Josh Pitzalis

Case study: David Stephens

Installing boilers is difficult work. David, a heating specialist who installs and looks after boilers around Exeter, in England, hurt his back. He fractured the base of his spine. His lower back was in debilitating pain, and he suffered extreme bouts of sciatica.

As a rehabilitative specialist, my job has less to do with anatomy, and more to do with helping people navigate the new, uncomfortable relationship they have with their bodies.

Trust is a big part of what people lose when their bodies get injured. We take these beautiful machines for granted, then one day they break down and turn against us. It’s important to know that, in most cases, these relationships can be mended. With a little guidance and some support, people can learn to trust their bodies again.

When I first met David he’d worked with a number of doctors and therapists. His recovery was at the point where he was about to return to work.

The problem was that he still had acute pain in the mornings. He couldn’t work like he used to. His ability to lift and move things around had been drastically undermined.

When we started, I asked David how much pain he was in on a scale of 1 to 10. 10 was breaking his back. He started at a 4. For one month, we worked together for 30 minutes, twice a week. At the end of the 8th session, we managed to get his discomfort down to a 0.

Every session, I would ask David how his back felt at the start of the session. The following graph is based on his perception of discomfort and is completely subjective.

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In the before and after photos below, there are yellow stickers at the base of David’s lower back. I drew a line along the bottom of the stickers to show how much we were able to reset his pelvis over the course of the month.

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David left pain-free.

The following case study is the most serious back pain condition I have worked with. The exercise program was simple but tremendously effective. I wanted to share this process to diffuse any skepticism around the efficacy of such a simple program.

If you sit at a computer all day and have an uncomfortable lower back, this is a great way to prevent things from getting worse. If you are already in pain, please consult a medical doctor before undertaking any of the exercises recommended in this post. I am not a doctor, and I do not pretend to be one.

Before I started, I made it clear that sciatica and lower back pain are different problems. I was going to address the back pain and monitor the sciatica to make sure it did not get worse. If the sciatica flared up as a result of the back exercises, then it was a separate problem, and I could recommend a specialist. I also explained that it was very likely that the sciatica will improve as the back gets better. We agreed to tread lightly and see how the treatment progressed.

In our first session, I conducted all the tests in this post as well as the ones in the post on injury-proofing your body. David performed badly on the bend test and the one-leg test.

At the beginning of every session, I would spend 5-10 minutes tilting the pelvis forwards and backward and side to side. Gradually ( on about our third session), we started working in little circles and then in bigger circles in both directions.

I helped David perform the deep unit exercise sitting on a ball (combined with the piston breathing exercise) for about a minute before moving on to the horse stance exercise. As he got better, I made the horse stance exercise harder by lifting one arm off the floor, then one leg, and eventually both (opposite limbs).

The next exercise was the lower abdominal exercise. Eventually, I progressed to the side bending exercise and stretch. After the core had been addressed, I performed the stretches, strengthening exercises, and conditioning exercises for the bend and one-leg pattern. I started with whatever David could do and slowly worked towards 3 sets of 12 over the course of one month.

Step 1 - Learning how to breathe comfortably

Yoga practitioners were perhaps the first to document the close connection between the way we breathe and the way we feel. Emotional calm is often reflected by deep rhythmic breaths, while anxiety and aggravation cause our breath to quicken and become shallow.

Interestingly, the connection works both ways. Learning how to breathe comfortably can reintroduce a sense of calm in your body.

Most people walk around breathing with a somewhat clenched abdomen. If you're one of these people, you've probably been doing it for so long that you've forgotten what a full breath feels like.

To begin, you will need to reset your natural breathing pattern by doing something called piston breathing. Stand in a relaxed posture (frame 1 below). Take a deep breath, allowing your belly to expand (frame 2). Then exhale forcefully through your nose. (If you cannot breathe through your nose, exhale through your mouth while pursing your lips like a trumpet player). If you’ve never done this before, stand by a wall because it might make you lightheaded the first few times.

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With David, I would perform these breathing exercises between mobilizing his hips and training his deep unit on a medicine ball. I explain how to approach deep unit coordination in my post on dealing with a stiff back.

Step 2 - The horse stance exercise

Once your breathing has been reset, move on to a movement called the horse stance exercise. When you begin, aim to perform the exercise 5 times a day (for a total duration of 1 minute).

If this proves too challenging, start each mini-exercise session with 30 seconds of piston breathing to activate the core muscles.

Once you are able to perform the basic horse stance exercise, the goal is to be able to breathe normally as you perform the exercise for a full two minutes.

