This is an excerpt from my write up on my second visit to the Washington University in St. Louis. I wanted to give this its own post.
A highlight of my trip was the direct conversations I got to have with Shirley.
As far as I know, I was the only non-therapist at this course. Oddly, not many questions were asked. I’m not sure if it was because people were lost (you could tell this course was brand new information for many of the students), it was a weekend course, people were forced to go to this for CEUs, or what, but after the first hour of lecture I thought, “Well, screw this. I didn’t come all this way to not speak” and I started raising my hand.
We were at the beginning of assessing the lower back, talking about standing alignment, and my question was:
“You touched on this in the last slide, and you have a sentence in your book stating to be careful extrapolating certain alignments with certain lower back issues, or really, any lower back issue. That standing a certain way rarely correlates with someone having lower back pain, or the types of movements they do. Could you elaborate on this?”
For those who don’t know, there’s a good amount of research showing standing in a certain alignment doesn’t necessarily cause lower back issues. A particular pelvic tilt is not the devil people make it out to be. This is important because it should be a wake up call to those who obsess over posture. Who pick apart every single thing on somebody, making them feel less coordinated than Lorde’s Grammy performance.
Paranormal Activity 7: The Lordes.
(GIF from CBS / buzzfeed.)
Of course, you have the groups who take this too far the other way. “Posture doesn’t matter at all! Stand however the hell you want!” This is pretty silly. If you make someone with good posture stand with excessively poor posture, you see right away how it can make someone feel. (Like shit.)
Next, what you also find is say someone stands in a posterior pelvic tilt, with their lower back a bit flexed:
What Shirley and I discussed is the above posture doesn’t mean the person has or will have a lower back flexion issue. In fact, even if this person flexes their lower back during many activities, that still doesn’t guarantee flexion is a problem for them. They could very well have an extension issue.
Going with the principles I went over earlier -the site of what moves too much and what direction it moves too much are the pain provocateurs- standing with your lower back in flexion does not mean you 1) Flex your back too much 2) Will have pain flexing your lower back. Standing with your lower back in flexion often means you have pain into extension!
As we age our spinal discs tend to atrophy. With less of a disc there’s less room for our facet joints to move, particularly into extension.
The facet joints become more likely to jam into one another when going through extension.
If you’re someone who has done a lot of lower back extension throughout your life, you can accelerate this process. Just like the tires on your car wear down the more you drive, you may wear your discs down the more you do stupid crap, like obsessing over deadlifting.
It’s natural for our lower back to have a little lordotic curve. This is our spine’s “neutral” to start out with. However, if you’ve become sensitive going into extension, say due to age, or by doing a ton of extension work (oh hey, deadlifting again) what’s a natural response? To keep your back a little flexed. You’re better able to avoid extension, and this way when you do go into extension, you have a little more room before causing pain. You’ve effectively altered your “neutral.”
“But what about a herniated disc? Too much flexion can cause a disc herniation.”
As I mentioned, this isn’t only caused by your movement patterns, age plays a role. I asked Shirley what age she felt extension is pretty much universally contraindicated, “About 60.” Meaning you could have lucked out and had a great back for 60 years, but it’s going to wear out where certain movements still aren’t going to agree with it. (Extension and rotation. Flexion is less of a concern.) This is why you can worry less about flexion at a certain point. Especially in an older person, they don’t have enough of a disc left to herniate! Something like stenosis -extension issue- is going to be much more of a concern.
Maybe now the internet can stop telling me how grandmothers need to arch their back and deadlift more.
–
Adam
August 14, 2014
Hey Brian, I may be going off on a slight tangent here but reading this post somehow reminded me of this issue. Namely, what is your opinion on the posterior pelvic tilt and lumbar flexion that often happens when a person performs a relatively deep squat? Do you consider it to be a huge no-no and if so how do you usually try to address it? I know a lot of the time the issue tends to go away when somebody squats with a raised heel, and so would that imply a tight gastroc or is there other issues that are coming into play here?
reddyb
August 17, 2014
Hey Adam,
If it’s an unloaded squat, like a mobility exercise (e.g. “Toddler squat”), I usually cue people to keep their back as straight as they can. I understand due to various factors this is generally not going to happen in a full squat though. And I’m usually ok with that.
