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Le Tour De France: Breaking the Back of it! Part 2

Prior to prescribing any treatment one would carry out a full assessment of the client and rule out any sinister causes of the back pain. Therapists look out for things call red flags, should you observe any of these expect to be referred for further assessment before receiving any treatment. Red flags consist of the following:

• Younger than 20 or Older than 55
• History of Cancer
• Unexplained Weight Loss
• Constant and Progressive Pain, even at Rest and at Night
• Generally Feeling Unwell
• Neurological Symptoms; Bladder Dysfunction, Incontinence, Numbness in Saddled Area
• History of Intravenous Drug Use or Steroids
• Severe Trauma to the Area
• Can’t Relieve Pain
• Structural Deformity
Once you have ruled out any serious pathology then you can focus on the treatment of the LBP.

How to Approach LBP Management:

Looking ‘Downstream’…

Some of the common contributors to LBP I have observed in active individuals and athletes are general muscular tightness. This is often observed in the hamstrings and gluteals (back of the thigh and the buttocks). I have found that looking ‘downstream of the complaint often helps reduce the stress upon the lower back. In a population that have a huge demand placed upon the lower limbs it is highly likely that these muscles will become tight and shortened. If these muscles such as the gluteals and hamstrings, are in a shortened state then they will be puling upon their attachment points, the pelvis and lower back area. If the muscles are tight then the hip capsule and joint itself may be tight also, placing extra responsibility on the lower back.

It is now more accessible for athletes to visit a sports masseur or have experts employ soft tissue techniques to loosen and lengthen tight muscles and joints. However, if we can encourage self-help and include strategies and exercises to maintain the good work of the masseur or therapist then this may help keep the lower back and whole body in an optimal state. Therefore, whether it is to prevent or manage LBP, it is a good starting point to include mobility and stretching work for these joints and muscles that are related to the lower back. A simple way of approaching this is to employ a thorough dynamic warm up of these joints and muscles prior to any training or competition, then post-activity a less intense more static stretch off of these muscles. It would also be wise to incorporate a day of functional mobility and stretching into the training program of the athlete.

This will help reduce any additional stress and responsibility to be placed on the lower back with the aim of either preventing the onset of LBP symptoms or reducing current symptoms.

Stopping it at Source…

Part 1 touched on the position the riders frequently take whilst on the bike. This is one of prolonged forward flexion (bending) of the trunk. It was also highlighted that studies have shown that within the cycling population this forward flexed position can be maintain and present in the athletes normal standing posture (Muyor et al., 2011,2012). Some of the hypotheses touched on in part 1 were based around the spinal extensors whether it be there susceptibility to fatigue, over-activation or a relaxation effect. With a lot of the focus being on this group of muscles, despite a lack of evidence, it may be a focal point for the management and prevention of LBP.

Now bad posture isn’t a diagnosis for LBP however, the reasoning behind bad posture can be a big contributor. So as a way of tackling these potential hypotheses it would seem that applying some form of conditioning to these spinal extensors may help not only reduce the likelihood and occurrence of LBP but also provide us with extra stability for the trunk during cycling.

My Theory and Potential Approach…
If we can get the cyclist to become more aware of their posture and level of activation of the spinal extensors during a bout of cycling it may help us tackle the potential flexion-relaxation hypothesis and the extensor over-activation hypothesis. If the athlete doesn’t know about their excessive flexion how do they know it is a potential cause of their LBP? Similarly, if they are unsure how to put themselves in a good position and posture how can they achieve it? Making them more aware of their posture means they can make minor modifications to produce an optimal position where there is stabilisation globally around the trunk reducing a relaxation response. This can be done by educating the athlete on neutral spinal posture, and how they can achieve a neutral posture. This should be done both in the cycling position and in standing because the two positions are different. In cycling we should look at the bike set up as well as the cyclist and find an optimal position for the saddle and handle bars that place the spine in a good position but also allows optimal performance. Also, we want to retrain the cyclist to adopt a more natural and neutral posture during standing rather than the observed ‘forward slumped’ posture in the literature to ensure that the stress on the spine is reduced.

