Why is low back pain considered a symptom and not a diagnosis?

Low back pain is a symptom because it only describes the location of discomfort, not its underlying cause. Dr. Sahrmann's approach focuses on identifying the specific movement patterns that consistently cause or alleviate the pain, which leads to a functional diagnosis and targeted physical therapy.

Can overdeveloped abdominal muscles contribute to low back pain?

Yes, overdeveloped abdominals can become stiff, increasing compression on the spine. If the rib cage's circumference cannot change by 2.5-3 inches from exhalation to inhalation, it suggests abdominal stiffness is a contributing factor. Asymmetries in the iliac crest further exacerbate this.

What is the Movement System Syndromes (MSS) approach?

The MSS approach defines movement as a critical body system, akin to the immune or metabolic systems. It recognizes that movement can not only be affected by pathology but also induce it. This framework emphasizes identifying abnormal movement patterns as the root cause of musculoskeletal problems.

How does Dr. Sahrmann explain the body's 'path of least resistance' in movement?

The body naturally takes the path of least resistance. If a faulty movement pattern is easier to perform (a 'worn groove'), the body will continue to use it, even if it leads to pain or pathology. Effective therapy involves identifying these patterns and making correct, more efficient movements easier.

What common posture issues contribute to shoulder and neck pain?

Many people 'wear their shoulders too low,' meaning the shoulders slope downward, placing strain on the cervical spine. This can be exacerbated by overly tight latissimus dorsi or by exercises that depress rather than elevate the shoulder blades, like rowing motions.

What is Dr. Sahrmann's perspective on stretching for muscle tightness?

Dr. Sahrmann argues that many cases of perceived 'short muscles' are actually 'relative stiffness' problems, where the passive tension of one muscle group is out of balance with another. Instead of isolated stretching, she advocates for improving the stiffness and coordination of opposing muscles, like strengthening abdominals to elongate hip flexors.

How old is Dr. Shirley Sahrmann, and what is her personal self-care routine?

Dr. Sahrmann will be 86 next month. Her routine involves daily quadruped rocking, 15 modified prone push-ups, hip extension and rotation exercises in prone, supine adduction with overhead arm slides, active hip and knee flexion, and specific straight leg raises while activating abdominals. She also walks 3-4 miles daily.

What are the common movement patterns that worsen low back pain while walking?

If one has a swayback with a kyphosis, the line of gravity is behind the hip joint, reducing gluteal activation. This leads to pulling legs forward with hip flexors (overusing the tensor fasciae latae) rather than pushing off with the feet, exacerbating lower back pain.

What is femoral retroversion and how does it affect hip movement and posture?

Femoral retroversion is a structural variation where the head and neck of the femur are rotated less than the average 15 degrees forward. This often results in limited internal hip rotation and a natural tendency for feet to point outward. Forcing feet straight can lead to issues in the knees, back, or hips.

Key Moments

Deep Dive on Tim's Low-Back Issues, How to Unlearn Painful Patterns, Movement as Medicine, and More

Tim Ferriss

Howto & Style6 min read109 min video

Aug 4, 2023|58,745 views|1,283|133

tim ferriss 4 hour body timothy ferriss ferriss tim ferriss blog timothy ferriss speaker Tim Ferriss Podcast Shirley A. Sahrmann low back pain anatomy mobility issues physical therapy

Save to Pod

Key Moments

On this page

TL;DR

Expert on movement, Dr. Shirley Sahrmann, discusses low back pain, movement impairments, and personalized rehabilitation strategies.

Key Insights

Low back pain is often a symptom of movement dysfunction, not a diagnosis itself.

Movement itself can induce pathology, making understanding movement patterns crucial for health.

Individualized assessment and correction of movement patterns are key to rehabilitation.

The 'movement system' is a complex system of systems crucial for overall health.

Lifestyle factors, including exercise and daily movement habits, significantly impact health outcomes.

Addressing relative stiffness rather than just muscle length is often key to addressing pain.