Once you can do this for two minutes, you don’t need to do it anymore because you will have corrected any anatomical dysfunction that may have previously caused you to breathe in an uncomfortable way.

Test yourself every few weeks to make sure you don’t forget how to do it.

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  1. Start on your hands and knees, making sure that your back is straight. You can use a stick to keep your back straight throughout the exercise. If you do use a stick, make sure that it touches the back of your head, the spot between your shoulder blades, and the base of your spine (with just enough room for a palm to pass between the stick and your lower back).

  2. Begin the exercise by exhaling powerfully. This will force the stomach muscles to tighten.

  3. The exercise involves keeping your tummy taught as you breathe in. The easiest way to do this is to visualize the distance between your belly button and the spine. As you exhale forcefully, your belly button will draw closer to the spine. As you inhale, your job is to make sure that the belly button does not move further away from the spine. Remember to keep your back perfectly still throughout the exercise. If you practice, regularly, you will see large improvements in a short period of time. Practice several times a day (for no more than a minute), and you should be able to do the exercise by the end of the week.

The exercise can be quite tricky at first, so here is a visual guide to the subtleties. To get the technique just right, use a stick to make sure you keep the following points in a straight line.

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When you perform the exercise, make sure that the stick stays parallel to the floor.

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For optimal results, clench the muscles around your genitals as you exhale and contract your stomach. The pelvic floor muscles are the muscles that help break the flow of urine when you go to the toilet. If you have trouble activating these muscles, you can google "Kegel Exercises" and do them as a separate exercise before you integrate them with the horse stance exercise. Horse stance exercises are the perfect core exercise. They produce the biggest changes in the shortest period of time. More importantly, they are simple to perform. The hardest part is learning how to distinguish between "clenching your stomach" and "holding your breath". This can be difficult for most people at first. however, this is a neurological barrier rather than a muscular problem which means that you can learn how to fix it fairly quickly.

Re-establishing a natural breathing rhythm is important because breathing with the chest alone places enormous discomfort on the muscles around the neck and collarbone.

Breathing comfortably and the horse stance exercise trains a muscle called the Transversus abdominis (TVA). The TVA is like a sheath that runs from the crest of your pelvis to the bottom of your ribs. It lies hidden beneath the more popular abdominal muscles on the surface.

People with conditioned TVA’s may not have sculpted abdominals, but they possess a beautifully slender midsection. Instead of doing months of stomach crunches, conditioning the TVA takes weeks (at the most) and leaves you with taught, firm stomach that only underwear models seem to possess.

Vanity aside, breathing comfortably also re-establishes the functional use of the core musculature that protects your back. Pressure changes in your spine play a key role in rehydrating the joints in your spine. The gentle lift from each breath helps offset the effects of gravity on your lower back.

Gravity pushes the weight of your entire spinal column down on the discs at the base of the spine. This squeezes more liquid out of them than can be replenished each night, leaving them dry, brittle, and prone to injury. Re-establishing a natural breathing rhythm keeps your discs healthy, hydrated, and supple, which goes a long way toward preventing injuries like slipped discs.

Lastly, uncomfortable breathing can also lead to poor digestion. When the body’s natural corset becomes weak, it fails to support the internal organs effectively. This drooping of the internal organs is known as Visceroptosis. The organs fall from their optimal position and place undue stress on the digestive system, which in turn can transfer the stress to the reproductive organs. An anatomically correct breathing technique prevents this from happening by increasing the pressure in the abdominal cavity.

Re-establishing a natural breathing rhythm reduces physical discomfort, makes you look fantastic, protects your lower back, and helps with your digestion.

Step 3 - Re-aligning your pelvis

Since the shoulders sit on top of the pelvis, it is usually best to start working on the pelvic curve and establish a level foundation before progressing to the shoulders.

There are two little dimples and the front and back of your pelvis. If you trace your finger across the curvature of your pelvis on either side, you will feel them. I have marked the dimples at the back in red (just above the buttocks) on the diagram below.

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The ones in the front are marked in blue below.

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The important thing to pay attention to here is whether the tips at the front level with each other and the dimples at the back level with each other.

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If either set of dimples is higher or lower on one side, then you will need to stretch out the higher side and strengthen the lower side. One of the best stretches for stretching the higher side is the sitting side bend.

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  1. Seated against a wall with your backside, back, head, and upper arms against the wall and legs crossed

  2. Bend to the side, keeping your back against the wall to the point you feel a comfortable stretch in the side of your back

  3. Hold the stretch, then relax and repeat on the other side Perform an exercise called the three-point side plank to strengthen the lower side. Perform this on the lower side only.

