As a CrossFit level 1 trainer with a 13-year physical therapy career and an interest in golf, running, skiing, and hiking, it’s fair to say that Dr. Jackson Bellis practices what he preaches when it comes to maintaining a healthy back.

Dr. Bellis is always challenging his own body and encouraging his patients to safely challenge their bodies to see what they can do.

“I really think we can make a big change in back health. And I think looking at the way we move, and the things that work and don't work, is a big piece of it,” he says.

Back health has everything to do with the way we move. Some of the most frequent patients who come into our offices are runners, golfers, and truck drivers.

And while their pain might have different causes, it all really comes down to movement, and a few go-to exercises can help almost any type of pain, Dr. Bellis tells us. It’s all about the hips, the abs, and the glutes.

Dr. Bellis shares actionable advice for how stretching and strength-training can serve as strategies to maintain and improve mobility.

Tune in to episode #40 of Back Talk Doc with Dr. Bellis to learn more about the tactics we should all be doing to help treat — and prevent — pain.

💡 Featured Expert 💡

Name: Jackson Bellis, DPT COMT

What he does: Dr. Bellis has been a physical therapist for 13 years, spending 10 of those years of service at Carolina Neurosurgery. He is also a certified orthopedic manual therapist (COMT) with experience in dry needling, selective functional movement assessment (SFMA), and titleist assessment. He enjoys CrossFit, running, golf, skiing, and hiking.

Company: Carolina Neurosurgery & Spine Associates

Words of wisdom: “One thing my patients always say is, I did not realize how tight I was. I did not realize how weak I was. If we never really get to the point where we're trying to see what our body can and can't do, we may not be enjoying it to the fullest.”

Connect: LinkedIn ⼁Website

⚓ Anchor Points ⚓

Top takeaways from this Back Talk Doc episode 

★    Think backwards. When trying to figure out the source of pain and how to treat it, it can help to think backwards and treat with opposite movements. For example, if someone has pain from bending forward, laying down in an extended position can help take pressure off the nerve. Treatment can be active, “like on the ground in a cobra position” or passive. “It’s a way to test out and find out Hey, this was a disc."

★    It’s all in the hips. “Everything in life is through the hips,” Dr. Bellis tells us. Understanding how the hips work can also help us understand what causes pain, and figure out the right treatments. Learning how to properly bend at the hips and use the hips during exercise can keep your back healthy and prevent injury. How to use your hips to bend (VIDEO)

★    The bridge and plank are key to a healthy back. Whether it’s lower back pain, seated pain, walking pain, or pain from bending over, Dr. Bellis swears by these two exercises that activate the glutes and the abdominals. Doing it correctly can help control the neutral position of the spine. “I have never had a person come in here with back pain who could activate their abdominals and activate their glutes,” he says.

⚕️ Episode Insights ⚕️

[00:00] Check out our sponsor: QxMD builds mobile solutions that drive evidence-based medicine and clinical practice.

[01:38] Introducing Jackson: Today’s guest is our very own Jackson Bellis, a physical therapist and manager at Carolina Neurosurgery’s Matthews office who has been with us for 10 years.

[03:12] Flexion-sensitive disc pain: We open our Q&A with Dr. Bellis with a common condition that can lead to a herniated disc: radiculopathy, or the type of back pain that comes from bending over.

[06:10] Restoring confidence: Figuring out what went wrong in the first place is step one in physical therapy for patients with herniated discs, and the first step toward building the confidence to bend again. All that power, Dr. Bellis says, comes from the hips.

[7:34] How to hinge: Dr. Bellis discusses common hip faults and how to properly use our hips to bend.

[8:44] Think opposites: One tactic that can help identify a disc herniation and reduce pain is working in opposites: extending the body in the opposite direction in which the pain occurred, making sure to work slowly and gently. Dr. Bellis gives us some at-home tips.

[12:01] Staying on the course: With constant twisting and rotating, golfing may be one of the hardest activities on your back. Dr. Bellis tells us how using the hips and upper back can keep golfers healthy. Back Talk Doc discusses golf rehabilitation in-depth in a prior episode with Dr. Graham Claytor.

[13:46] Standing pain: The causes of lower back pain when standing or walking usually comes from spending too much time in a hyperextended position. Treatment differs from patient to patient. We discussed spinal stenosis with Joe Cheadle on episode 16 of Back Talk Doc.

[18:37] Sitting pain: Carolina Neurosurgery often sees truck drivers coming in with increased back pain. Sources and treatment of that pain can differ, from pelvis imbalance to a disc issue.

[23:10] SI joint pain (or Sacroiliac Joint Dysfunction): Treatments as simple as daily leg extensions can help relieve sacroiliac joint pain, the pain from the joints where the hip bones and the sacrum meet.

[27:24] Keep the glutes active: Dr. Bellis shares his go-to glute exercises and explains how they can help the back, from relieving SI joint pain to strain from golfing.