THE HALLMARK OF MOVEMENT IMPAIRMENT SYNDROMES

Dr. Shirley Sahrmann, a legendary figure in physical therapy, introduces her revolutionary approach to understanding musculoskeletal problems. Her work emphasizes that movement itself can lead to pathology, and the book 'Diagnosis and Treatment of Movement Impairment Syndromes' was a pioneering effort to categorize these dysfunctions based on movement patterns rather than just symptoms. This approach, which identifies diagnostic categories based on movement, aims to uncover the root cause of pain by analyzing how specific movements either cause or exacerbate discomfort. This marks a significant shift from traditional methods that focused on treating symptoms as consequences of a problem.

LOW BACK PAIN AS A SYMPTOM, NOT A DIAGNOSIS

A core tenet of Dr. Sahrmann's philosophy is that 'low back pain' is not a diagnosis but a symptom. The true issue lies in identifying the specific movement that consistently triggers or worsens the pain. By naming the pain after the problematic movement and observing how changing that movement alleviates symptoms, therapists can address the underlying cause. This nuanced perspective highlights the importance of a physical therapist's expertise in discerning the exact motor patterns contributing to the pain, moving beyond generic labels to individualized solutions.

THE MOVEMENT SYSTEM AND LIFESTYLE'S ROLE

Dr. Sahrmann emphasizes the concept of the 'movement system' as a crucial body system, comparable to the cardiovascular or nervous systems. This system is fundamental to our existence, and its dysfunction can lead to pathology. She draws a parallel to the nutrition system, noting that just as we take certain aspects of nutrition for granted, we do the same with movement, often performing actions incorrectly without realizing it. She stresses that it is not inevitable to experience decline; lifestyle choices, including how we move and exercise daily, play a pivotal role in improving health outcomes and preventing issues.

ADDRESSING SPECIFIC MOVEMENT DYSFUNCTIONS

The discussion delves into specific issues, such as overdeveloped abdominals leading to spinal compression, and asymmetries like one iliac crest being higher than the other, indicating a side-bending posture. Tightness in muscles like the tensor fasciae latae (TFL) and piriformis, alongside issues with the iliacus and adductors, are common findings. Dr. Sahrmann suggests corrective exercises, including quadruped rocking and specific hip rotations, to address these asymmetries and muscle imbalances, emphasizing the need for targeted movements to improve alignment and reduce pain.

THE IMPORTANCE OF HIP MOBILITY AND BREATHING

A significant portion of back pain, potentially over 70%, is attributed to suboptimal hip movement. When hips lack the necessary range of motion, the body compensates by using the lower back more, leading to pain and injury. Dr. Sahrmann also highlights the role of breathing mechanics, explaining how abdominal stiffness can limit rib cage expansion. Corrective strategies involve elongating the abdominals through movements like arm raises and side bends, focusing on controlled breathing to improve thoracic mobility and reduce reliance on the lumbar spine.

REPATTERNING MOVEMENT AND FINDING BALANCE

Changing ingrained movement patterns, like how one walks, requires time, attention, and specificity. This involves identifying impediments to proper movement, performing specific exercises, and integrating corrected patterns into everyday activities. Dr. Sahrmann also touches upon 'squeezing' or 'collapsing' syndromes, where either excessive muscle tension or a lack of muscle support leads to spinal compression. The goal is to find a balanced state, avoiding both extremes to optimize function and reduce pain, particularly relevant for both younger individuals and the elderly.

THE ROLE OF STRUCTURE AND INDIVIDUAL VARIATION

Dr. Sahrmann stresses the importance of recognizing structural variations, such as femoral retroversion (the angle of the femur), which are innate and influence movement patterns. These variations need to be considered in assessment and rehabilitation. She advocates for a personalized approach, moving away from generic exercise recommendations. Understanding how individual anatomy interacts with movement is crucial for effective treatment, ensuring that exercises are not only performed correctly but are also appropriate for the person's unique biomechanics.

CORRECTIVE MEASURES FOR SHOULDER AND NECK PAIN

The conversation extends to shoulder and neck issues, with Dr. Sahrmann noting that many people 'wear their shoulders too low.' This posture can negatively impact the cervical spine. Corrective strategies often involve strengthening the serratus anterior, which acts as a sling to support the shoulder blades. Exercises like wall slides and focusing on proper scapular upward rotation are recommended, emphasizing that consistency in daily posture and movement is as critical as dedicated exercise routines.