Strengthening the lower side can be achieved with a lying-side bend.

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  1. Lying on your side with the knees and hips flexed to 90°.
  2. Rotate your legs and lift them up whilst simultaneously side-flexing your upper body.
  3. Hold and slowly lower.

If you want to add resistance to the exercise, place a medicine ball or a football ball between your legs as you lift them.

Step 4 - Strengthening your inner unit

Once your deep unit has been activated, you're breathing comfortably, you have control over your TVA, and there are no major misalignments in your hips, it's time to start strengthening your inner unit.

I have explained how to do the following exercises with a blood pressure cuff. If you don't have one, that's fine, just use your hand and make sure you can feel yourself pushing into it.

Josh Pitzalis

  1. Lying on your back with a blood pressure cuff or your hand placed underneath your low back at belly button level.
  2. Bend your knees to 45° raise one leg in the air keeping the knee bent. Pump the cuff up to 40mm/hg draw your belly button inwards, and slightly rotate your pelvis backward, which will flatten your low back into the cuff, rotate your pelvis to the point where the pressure in the cuff raises to 70mm/hg. If you do not have a cuff, rotate your pelvis until you feel a light pressure on your hand.
  3. Lower the leg back to the floor, maintaining the pressure on the cuff. The pressure on the cuff should not vary greater than +/- 5mm/hg throughout the exercises.

Exercise progression 2: The same but with your legs bent to 90 degrees.

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Exercise progression 3: This time with both legs.

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Exercise progression 4: Knee nudges

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  1. Lying on your back, with your hips flexed to 90° and knees bent to 45°.
  2. Draw your belly button inwards, rotate your pelvis backward, flattening your back into the floor, and lift your knees 1-2cm towards the ceiling, imagine you have a piece of string connected to the ceiling and your knees, and it is lifting your knees up.

Exercise progression 5: Legs extended

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  1. Lying on your back, with your hips flexed to 90° and legs straight.
  2. Draw your belly button inwards, rotate your pelvis backward, flattening your back into the floor, and lift your toes 1-2cm towards the ceiling, imagine you have a piece of string connected to the ceiling, and your toes and it is lifting your feet up.

Step 5 - Bending and balancing

Testing your bend pattern

The bend test involves performing a prone hip extension: lying face-down on the floor and lifting one leg up without bending your knee. Perform each side separately. Ask someone to place their hands on your hamstrings (the back of your legs) and the gluteus maximum (the big, round, meaty muscle of your bum) as you perform the exercise. If the hamstring contracts before the gluteus does, you have a dysfunctional bend pattern.

Testing your balance pattern

The balance test involves standing on one leg for one minute with your eyes closed.

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If you can’t hold the exercise for a full minute on each side, then you have a dysfunctional single-leg pattern (balance).

The single-leg deadlift

Both bend and balance dysfunctions and typically corrected by performing the single-leg deadlift. The single-leg deadlift is an excellent exercise that improves unilateral ankle, knee, and hip stability.

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  1. Standing on one leg.
  2. Reach down, keeping the natural arch in your low back.
  3. Grasp the bar a little more than shoulder width apart (clean grip).
  4. Pick your chest up, look forward, inhale, drawing your belly button inward.
  5. Bend forward slightly until the bar is at knee level; lift your torso to the top position, exhaling through pursed lips through the most difficult point of the movement. Imagine trying to push the ground away from you with your feet.
  6. At the top, repeat the inhaling process before lowering to the ground.

If your bend is imbalanced, you'll want to precede your single-leg deadlifts by stretching out your hamstrings and firing up your buttock muscles with a bridging exercise like a supine hip extension.

A faulty balance pattern will involve stretching out the adductors, IT band, and quadriceps before doing the exercise. Variations on all these stretches are easily googleable.

The important thing is to do the stretched and activation exercise immediately before the single-leg deadlift. Don't wait around between the pre-exercise work and the actual movement, think of it all as a single exercise. You stretch tight muscles out to deactivate them during the exercise, fire up a weak muscle to engage it, and then perform the movement so that those respective muscles are more or less engaged during the movement.

It's important to understand that our bodies have six primary movement patterns. People can push, pull, bend, squat, balance, and rotate. David was in good shape, except for his ability to bend and balance.

Fixing a complex movement pattern is about more than just stretching tight muscles and strengthening weak ones. The job is to gradually reintegrate each of the pattern’s muscle groups in the right sequence so that the whole movement chain is coordinated smoothly.

In each session, I found the limits of what David could do and then gently pushed the boundary. As a general rule of thumb, with any kind of rehabilitative work, if it feels sketchy, then it is sketchy.

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