EMPHASIS FOR THE MONTH OF NOVEMBER

Fixed flexion

As in, your spine….

The power of a ring can change Smeagol to Gollum. This creature who is doomed to live in the shadows can teach us a lot about life, but do you know what we really need to focus on?.........Gollum’s spinal flexion.  Because, evil powers aside, spinal flexion is a tricky subject.  It is not cut and dry.  It seems these days so many people are either in the camp of “flexion is good for your spine and should be practiced like any other movement exercise” or they are in the camp of “flexion is bad and will make your back explode.”  So, is there a right or a wrong? Is there a goldilocks happy medium? Do we want to crawl around like Gollum? Well, of course we don’t want you to succumb to the power of the ring, but we do want to address the importance of spine health, and within that realm, spinal flexion.
 

If you have been coming to Paragon for a while, then you have heard us harp on this subject repeatedly. Just know that it is all out of love, Goners. If you are new to us, then get ready to dive into the depths of spine health and what we at Paragon are passionate about: helping our athletes become better athletes. We are going to look at this subject through the lens of the strength and conditioning world. There are movements that certain people will have to avoid because of injuries or limitations, and from a clinical standpoint this subject could potentially look different. But, here at Paragon, what we see often are that many people’s spines are stuck in certain positions, particularly lumbar extension, and this means that their pelvis is tilted anteriorly. They think they are in “neutral” but really they are constantly in extension, and their spinal erectors can’t seem to quiet down. They are as far from Gollum as you can get. So, what does this mean? What are the implications of a spine that is constantly in extension? What happens to a spine that cannot find flexion? We are not saying this movement pattern is faulty, but it can be a sensitive area. Our goal is to keep you healthy, and we have heard about a lot of pain in the lower back region. Anyone out there experience that? ;)
 

This is what we want you to hear: You need to be able to find fixed flexion and fixed extension in your spine. If you can’t find flexion and extension, then you will not be able to find a “neutral” position.  (Really, a “neutral” spine is undefined. It is different for each individual. But you need to be able to feel your own balance, and know how to move and control your spine in both positions). Our bodies are really, really strong (especially Paragon bodies!!) They are adaptable. They are resilient. So, you want to be able to flex your spine in daily life and not feel pain? Well, let’s work in that position so your body can adapt!
 

A very big and important bottom line: We can’t talk about the spine without talking about the pelvis. It plays a vital role in your ability to produce strength efficiently and safely (duh, right? I know, a very obvious comment, so let’s go into more detail). There are so many muscles that hold real estate on the pelvis. Let’s talk about a few key factors here:

Obliques: the internal and external obliques are very important for postural control and the way the pelvis and back move. When walking or running, any time the leg is in the air, that oblique on the ipsilateral side is in charge. So, yeah, pretty important. A big job of the internal obliques is in rotation control. It maintains deceleration of extension of the spine; deceleration of contralateral flexion of the spine; and deceleration of pelvic anterior tilt (that lumbosacral extension we keep mentioning).

Gluteus Maximus: No mystery here, the glutes are important. (you don’t need to have Gandalf powers to know this). It is  important  to be able to achieve terminal hip extension for an athlete. This means you must have strength of the glutes into that terminal range so you can actually achieve the range of motion and access it functionally. If you does not, then extension movements may occur in the lumbar spine via some anterior pelvic tilt (Waerlop I, Allen S).

Latissisumus Dorsi: The lats extend from the sacral, lumbar, and lower thoracic vertebrae to the armpits. If the lats are tight, and you go to raise your arm overhead, then your lower back most likely will move into extension in order for you to get the mobility. This mobility has to come from somewhere in order to lift your arm, so if your lats don’t permit your shoulder to move well, then your lower back will take on the motion.

Erectors: again, we have so often seen erector muscles that cannot quiet down, . It is fairly simple, they should be able to relax. You would not want to walk around all day with your biceps flexed. Once again, if they are always “on” then they will pull on the back of the pelvis.

Anterior hip tonicity: There has been a lot of attention lately on the psoas muscle and “tight” hip flexors. Maybe too much attention. However, if the musculature in your anterior hip likes to work too hard, inhibiting your glutes, this can pull your pelvis into an anterior tilt.

Motor control/dysfunction: an unawareness of the back body and what it is actually doing in space is an important topic. We will touch on this a bit more in our pain section, but if the body is not aware of a certain area, it can send pain receptors to that area when there is no actual mechanism of injury there (Campbell JN, Meyer RA). So, how can you become more aware of your back? Be able to get into full ranges of motion and stay there in a stabilized way.

Diaphragm: The importance of breathing: the obvious thing that is usually not talked about often enough. It is such a huge piece of the puzzle that is overlooked, and so, we have asked our good friend Jim Wittekind, PT, DPT,  to enlighten us on the subject. “Dysfunctional breathing usually results in increased extension, or back bending, through the lower spine. This is accompanied by a front chest that is opened up in a state of hyperinflation, a mid back that is flattened, and an excessively rounded upper back near the base of the neck.”  To read the rest, see his attached piece on breathing. It is chalked full of awesome information.
 