STRETCHING, STIFFNESS, AND MOVEMENT CUES

Dr. Sahrmann clarifies that many issues are related to 'relative stiffness' rather than actual muscle shortness. Stretching a muscle may not be effective if underlying stiffness in opposing or synergistic muscles is not addressed. She illustrates this with the example of hip flexor tightness, suggesting that strengthening abdominal muscles can elongate the hip flexors. The body naturally follows the path of least resistance, so identifying and modifying these ingrained patterns of movement is key to long-term improvement and injury prevention.

PRACTICAL APPLICATIONS AND SELF-CARE

Dr. Sahrmann shares her personal self-care routine at 86, which includes quadruped rocking, modified push-ups, hip extension and rotation exercises, and specific prone movements. These routine activities, performed daily, are crucial for maintaining her physical and cognitive sharpness. She advocates for a disciplined approach to movement, emphasizing that consistent, correct execution of everyday activities is paramount for improving health and overall quality of life, especially as individuals age.

THE DANGER OF MALADAPTIVE MOVEMENT PATTERNS

The discussion highlights the potential harm in certain common exercises, like bridging, especially for individuals with specific spinal characteristics. If the spine doesn't move harmoniously with the pelvis during an exercise, it can lead to pain and injury. Dr. Sahrmann advises caution and personalized assessment, stressing that gluteal activation, while beneficial, can be detrimental if it causes excessive posterior pelvic tilt without corresponding spinal movement, potentially leading to a 'pulling out from under the spine' sensation.

EMPOWERMENT THROUGH MOVEMENT AWARENESS

A critical aspect of Dr. Sahrmann's approach is empowering individuals to take control of their symptoms. By demonstrating which movements cause pain and which alleviate it, patients gain a roadmap for self-management. This awareness helps reduce fear and anxiety associated with pain, fostering a sense of agency. Understanding that everyday activities are the root cause and can be modified provides a powerful tool for long-term adherence to rehabilitation and improved quality of life across all age groups.

Mentioned in This Episode

●Software & Apps

●Organizations

●Books

●Concepts

●People Referenced

Movement & Back Pain: Practical Strategies

Practical takeaways from this episode

Do This

Check rib cage expansion: aim for 2.5-3 inches change in circumference from maximum exhalation to inhalation.

In standing, separate feet (abduct hips) to test for hip flexor (TFL/ITB) and iliac crest asymmetry issues.

Practice quadruped rocking: hands and knees, let hips drop to 90 degrees, pushing back with hands to rock and improve hip asymmetry. Slightly laterally rotate hips to avoid knee issues.

In prone, flex knee to 90 degrees or more (leg falling on thigh), lift thigh 10 degrees using gluteal muscles for hip extension.

In prone with knees flexed, perform hip rotation (windshield wiper) with both legs simultaneously for efficiency.

In prone with straight legs, alternately perform hip extension (activating gluteus maximus for 10 degrees).

In prone with straight legs, alternately perform hip abduction (one leg out to the side 10 times) to use gluteus medius against gravity.

In supine, bring one knee to chest, put it down, and alternate with other leg 10 times.

In supine with one foot on floor and knee bent, perform straight leg raise with the other leg, slightly turned out, while tightening abdominals to protect the back.

In supine with one leg straight and the other foot on the floor (knee bent), let the bent leg go out to the side while contracting abdominals to control trunk rotation.

Practice tightening lower abdominals (external obliques) in standing to create a slight pelvic tuck and reduce lumbar sway without overextending.

Use armrests on chairs to keep shoulders supported and avoid hanging down for long periods.

When side bending, aim for rotation through the chest, not the lumbar spine, focusing on passive elongation (imagine heavy elbow) rather than active contraction.

Ensure sufficient terminal hip extension during walking by pushing off with feet rather than pulling with hip flexors.

For those with femoral retroversion, allow feet to turn out slightly when standing or performing rotational activities like golf to avoid undue stress.

Avoid This

Do not rely solely on imaging (MRI) for movement-related pain diagnosis.

Avoid excessive or prolonged use of the iliopsoas, especially during acute back pain phases; use hands to lift legs if necessary to minimize use.