If it’s an older person with some lower back history, this lumbar flexion usually feels nice for them. An exception here is in some younger people with a lower back history, you want to be careful about embracing any lumbar flexion. For many young men, particularly taller ones, excessive lumbar flexion is part of what’s causing their issues. Even if it’s unloaded, I avoid it.
In a loaded squat, I never let someone go to a depth where their lower back rounds. I barely squat people below parallel with a load, so this is pretty much never a problem. (Going to parallel rarely coincides with the lower back rounding. It’s once you start going below parallel this becomes more likely.)
Because nearly everyone I have who squats is going to be wearing shoes which likely already have a heel lift, I never add a heel lift. Overall, I’m trying to get people out of excessive heel lifts.
I really only see ankle ROM affect someone’s squat if they go very deep. So, if someone’s lower back is rounding at the depths I usually work at -90 degrees (parallel) to ~110 degrees- then that’s probably as much as their hips can bend, due to things like the orientation of their hip socket. That is, hip ROM usually a limiting factor before ankle ROM. I know ankle dorsiflexion has been obsessed over on the internet, but I don’t think the obsession is proportional to the amount of people who have a problem.
A good way to understand / recognize someone’s hips limiting their squat depth is to have them squat horizontally, such as the backward rocking exercise (embedded below). Because the ankles are plantar flexed the entire time, and the person doesn’t even have the load of gravity, if there’s a limitation it’s likely due to something structural at the hip. (Something structural limiting how much hip flexion they have. Something that’s unlikely to change much, if at all.)
Backward Rocking exercise: Note the cueing I use in this video is specifically for someone trying to loosen up their lats. It’s not the cueing you would want to use if you’re trying to see how much hip flexion someone has. In that case, you would tell the person to go back as far as they could without their lower back rounding. After maybe a few sets, you get a feel for how deep someone can go. Women can often go deeper than men, and few can go butt to heels with a straight lower back. At some point their femur hits their acetabulum and the only way they can go deeper is to get the flexion from the spine. This is another one of those internet myths: Everyone should squat ass to grass. They really shouldn’t, and most can’t.
Hope that all makes sense.
Adam Napper
May 15, 2016
Thorough stuff as always Brian. Adding the comment discussion here… Since the gastroc crosses the knee, at the bottom of the squat it is not in a stretched position. So it would be unlikely that gastroc tightness is limiting ankle dorsiflexion. If you suspect ankle dorsiflexion is limited when the knee is bent, you can easily test this suspicion by having the person lay face up, bend at the knee and hip, and passively take their ankle into dorsiflexion. If the ankle doesn’t move much, then voila! Suspicion confirmed. But, this only means you’ve identified the joint don’t have that particular range available. You haven’t identified a cause. Bone hitting bones (structure)? Tight ankle plantarflexors? Likely their ankle will not be the limitation anyways as Brian said. -Adam (not the same Adam as the original comment)
reddyb
May 17, 2016
Very good comment. Thanks for adding it Adam.
Paul Vandyken
August 20, 2016
Hey Brian,
I was on the hunt for Deadlift materials on ages for my blog [redacted] today and found this on your website. This article will definitely help me well with my writing.
Thank you for this helpful article!
reddyb
August 23, 2016
Glad you found it helpful.
(Sorry to remove your URL, but my policy is largely to remove URLs that seem rooted in self promotion, to keep down on spam. I understand you may have had no cynical intentions, but the URL did not seem relevant.)
Patrick Köhler
November 16, 2016
Hi Brian,
your blog is amazing. great stuff. thanks for that. got a question on this article
1. i guess doing lets say 2 static and 2 dynamic sets twice a week is not a problem in older people?