[29:54] Essential exercises: Dr. Bellis recommends two exercises for anyone and everyone, with or without pain: the bridge and the plank. These exercises can lead to greater control of the spine. “Like we talked about, where does the power come from? Power comes from the hips.”

[32:51] The great hamstring debate: Is stretching our hamstrings really necessary? It depends on who you are and the type of activity you do every day. “When I'm meeting my average person to learn how to bend over [to load] the dishwasher, I can get that person to learn how to hip hinge pain-free without necessarily having to stretch their hamstrings.”

[35:58] Words of wisdom: Dr. Bellis shares his advice on challenging your body and paying attention to previous injuries.

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Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.

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Welcome. You are listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery and Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.

Those that have been following the podcast over the last two years know that I am very passionate about the role of physical therapy in helping people who suffer with back pain. In fact, I'm obsessed with everything related to back pain, and that's my mission on Back Talk Doc is to provide you with angle possible to help you have a healthy spine, a healthy life, and really feel your best. In our group at Carolina Neurosurgery and Spine Associates, we have a fabulous team of physical therapists that help thousands of people each year, and today I'm pleased to have Jackson Bellis on the show to help go through... what I like to do is just... today's topic is really going to be kind of a Q&A session with Jackson about back pain and the different approaches that are out there, and he is one of the experts here at the group. He's our manager in our Matthews office. And Jackson, welcome to the show.

Thanks for having me glad to be here, Dr. Lakhia.

By way of introduction, Jackson's been a PT for about 13 years and 10 years with our group. He's a certified orthopedic manual therapist and Titleist trained. He's CrossFit level one certified and SFMA trained. He enjoys running, CrossFit, golf, skiing, hiking, so he kind of practices what he preaches and just sees hundreds of people a year with spine conditions, isn't that right?

Oh man, all the time, but a lot of times there's a lot of commonalities between everybody in what I see, but definitely a good amount of people kind of moving in the wrong direction with their back.

Yeah. And that's why we're here. We're here to help. So let's jump right into today's topic, which is a Q&A with Jackson Bellis regarding back pain, disc herniations and current state of the art in terms of physical therapy approaches. What I'd like to do is break this down into maybe four different categories of individuals. Those that are listening, you might resonate with one of these groups, and I think these are some of the more common complaints that I hear and reasons why people come to see me for help.

First of all, I would say far and away, and this is even one that I kind of deal with myself, is flexion-sensitive disc pain and radiculopathy. And in layman terms, that's basically people out there who tend to hurt their back when they bend over. So a common complaint could be, "Hey, I was just putting on my socks and shoes and I felt like someone stabbed me in the back. And then either I just had severe back pain or I started to on my leg," or "Every time I put my socks on or every time I reach into a drawer leaning over, bending over," man Jackson, is so common. Dive into this topic about flexion-sensitive back pain.

Yeah, you got it right on there. I will say from what I've seen, the main way you're going to herniate a disc is from some kind of torsion flection, twist, and especially if you load that spine with carrying something, so you got it. I bend over. I lifted, I did a deadlift wrong. Oh, I've had sometimes over summertime, people sit in a chair for too long and that low chair at the beach and they'll get up, have this excruciating pain, pain down the leg or heck, that pain might not have gotten so inflamed that day, but they get it a day later. And that's what I usually go back to and I'll ask them, "What did you do the day before?" But I would say, I mean, you hate to say 100% of the time that every single person with that herniation that's why you talk about those commonalities that you start to see on every single person, it is going to be some kind of flexion. That disc again, is going to bulge backwards and hit that nerve, but it's got to come from some kind of loading in a flexion and twisted position.

And what I would say is that usually you're going to see this in a younger population. Always. I would even... I start hitting the number around 50, 50 or younger. I can almost say most of those people who are coming in with some kind of disc pathology, not usually you're going to find something else like a spondylolisthesis or an arthritis or a stenosis. It's probably most likely going to be that person who's under the age of 50. Hey, they might be working out a bunch or as we've seen in studies, sometimes it takes about 500 times for someone to bulge out a disc. So they might not have lifted something heavy, but if that person who bent down, picked up a pin in their back went out, well, it was the 500 times you bent down with a little too much flexion in that back, not using your hips that you start to eventually bulge that disc out enough where now you're starting to have symptoms.

Well, I was not aware of that. So that's kind of a number out there in terms of repetitive activities, Jackson, 500 times, and then it fatigues it?

Yeah, exactly. And they'll do like in vitro studies and they'll actually try to... I'd have to go back and leave the studies, but we'll stress this fiber, those annular fibers around that disc and say how many times does it take to stress that fiber out to eventually get that jelly, that nucleus pulposus, to bulge out and then hit that nerve.

Okay. So when someone comes in with this type of problem, how do you restore their confidence in their ability to bend over?