Do not perform bridging exercises if they cause back pain, as they can lead to posterior pelvic tilt without spinal movement.

Do not try to force feet to point straight ahead if you have femoral retroversion, as this can put stress on knees, back, or hips.

Do not spend long periods with shoulders hanging down; support them with armrests or by placing hands on hips.

Common Questions

Dr. Shirley Sahrmann is a Professor emerita of physical therapy at Washington University School of Medicine. She is a recognized legend in her field, known for developing diagnostic categories based on movement dysfunction and publishing influential books such as 'Diagnosis and Treatment of Movement Impairment Syndromes.'

Topics

Health & Longevity Human Performance Posture Correction Low Back Pain Musculoskeletal Health Movement Dysfunction Hip Mobility Abdominal Stiffness Thoracic Kyphosis Rehabilitation Exercises

Mentioned in this video

People

Shirley A. Sahrmann

Professor emerita of physical therapy at Washington University School of Medicine, Catherine Worthington fellow of the American Physical Therapy Association, and author of influential books on movement impairment syndromes.

Eric Cressey

A well-known performance coach with a physical therapy background, who highly praises Dr. Sahrmann's first book for its influence on his career, especially with baseball pitchers.

Dave Elitch

A professional drummer who referred the Essential Anatomy 5 app to Tim Ferriss, known for helping people improve their mechanics and technique.

Concepts

Dynamic Neuromuscular Stabilization

A rehabilitation approach that builds movement patterns based on developmental chronology (e.g., from supine to crawling). Dr. Sahrmann expresses skepticism about its strict application for adults.

Iliac crest

The uppermost border of the pelvic girdle, a bony ridge on the hip, used as a reference point for anatomical explanation.

Piriformis

A deep gluteal muscle mentioned as being very tight and sensitive for Tim Ferriss.

Psoas major

A large muscle that joins the upper and lower parts of the body, connecting to the lower back and contributing to lower back pain. It directly acts on lumbar vertebrae and intervertebral discs.

Quadratus lumborum

A squarish rectangular muscle in the lower back area, described as a 'Grand Central Station' of various functions related to back stability.

Adductors

Muscles on the inside of the thigh, noted as being very tight and potentially weak for Tim Ferriss, with their release providing back relief.

Rectus abdominis

The 'six-pack' muscles that run down the front of the abdomen. If too short or stiff, they can pull down on the thoracic spine, contributing to kyphosis.

Tensor fasciae latae

A muscle at the outside, very top portion of the thigh, often considered a hip muscle, used for pelvis balance and hip abduction. Its stiffness can contribute to low back pain.

Stenosis

An abnormal narrowing, specifically spinal stenosis around L4 L5 in the lumbar spine, which can put pressure on nerves and cause pain.

Iliacus

A hip flexor muscle, distinct from the psoas as it attaches to the pelvis and not directly to the vertebrae. Its release can bring symptomatic relief for back pain.

Drugs & Medications

Scheuermann's disease

A condition that occurs during teenage years, characterized as an idiopathic compression fracture of the thoracic spine, leading to kyphosis.

Organizations

Washington University School of Medicine in St. Louis

Dr. Sahrmann's academic institution, where she is Professor emerita of physical therapy and was the first director of their PhD program in movement science.

University of Indianapolis

An institution that awarded Dr. Sahrmann an honorary doctorate.

American Physical Therapy Association

An association that recognized Dr. Sahrmann as a Catherine Worthington fellow and awarded her the Mary MacMillan award, its highest honor.

Books

Movement System Impairment Syndromes of the Cervical and Thoracic Spines and the Extremities

Dr. Sahrmann's second influential book, which further promotes movement diagnoses and applies to various body regions.

Diagnosis and Treatment of Movement Impairment Syndromes

Dr. Sahrmann's first book, translated into seven languages, focusing on diagnostic categories based on movement dysfunction and tissue adaptations.

Software & Apps

Essential Anatomy 5

An app for iOS and Android that provides rotating views of muscles (like QL and psoas major), the circulatory system, and other anatomical structures.

Found this useful? Build your knowledge library

Get AI-powered summaries of any YouTube video, podcast, or article in seconds. Save them to your personal pods and access them anytime.

Try Summify free