2. does this also count for thoracis spine? because most of the (older) people have a kyphosis. i usally do 2 -3 sets for thoracic extension and some mobility sets ( wall slides, etc) with older clients with kyphosis. should i stop this?
for example this extension exercise: you can deleate the link after watching
https://www.youtube.com/watch?v=n8sCccxnBuE
thanks a lot
patrick
reddyb
November 21, 2016
Hey Patrick,
Thank you for the nice words. Glad you’re liking the site.
Good question on the thoracic spine. The same degenerative process is involved, but as you alluded to, generating too much thoracic extension is not typically a problem for older people. Getting enough is, as geriatrics tend to fall into thoracic flexion.
That said, what we’re really trying to do then is get people back to neutral thoracic spine wise. We’re trying to get them *out* of flexion, opposed to get them into extension, if that makes sense.
So while I work on extending the thoracic spine a good deal in older people, I wouldn’t say I actually put them into extension much. Instead, I’m fighting like hell to get them out of flexion.
That said, I can’t remember working with any older people who had any pain getting into thoracic extension. With the upper back there isn’t going to be the pain / injury history that most will have with their lower back.
Going up further, cervical extension is where you’d again want to be very cautious with too much extension.
How you want to go about getting working people out of thoracic flexion can vary quite a bit. I tend to favor work where the arms are also moving. Example exercises in this post, where you can see the emphasis on also getting the upper back straight: https://b-reddy.org/2013/09/05/a-progression-to-lifting-your-arms-overhead-pain-free/
Patrick Köhler
November 22, 2016
Thanks for the reply, i really appreciate that!
My english is not the best, i hope i understood everything haha.
Thanks for the link, its also great stuff. I like doing such things as well, more like mobility drills for thoracic extension, combined with soulder elevation.
In my thoughts, a lack of thoracic extension could also be a reason for LBP, because the person has to generate more lumbar extension to reach something overhead for example.
The Video i posted (thats me, hallo 🙂 ) is not a typical movement for a kyphosis person of course. so i think they are not even able to get an thoracic extension in the shown exercise. but in my thoughts they should reach for a maximum “extension” to train the weak erectors in this arae. what do you think about that?
again, thanks a lot. you are really great. especially your eyes. i wish one day i could see such small things in posture as you do.
best wishes from austria,
patrick
reddyb
November 23, 2016
“a lack of thoracic extension could also be a reason for LBP, because the person has to generate more lumbar extension to reach something overhead for example”
I don’t see it often, but whenever I assess someone with a lower back history I check this.
Striving for maximum extension is the way to go, yes, but so long as there is not compensation. Like you hit on, it’s very common to compensate with extension at the lower back when someone who lacks T-extension tries to generate T-extension. (I just don’t often see lower back pain as a result of that. It happens, but not regularly.)
Thanks again for the nice words. The eyes come with practice!
Patrick Köhler
November 29, 2016
thanks brian!!
Chris
January 20, 2017
Hi Brian!
I agree with vast portions of your very good article. I am of a different opinion concerning the deadlift mechanism: Your conclusion to dl less for seniors would be logical if the dl was a back extension exercise. It is not.
It is a hip extension exercise. The crux – and practical use of a dl for everyday purposes besides the improved strength, balance etc – is to learn how to keep the spine rigid in its natural position (isometric strength) and to move only at the hip joint (hip hinge movement). And only so far as far as the spine doesnt flex or extend –> use individual ROM. To “arch your back” is simply a cue to activate the erectors and withstand lower back flexion during hip flexion – it doesnt mean you should overextend your spine. Every good coach makes sure the client understands this.
Regards
Chris
reddyb
January 20, 2017
Hey Chris,
While I agree one point of deadlifting is keeping the spine in a certain position, don’t think you’ll be able to find many deadlift videos where the spine remains neutral / rigid from its starting position. If the lumbar spine is straight / flat, such as at the bottom of a deadlift, then that’s not neutral. Some lordosis would have to be maintained the entire rep.
What typically happens is the lumbar spine flexes some at the bottom of the rep -meaning it’s flat- and then it goes into at least some lordosis at the top of the rep -meaning it’s neutral- but also meaning it went through some flexion and extension.
