1. Assessments take time. When looking for proper treatment, proper assessment of the issue takes time.
2. Every spine needs movement. But every spine will have its own movement window.
3. Stay in your lane. Know you field and know it well, but always have a referral network.
4. Stretching is not a magical fix. Tight hamstrings isn’t the immediate answer for fixing your non-specific low back pain
Despite the advancements in technology, medical development and ergonomic chairs, many people are still suffering from low back pain.
DTS Fitness Education Director of Education Ben McDonald speaks to low back specialist and strength coach Joel Proskewitz about his own back injury journey and how to address clients with back pain (listen to full 39 minute podcast here).
A student, and now instructor, for Dr. Stuart McGill of BackFit Pro, Proskewitz is keen to emphasize every client who has back pain will have different outcomes and rehabilitation programs based on the initial assessment.
#1) Assessments take time. Not one person will have the same injury or assessment outcome.
As someone who’s doctor once told him to stop working and get a desk job or he’d end up in a wheelchair due to a fractured spine, Proskewitz notes his previous injury has helped connect with other clients with back pain. It was through his own journey to fix a potentially debilitating back injury that Proskewitz found Professor Stuart McGill.
McGill, known for his work on low back pain and the “McGill Big 3”, typically has three hour long assessments to address every potential issue a client suffering from low back pain may have.
“The thing that struck me what how definitive (the doctors) were about their resolution after seeing me for 15 minutes,” says Proskewitz of his experience. “That really bothered me because as a trainer my assessments were one hour. So someone would come in and we would do an hour assessment, but this neurosurgeon I saw, from start to finish would be 10-15 mins after looking at my MRI.”
The root of the assessment is not immediately finding a solution, but to discover the problem first, he adds.
“If someone is dealing with chronic back pain and they’ve seen multiple clinicians or trainers, and they still don’t have a resolution, have you sat in front of someone who has given you a very thorough in depth assessment to precisely determine what is going on in your back,” says Proskewitz. “If that is so, then they should then have not necessarily the resolution to have you pain free, because pain in multifactorial, but they should at least have a guide or a road map to direct you from where you currently are to where you want to be. It all begins with an understanding of what the problem is.”
Now working alongside McGill as an instructor, Proskewitz notes the assessment protocol gives the clinician a better understanding of what the client can tolerate, what their capacity for work is, what is hurting them, is it a disc, is it a bony structure, and can they flex their spine without pain.
The assessment portion follows a movement-based protocol where the practitioner will place the client in certain flexion or extension positions, rotation and traction. The outcomes of each movement screen will determine a movement-based exercise program.
Realistically, not every practitioner will have three hours to spare for an assessment. In an ideal world, Proskewitz would like to see people in the healthcare and social care system increase initial assessment times from the typical 15 to 30 minutes.
“My hope is this, even if you only have half an hour, make that half hour as meaningful as possible,” he says. “Determine what tests are going to be suitable for that person, listen to them and do as best as you can in the confines of your space and time. My hope is that health care and the social health care system understands that clinicians need more time to see patients. Truly half an hour you’re just scratching the surface. We can’t create a solution if we don’t know what the problem is.”
#2) Every spine needs to move based on the person’s own movement window
The spine is a multi-facetted joint that needs movement.
That said, everybody has a certain movement window, cautions Proskewitz. “Someone with no back pain has a bigger movement window than someone who has back window is more narrow.”
Followed after the assessment, the prescription of the exercise or movement window is delivered based on the outcomes.
“The outcome tells me the tolerance of that particular person’s spine; the capacity of what they’re able to do,” he says. “It also tells me from the mental perspective where they currently are. Are the phenomenally fearful, are they a resilient person that can handle a hell of a lot more than another person who has more of a fragile mindset. All of these things need to be taken into consideration with the ultimate goal to slowly increase their movement window and their tool box.”
In short, movement is essential to a person’s prescription but every prescription should be catered to that person’s results.
#3) Stay in your lane. Know you field and know it well, but always have a referral network.
“ I’m a true believer in we need to stay in our own lanes,” Proskewitz states. “A lot of people will look at me and say, Joel, you're a strength and conditioning coach, what are you doing with low back rehab? The thing is, I’ve been in the orthopedic game for over 25 years.”
Part of his success as an orthopedic rehab and strength coach stems from his large network of other clinical practitioners. He has three physical therapists on site at his facility, and four spinal surgeons down the road with a direct link too.
“I know what I know and I know what I don’t know. On that basis, I’ve never ever pulled the wool over my patients. I’ve never told them I can fix them up and take their pain away,” he says. “If you don’t know, you don’t know. Refer out. Two really great brains are better than one. It allows the trainer to expand their actual tool box.”
If you’re able to step back and acknowledge your client needs to see someone else, once they are better they will trust your word on the road to improving their health.
“If the trainer refers to a person and the client gets better and comes back for training, that trainer is really regarded as done the right thing and that client can never ever point fingers at their trainer,” says Proskewitz. “If you don’t understand the why, hopefully you know someone who does.”
#4) Stretching is not a magical fix. Tight hamstrings isn’t the immediate answer for fixing your non-specific low back pain
Part of the problem with fixing low back pain is many people assume they need more flexibility and to continue stretching their hamstrings.
“There’s a misconception that a lot of back pain patients are given that there is a correlation between stretching their hamstrings and getting their hamstrings loose, and the alleviation of their back pain or the removal of pain triggers or back pain,” explains Proskewitz. “When someone injures their back, whatever the injury is whether it’s muscle, ligament or disc, the body perceives there is a threat, which sends a signal to the central nervous system which is the brain and spinal cord, and the thing that is easiest to interrupt the central nervous system would be a disc bulge.”
The body will continue to perceive the disc bulge as a threat, and in response, the body will tighten up certain muscles to stop that person from doing a particular movement that could make the threat more impending.
“If you look at it that way and you determine what the threat is and the cause is and the removal thereof, the flexibility and natural range of motion will come back over time. Stretching your hamstrings is not going to magically fix your back,” he adds.
The ultimate goal is to give the client a better understanding of their spine, their body, and what they need to do to help themselves.
“I don’t want them to rely on me or to rely on someone else for the next eight months to get rid of their pain,” concludes Proskewitz. “My goal is to create self-efficacy for that person to understand and overcome their back troubles. The number one thing for me is to determine the cause and in turn create a resolution for them to create self-efficacy and to empower them. It takes away the fear of preventing them from doing things.”
Resources and References from the Podcast
Backfitpro Course (In Class): https://www.backfitpro.com/clinicians/courses/
Book: Gift of Injury - Canada: https://www.amazon.ca/Injury-Stuart-McGill-Brian-Carroll/dp/0973501863/ref=sr_1_1?hvadid=224487941514&hvdev=c&hvlocphy=9001326&hvnetw=g&hvpos=1t1&hvqmt=e&hvrand=3390147732787810232&hvtargid=aud-748886260307%3Akwd-368080320606&hydadcr=22428_9261604&keywords=gift+of+injury&qid=1574718470&sr=8-1