In relation to the above if they can learn to control their spinal extensor activation once in a good position then they will be conditioned enough to reproduce the optimal amount of activation needed to provide the stability without over-activating them and risking muscular strain and spasm. Providing feedback and cues where possible about muscle activation would be of great benefit. If you have access or are part of an elite set up include biomechanical data to help assist you.

As well as targeting the awareness and ability to control these muscles, we should improve their endurance. Even with good control and awareness if the muscle is prone to tiring early on, the control will be useless in the long term and the muscle fatigue hypothesis may come into play. Therefore as well as conditioning the athlete to simply becoming aware of their control and posture we need to be conditioning these to prolonged stress and allowing them to become accustomed to having to work for longer periods.

The final hypothesis was based upon mechanical creep. If the cyclist develops better control, they will have increased the active stabilisation of the trunk and therefore taking some of the responsibility off the passive structures such as the ligaments. If these structures are under less stress they are less likely to experience creep and deformation. Therefore by simply designing a creative conditioning programme that targets the regularly overlooked minor muscles of the spine we can help reduce the likelihood of the potential hypotheses of LBP in cycling.

Now this article is by no means saying that spinal extensors are the root cause of all LBP in cycling. The evidence for the mentioned hypotheses is limited and should not be taken as the be all and end all of LBP in cycling. However, I think it is wise to consider and incorporate these principles and muscles into the athletes’ normal training regime. Often these smaller areas are overlooked and trainers will focus on the larger more obvious muscles used in an activity. For example training strength and power in the legs. This is obviously essential and if the rider is strong and powerful in the legs this is great but what if they have back pain because their spinal extensors or other minor muscles groups aren’t conditioned enough to stabilise the body? Therefore overlooking these areas may hinder performance and restrict the overall ability of the rider.

Putting Theory into Practice…
I have worked with athletes and gym users in the past with LBP, when asked what have you been doing to help yourself, I get the same responses. They will all have tried or been told to try doing mat work, static stretches, and other standard back rehabilitation exercises. I have found great success in relieving symptoms using these exercises. Some of the exercises I have found most useful are listed below:
• Lumbar Rotations,
• Knee To Chest Stretch (Alternate and Both Legs),
• Cobra Pose,
• Prayer Stretch,
• Cat and Camel,

These did work for my clients. But where do you go from there? There has to be a progression, one of my clients managed to help relieve their symptoms through the standard exercises, but as soon as they return to their activity and the activity that may have contributed to the LBP they are back where they started.

So I always take a functional approach to rehabilitation and injury prevention, and follow up with functional exercises. Why condition or exercise your body in a controlled static environment if the sport or activity you do is dynamic? You can apply the principles discussed such as making the cyclist aware of posture and muscle activation, and place the target muscles under load whilst the athlete is working in a similar environment or performing a functional movement. As a trainer, coach, therapist you can be creative with what you choose to do. If it targets the area you want and has some relation to the sport/activity then you will be in a much better place to condition them compared to doing isolated or static movements alone.

For example have your athlete working on a static bike so the lower limbs are replicating their function during a ride. Then you can place the extensors under load using a weighted vest, have the cyclist focus on maintaining a more neutral spine whilst riding, or you can even simply have them perform extensor movements such as back extensions whilst in a riding position or whilst pedalling. There are many options you can take this is just a very basic example.

The take home message is that general exercises can be used to help relieve symptoms or be included as warm up or preparation for training or competition. However, functional work needs to be included to ensure that the stability can be maintained during activity. This can be achieved by conditioning the muscles in a position or environment that is functional and replicates the sport or activity. If we can create the competitive and functional environment during training and strengthen where we need to under these conditions the cyclists will be in a much better place to reduce the likelihood of LBP.