Even if we said people could maintain lordosis the entire rep, that they had this type of mobility, we’re saying the average deadlift set contains no deviation from neutral. If we’re being honest here, people aren’t this good at technique.
(And that’s just the lumbar spine. Finding any heavy deadlift videos where the thoracic spine remains neutral will also be tough. Extra kyphosis is all but guaranteed.)
Now its true this extension the lumbar spine goes through could be only relative to where it’s been extension, not absolute extension, which would be going into extra lordosis. That assumes the person never say, leans their shoulders back at the top of the rep, which many do (they lockout the lift too much). Again, assuming the average set contains no out of neutral movement.
But say that’s true, then coming back to grandma- going into any lordosis means her going into absolute extension. Because her neutral has been moved.
So if we want to say grandma can deadlift where we’re conscious that when we tell her to arch her back that means for her back to stay in neutral, and her neutral actually means a lumbar spine in some flexion, that when she stands up at the top of the rep she can’t allow her lumbar spine to go into any lordosis -we’re saying her deadlift means not standing all the way up like a regular person- then sure, it can be done. But then we’re toying with what deadlift means, toying with common deadlift technique advice -how many trainers are coaching their clients to arch their back so their spine is in some lumbar flexion?- making the argument the average personal trainer / trainee is thinking of this, and the average grandmother is this coordinated.
What’s more likely is she has some osteoporosis and will think you’re insane if you ask her to lift 135 lbs off the floor :).
Chris
January 20, 2017
Thank you for your reply, Brian!
First I see the possibilites of a correctly executed deadlift brighter than you.
Then, when flexion and extension in a DL occurs, the open question is how much of flexion or extension leads to which results. This is probably a dose-respone-relationship with various variables – and thus an empirical question.
So far different experts have uttered different opinions on that matter. And while I am leaning towards a more risk-averse stance, as Stuart McGill or Shirley Sahrmann, others have a different opinion of safe flexion and extension capabilities of the spine: https://www.researchgate.net/publication/232156729_To_Crunch_or_Not_to_Crunch_An_Evidence-Based_Examination_of_Spinal_Flexion_Exercises_Their_Potential_Risks_and_Their_Applicability_to_Program_Design
So far, what empirical evidence shows is that that resistance training in elderly (that comprises deadlifts) has positive outcomes. We definitively would need more data to verify the points you make – ideally in a dl vs non-deadlift vs control (no resistance training) study in the elderly.
Regards
Chris
reddyb
January 20, 2017
That’d be great. Unfortunately this can be where solid research is tough to come by. Off the top of my head, I’m not sure any researchers will be willing to include people with stenotic spines in their sample / do we count smith machine deadlifts as deadlifting? / do the subjects have lifting experience? / conventional vs sumo?
In the mean time, any benefit of deadlifting could be acquired through not deadlifting. The ones you mentioned, strength, balance, maintenance of rigid spine, deadlifting isn’t needed for any of that. If we look at this from a risk-reward standpoint, I find it hard to come across a persuasive argument the population with the most degenerated spine should be doing what is notoriously the hardest exercise on the spine. There is a graveyard of backs in the deadlift cemetery.
Doesn’t mean everybody in their 60s and up should avoid deadlifting. But for the average person it’s unlikely to have the greatest reward to risk ratio.
Chris
January 20, 2017
Oh, there already is research with people of all ages and low back pain deadlifting. Look on pubmed, out of my head iirc in this study there should be more references to such research: https://www.ncbi.nlm.nih.gov/pubmed/25559899 You will surely find more.
The research questions you asked are pertinent to any human research, back pain and DL are no hinderance to that: population and setting variables.
To the alternatives: Well, if you want to train the hip hinge – i.e. keeping a rigid spine during hip flexion and extension, the movement you do when picking things up in daily life – you gotta do the hip hinge.
Regardless if its the DL and its variations (I recommend a pure hip hinge pattern without knee extension like the SDL or RDL for novices), back/hip/hyperextensions or GMs. They are very similar movements and have very similar problems if not done correctly – and very similar advantages if done correctly.
