped, around big, thick, or inflamed muscles.
Absolutely; we have various screening and self-care protocols for new and existing lifters at the club. I’d be interested to hear your thoughts on anything that you add or take away from what we do currently.
For new or existing lifters we follow a 123-approach shown below, and we follow the patterns we find to build a training program with achievable tasks for the lifter. We find that the the plan, no matter how basic, is the key to improving mindset around a problem and moving forward.
- 1 Refer out In acute or chronic cases we refer for a full diagnosis to insure they are safe to train and to avoid any unpleasant disasters.
- 2 Basic Movement/posture screens with our lifters, checking e.g. squat, OHS, pull horizontal vertical (hinge & row), push horizontally vertically Push up OH Press. If issues appear then we dig a little deeper
- 3 Full Assessment – using prone, seated and standing screens and drills to discover if the issue is caused by breathing, bracing, core control, or postural, joint or strength imbalances, producing dodgy motor patterns or restricted ROM. And decide if there is a need for further help.
As coaches we are always looking for technique Red Flags – precursors to back problems occurring and seek to eliminate them. Our red flags are..….poor posture/core control, inefficient breathing patterns, joint restrictions/muscle imbalances, and the female menstrual cycle. Some Red Flags in lifting are easily recognisable to others and look like….
- Prawn like deadlifts – a rounded or flexed back in pulling movements,
- Poor depth or butt wink in the squat, plus balance or knee valgus issues.
- Wiggly worms – often seen in pushing & pressing movements showing up as excessive lower back arching along with overhead reach restrictions.
I find 90% of these can be improved with focused practice and a program that encompasses learning to….
- Breathe / brace correctly for loaded movements and relaxation
- Perform corrective mobility and or activation drills
- De-loading the bar & practicing good lifting form and not rushing back too quickly to the loading of a movement.
- Help women to track their menstrual cycle – to understand the times when they can be unstable/weaker and more prone to injury when training)
- increase understanding of other influencing factors such as – stress, nutrition, hydration etc.
It sounds like Lakeside is a place where people take care of themselves, don’t push through pain, and would stop a workout if they injured or reignited an injury, you refer out to someone for help, and care about what they found out before returning to training. I love hearing everything that you do to care for your athletes. How do you screen for bracing, and breathing?
We coach breathing drills from a supine position on the floor, check for diaphragmatic breathing, the ability to draw breath deep into the core, and use of the transverse abdominals to stabilise the trunk, I like Z breathing drills, which were taught to me early in my lifting journey. We then progress this to standing and more dynamic movements. The combination of breathing and bracing is also practiced with a held breath (valsalva maneuver), to support lifters under heavy loads. The breathing aspect is something that lifters do tend to avoid practicing, because spending time doing this may seem like quite a foreign practice. Any tricks you use?
Yes, the lifting crowd is not always keen on just being still in breathing as they would rather be moving! I like to get them to play with resistance bands, tied around their lower rib cage or their upper chest so that they can feel resistance and tactile responsiveness, to feedback on their breathing. It’s rewarding and feels doable when they have a tool to work with. Also, they can try sitting with their back to a wall, butt on the floor and knees bent, then ask them to find a neutral spine and cross their arms around their front chest. Then try to breathe into the wall to find their back breathing too, it works best after they’ve done some mobility or rolling on their back.
Awesome, I love some different variations. We will try them out!
Could you walk us through your basic protocol with clients and is there anything unusual you do?
I start the process of screening from my intake forms – I do breath and postural assessments, including basic standing, overhead reach and backbend. From there, you can see limited mobility in their ankles, thoracic spine or shoulder flexion real quick. Similarly, in a forward bend, look to see if hips are way behind their ankles, or if they bend with a rounded spine, or flat spine, using their cervical extensors to keep their stability. A single leg stance test will also indicate hip and glute stability, which is important, especially for sacroiliac joint problem people in particular.
It sounds like you already look at posture, mobility/ stability drills to activate the core and the nervous system before doing any lifts. I too focus on standing postures from the front, and side, to the simplest idea of what muscles they are using just to get through their day. If that person is balancing more towards the toes then back erectors are probably jacked up before they step in to train so they will probably need more core activation. And those who are naturally excessively lordotic and have imbalances or an unbalanced standing postures by habit. These people tend to look like the Leaning Tower of Pisa, leaning over their toes and are often extension intolerant, because they’re in extension all day, just to stand up.
Absolutely, the power of activations is huge in alleviating lower and upper back or shoulder issues too, if the shoulders can’t get into full flexion, the spine will create the mobility the shoulder does not have which is not ideal!
Yes, I use shoulder flexion tests on everybody, especially with weight lifters as most people really can’t get their arms/shoulders through flexion past forehead hairline area, without sacrificing the midline without a backbend; these people clearly can lift, but they need a combined core and shoulder mobility program.
I also really like to know where people’s scars are from their intake form, even if it’s wisdom teeth or C- sections, or stepping on a nail as a kid. Scars can cause messed up neurologic signalling. I’m a level three neuro kinetic therapist, so I’ve found a tonne of messed up issues relating to scars as they are a trauma and can be indicative of other issues. My scar work is more energetic, rather than pulling them apart or trying to break them up.
We all agree BP and injury is pretty miserable – you mentioned starting with mindset and breath How do you approach this as part of your rehabilitation process for people learning to trust their bodies again?
The first thing I work on is mindset with people – how they describe themselves, their body and their issues. I will ask what brings you to me? What can I do for you? What is the main thing I can help with? There’s usually a tonne of blame, hate, or betrayal that they feel by their body in their language, e.g I’ve put all this time into you and this is what you’re doing to me?!
Like your body is punishing you by getting injured? Especially with athletes, there’s a huge sense of the body failing them which turns into they are failing their training and thinking I am a failure. It is very normal but is building a pessimistic negative mind set! So Just talking things through for people is reassuring, allowing them to break through their mind chatter to be more in tune with their bodies. Athletes or people who do intense, hard sports, are often creating so much stimuli in their body that they don’t listen to it. It’s like a displacement – I’m just going to train hard so I don’t have to feel anything at all.
Often people feel pain they say ‘ouch, it hurts- its pain’. Stop using the word ‘pain’ altogether, is actually helpful to feel less of it, so I think crushing that is probably the number one change and is super easy to do.
Secondly, I help people breathe better. When injured, the hormone cortisol goes up, and we are in a constant stress response due to the injury. I teach people to relax, sit and breathe, emphasizing breathing, to calm the nervous system, so the body can heal itself. If you show them the mechanism of how breathing heals, and build it into home practice, they know why and how it will help them and they’re a lot more motivated to do it.
I like them to find a place where they can be quiet and start to sense what their body is telling them. There is a spectrum of sensations happening in your body, so they need to listen and interpret what their body is telling them, to be able to determine which tools may be useful to use for their back today.
Are the sensations pinchy or is it tight? Is it tired, cramping or fatigued? Is it stabbing, dull or sharp?
Once you start to understand that spectrum of what your back is telling you, it allows you to discern which tools are appropriate for the best relief and you can move forward with resolving the problems. I help facilitate this process and work with other practitioners to enable people to keep going.
Awesome -I have really enjoyed talking with you today and look forward to more conversations in the future, if our followers would like to get in touch or find out more about your work where can they find you?
My website is https://retrainbackpain.com and I am on instagram @retrainbackpain feel free to send me a DM
The Early bird offer for a 60 minute movement analysis at Lakeside Weightlifting is available on the link below for the next 48 hours.
Book references –
Back Mechanic – Stuart McGill
Movement Assessment & optimisation – Quinn Hennoch