It is almost impossible NOT to flex your spine. Think about your day to day life - you bend over to pick up your shoes, or feed your dogs, or plant a garden. We know you don’t live in a cave and crawl around like Gollum, but you do flex your spine constantly. Watch any professional sport, and you will see flexed, loaded lumbar spines. Watch  rock climbers, mountain bikers, snowboarders, golfers - spinal flexion is used and it is loaded. Picture rowing, kicking, wrestling, skiing….the list will go on and on. Sports which are flexion biased do not have greater degrees of low back pain versus those in neutral (Foss, et al 2012). So, in order for your system to tolerate these sports and day to day activities, we must not avoid that position, we must teach the body to do it and do it well.
 

Let’s revisit our talk on proprioception. Proprioception includes the senses of position and movement of our limbs and trunk, the sense of effort, the sense of force, and the sense of heaviness. Proprioception uses receptors located in the skin, muscles and joints to build the internal sense of our bodies. Quality of movement is dependent upon neurologic information feedback from proprioceptors within muscles and joints to the higher brain centers. We can improve this neurological function with certain exercises.  We want you to have as much awareness of your pelvic position and lower back position as you do with your elbow or shoulder. If we can improve your lower back awareness, then we have a good chance of improving pain or avoiding pain (Areeudomwong et al 2016).
 

Speaking of pain, any of you hobbits have lower back issues?
"Damage" in the spine is poorly linked with pain.  Loading of the spine is not very well linked with "damage" or degeneration (Lehman 2016). The body adapts, remember? Those strong Paragon bodies, if repeatedly loaded in flexion, can adapt in the spine and the disc. Another interesting fact, disc herniation is estimated to be involved in low back pain 2-5%. That is it, small number, right? But then there are those folks that have no mechanism of injury, yet they have pain (Jacobs et al 2016). It is all over the map. And we do not want to create a long term fear of movement.  Have you heard us throw around this nocebo effect term? Nocebo is the opposite of placebo.  Instead of causing a positive result, it creates a negative or harmful one. The words herniated disc or degenerative disc disease do not have any inherently harmful powers of their own.  However, the vision that they create in the mind of an athlete can be devastating (Winfried et al 2012). If you did not know you had a herniated disc, you may never feel pain.  So, what we want most, is for you to move without fear. Remember that your body is strong and resilient.

Ok hobbits, time to recap:

The lumbar spine has a great propensity to flex and extend, with up to 14 degrees of movement available per vertebral segment in the lower sections (Dutton 2012). This means there’s inherent mobility in flexion that if not trained could be lost. To avoid using full extension and flexion would be like not moving other body parts through their full range of motion. So, if your pelvis is stuck in an anteriorly tilted position, and you have no idea how to get it into a flexed position, you may need some practice (same goes for those that are stuck in a posterior pelvic tilt; it’s all about balance folks). We want you to be the most pain-free, best versions of yourselves. We do not want you to crawl on all fours like Gollum (well, that’s not entirely true, sometimes we do). What we do want is for you to have healthy hips and spines for a long, long time. So here is to heath, Goners, and all the adventure that lies ahead.

“Then something Tookish woke up inside him, and he wished to go and see the great mountains, and hear the pine-trees and the waterfalls, and explore the caves, and wear a sword instead of a walking-stick.” –J.R.R. Tolkien
 

Sources:Areeudomwong P1,2, Wongrat W3, Neammesri N3, Thongsakul T3.  A randomized controlled trial on the long-term effects of proprioceptive neuromuscular facilitation training, on pain-related outcomes and back muscle activity, in patients with chronic low back pain. 2016.

Campbell JN, Meyer RA. Mechanisms of neuropathic pain. Neuron. 2006;52(1):77–92.

Dutton, Mark. Dutton Orthopedics Examination, Evaluation, and Intervention, 3e. 2012

Foss IS1, Holme I, Bahr R.  The prevalence of low back pain among former elite cross-country skiers, rowers, orienteerers, and nonathletes: a 10-year cohort study. 2012

Jacobs JV1, Roy CL2, Hitt JR3, Popov RE4, Henry SM5. Neural mechanisms and functional correlates of altered postural responses to perturbed standing balance with chronic low back pain. 2016

Lehman, Greg. revisiting the spinal flexion debate. 2016

Veres SP1, Robertson PA, Broom ND. how loading rate influences disc failure mechanics: a microstructural assessment of internal disruption.

Winfried Häuser, PD Dr. med.,*,1 Ernil Hansen, Prof. Dr. med. Dr. rer. nat.,2 and Paul Enck, Prof. Dr. rer. nat. Dipl.-Psych.3 Nocebo Phenomena in Medicine Their Relevance in Everyday Clinical Practice. 2012

Waerlop I, Allen S. Gait Guys. https://www.thegaitguys.com
 

-Laurel Lippard