So whatever exercise you may choose for training the hip hinge – it always comes down to correct individual technique.
reddyb
January 22, 2017
-Study uses an extremely unlikely situation having that type of coaching.
-I could have missed it, but the study doesn’t appear list what the inclusion and exclusion criteria is.
-Considering nobody was above 60, the average subject age was 42, and no exclusion criteria given, I’d be surprised if any stenotic spines were allowed / this study doesn’t comprise what my original article is about.
-I believe you’re already saying this- a deadlift is a subset of hip hinging. Thus, in daily life you do not have to deadlift objects off the floor. You can kneel down, you can single leg RDL the movement, you can use your toes to bring the object to you, etc. You may need to hip hinge those objects. But as you said, you can do versions of a hip hinge.
This is where the disconnect is. A deadlift is a specific exercise. We can’t generalize it to mean any time somebody leans over and stands up. Do I have clients work on hip hinging -leaning over and standing up? Yes. Do I have elderly clients hip hinge a barbell off the floor? Very unlikely.
I think you’re getting at an elderly person can deadlift. I’m not arguing that. What I’m getting at is should they? Or should they go with an alternative.
-Tangentially -this is more a general statement than our specific comments here- it’s worth mentioning this daily life argument always makes it seems like people are lifting objects off the floor a good deal every day.
1) If that were true, why would need to work on it much, such as strengthening the movement? People type a lot, they sit in a chair a lot, but we don’t say we need to work on finger strength in the gym or work more thoracic kyphosis.
2) In reality your average person isn’t lifting much off the floor on any consistent basis. And if they are, it’s unlikely more than ~30 pounds. Meaning it’s still not similar to what we think of when we say deadlifting.
-All in all, I think we’re agreeing more than not here.
Chris
January 23, 2017
Oh sorry, i referred you to the study for further references concerning strength training in master/elderly populations, i wasnt talking about that specific study. (Because I was lazy looking for studies on your behalf and thought this study probably would cite some other studies). Sorry for that misunderstanding.
DL vs versions of hip hinges: Yes, “single leg RDL” is a hip hinge exercise as DL is. I mentioned that all hip hinge exercises have very similar disadvantages when performed correctly and disadvantages performed incorrectly. Ah, I think where our different opinion stems from when reading your second point: It sounds as if you picture, and i would imply, doing a DL means doing it at a very high load of %1RM resp. high RPE and with huge absolute loads with questionable technique in elderly clients. Whereas your example of a single-leg RDL would be a very low intensity, techniqually perfectly performed exercise teaching more technique than training for strength.
Well, this is an ascribed individual idea of yours (that i would imply that) to these exercises – i havent said anything of that.
However, my conviction contrary to yours is that indeed the “general grandma” @ 60 should do a hip hinge exercise variation, ideally learning two or more. DL being a very practical one. Maybe the sumo DL mimics most closely the way we pick up moderate to heavy (individually speaking) things in everyday life. With a single leg RDL the most common way to pick up light things.
Ofc, in a very impaired sub-population where you couldnt either teach a DL or a single leg RDL or any other hip hinge variation you have to find alternatives, like bringing the object to you with your toes. I think we agree this is not the majority of grandmas were talking here (and ofc the grandpas we have neglected here woefully).
Concerning the resistance: “Why do u have to train with a weight thats higher than your usual thing u pick up from the floor?” Pretty simple, at least two reasons:
1) The benefits of resistance training comprise, but are not only learning a technique and posture: Research has found numerous health advantages for resistance training in elderly people, from altered body composition and a host of related positive consequences to cardiovascular effects of training to bone density improvements. For these effects to happen, adequate stress is key – and for women above 60 that does not automatically mean zero weight and only learning posture and technique but adequate resistance! According to this review, > 70%1RM turned out to be very important for the positive outcomes. https://www.ncbi.nlm.nih.gov/pubmed/26420238
And hip hinge exercises are an integral part of a resistance exercise program – one of the six main movements.
2) For our more specific goal, picking up a weight from the floor, a certain strength reserve is helpful: If a 65-year-old woman can deadlift 6 reps x 30kg (e.g. @RPE 8) with good technique in a prepared and fresh state with concentration with an ergonomic barbell, dumbbells or trap bar – she will be more likely to successfully lift up her 10kg grocery cart the six steps/(treads? I probably dont know the proper word for it in the english language) to her home in a tired state while not focused 100% on the task in a less ergonomic setting with the stairs and a more awkward object.
Thats why we need to train with a somewhat higher resistance than we encounter in our daily tasks.
Hm, I dont think i have to address the questions you pose under your point 1), do I? I find them pretty self-explanatory if you think about what the completely different nature, goals and demands are in this situations compared to DL/hip hinges.
Chris
January 23, 2017
So wrapping it up I see where your coming from: Your professional window on the world is a facet of mostly – acutely or chronically – impaired patients. So I understand where you are in the dimension of risk-aversion.
I think its important we dont copy that view to give general recommendations of very low intensity training to the general elderly public (“Why Grandma shouldnt deadlift”). With new studies emerging every month showing that obviously the advantages of resistance training in elderly outweigh the possible risk (again: that ofc can be decreased considerably – a goal everyone has to work on):
Or in the words of resarchers that did a meta-analysis on resistance training for people > 65 years:
“CONCLUSIONS:
Progressive resistance training with high intensities, is the most effective exercise modality for improving preferred gait speed. Sufficient muscle strength seems an important condition for improving preferred gait speed. The addition of balance-, and/or endurance training does not contribute to the significant positive effects of progressive resistance training.”
https://www.ncbi.nlm.nih.gov/pubmed/26126532
But even in not-so-healty-elderly populations, resistance training had a positive effect on health markers:
https://www.ncbi.nlm.nih.gov/pubmed/28084062
https://www.ncbi.nlm.nih.gov/pubmed/27999852
https://www.ncbi.nlm.nih.gov/pubmed/25795931
https://www.ncbi.nlm.nih.gov/pubmed/27932360
https://www.ncbi.nlm.nih.gov/pubmed/28053820
———————————————————————–
So, lets have a more adequate title: “Why average Grandma should deadlift – or do any other hip hinge – with adequate resistance!”
Hmm, not as catchy as your title I admit, as it often is when giving nuanced opinions rather than black-or-white ones.
I am convinced it fits the evidence better, though. 🙂
reddyb
January 23, 2017
Responding to both comments:
-Intensity is not my point. My contention is a deadlift is an off the floor exercise. A single leg RDL / other hip hinging is not. That said, a deadlift, when trained for strength, is one of the most intense exercises there is.
Resistance Training Recovery: Considerations for Single vs. Multi- joint Movements and Upper vs. Lower Body Muscles
http://digitalcommons.wku.edu/cgi/viewcontent.cgi?article=1653&context=ijes
Huge absolute loads are not relevant either. A 100lb deadlift is at least 100% more than what an average person regularly encounters in daily life. Never mind an elderly person.
-“Why do u have to train with a weight thats higher than your usual thing u pick up from the floor?”
I never said this either. I said a deadlift is not similar to the daily demands of an average elderly person, as I just reiterated.
-You’re again citing research which is not relevant to the post.
-Grocery analogy doesn’t work e.g. people can lift their groceries without them going on the ground, you can lift one bag differently than you can lift a loaded barbell, etc.
-I never questioned the benefits of resistance training.
-I’m not going to title an article something I disagree with.
-Between incorrectly bringing up my background and your final remark, you’re veering into ad hominem, which I tell all commenters to be careful with. I give the benefit of the doubt initially, but I don’t allow that here. I freely admit I could be wrong in your intentions, but I’m very sensitive to this due to how internet comments can get.
Where to wrap up on my end, I appreciate the conversation, have no problems with disagreeing, but don’t like where this has gone and is potentially headed, and think we’ve talked about this plenty enough. So I’m going to cut this exchange here.
Thank you for coming by and taking the time to comment.