Yeah. Yeah. We're talking about just strictly getting back to bending, let's see what we did wrong. And I again, go back to the physical therapist. I'm all about movement. I'm all about figuring out what we did wrong in the first that now caused our spine stress. And so I would say, as I pretty much say with all my patients, and especially with disc bulge, it had to do with how you bent over. How you bend is through the hips. How we do everything in life is through the hips. [inaudible 00:06:48] we'll talk a little bit more about this in the podcast later about an arthritic condition, but how we walk and stand, how we swing a golf club, how we swing a baseball bat, how we jump, power clean in CrossFit. The power comes from the hips, so if we stop using those hips, what you'll find in a lot of my back patients is that they have weak glutes, also probably some weak abdominals, but they have forgotten how to use their hips. And so as we get towards the end of treatment, I want to keep you from ever bulging that disc out again, and so that goes back to how you move.

And so I actually, a lot of my training is actually teaching people how to bend, i.e. teach them how to deadlift, but I'm not using any weight. I'm just teaching you how to use your hips to go to bend, which is very similar to a deadlift.

Describe that further. So are you talking about, when you say use your hips to bend, are we talking about kind of sticking your hips back and hinging at the hips?

There you go. Yeah. It's called hip hinge. Sometimes they call it like grooving that hip hinge. So kind of start to think of a swing and that's why I say it starts at the hips. You got to be able to migrate those hips back as your trunk goes forward. And a lot of times patients are actually scared because they've always heard keep your back straight. Well, you were right. You were correct. Keep your back straight, but it doesn't have to be straight up and down as in vertically, it just needs to stay straight, whether it's vertical or horizontal. But if my trunk is now leaning forward, my hips have to go back. And so if my hips start to keep going backwards, now we're going to start loading the glutes and the hamstrings as opposed to your low back, which is where the stress will end up.

You know what, let's find a link for the listeners. We'll put a link to probably a video, maybe a good YouTube clip on how to properly hip hinge. And again, this podcast is definitely for informational purposes only. I don't want to encourage people to take things in their own hand if you have an issue. Certainly see a physical therapist. But we can definitely link to that, so you can visualize that. Now, when someone comes in though with not just back pain, but radiating pain down the leg from a disc herniation that occurred bending over, what are your strategies as a physical therapist to help them kind of get that pain out of their leg and restore their function?

Yeah. And a lot of times just thinking about the opposite of however we hurt ourself. So if we hurt ourselves with bending and twisting, well, you would almost think the opposite of that should help to relieve my pain and restore kind of the direction of movement that is difficult. And so yeah, if they bent forward, then as we... and as McKenzie, someone you have mentioned before as well, that found out many years ago, that when I get these people into an extended position, it seems to centralize the disc, take pressure off that nerve. But yeah, so the first thing I start doing, and the great way to even diagnose it, is I get them to lay on their stomach. Hey, when we start to bend backwards, don't bend backwards too much. I'll get patients who bend backwards too fast and like, "Oh, that hurts." I'm like, "Hey, slow it up. And can you feel that pull in that low back?"

So I started to get them in that McKenzie lumbar extension position, and let's slowly start to work that backwards. And usually after a couple, they'll say, hey, that does feel like it's getting easier. I can work into it. And usually even after a couple weeks of that, along with some other stuff, traction and mobilization, which a joint mobilization. So there's some different ways we can extend the back. You can do it actively like on the ground, like in a cobra position, like in yoga. You could passively do it. I could almost try to lift you up myself or traction you myself passively, or I can use a joint mobilization to go to that specific level to help extend that one level where the disc is at. So that's me taking my hands, my fingers to help move that joint into a more extended position and usually as I work into it, people say, oh, I do feel it getting better and better. We go back to the extension. They say, hey, even feels better when I extend now.

And actually, we can test/retest. So hopefully I'm not going too fast. This is too much. So I can even get that person back up and say, let me see your bend over again and like, oh, it is easier. So it's a way to test out that, hey, this was a disc. Hey, I will say... again, I hate to say 100% of time, but extension with a disc is money. It's the direction to go. It's a way to confirm a disc diagnosis I would even say as well, and that person, most of the time, will improve depending on the severity of the disc bulge.

Excellent. And that's really the most common scenario that I think we encounter in the clinic, and those are some great tips and thoughts on how to kind of view back pain that occurs with bending. You have to reestablish number one, how you bend. So hip hinging versus compressing the disc with flexion and then kind of treating the opposite position of injury, avoidance of twisting and heavy loading. So I think that's a nice summary of that. Thank you for that.

Yes, sir. And then actually, you can even use a little bit of twisting, with going the opposite direction, kind of talking about that opposite direction. If you twist it to your left and bend over going to the left, well, if I extend you and kind of twist back to the right, I can even help to kind of close down that disc with a little bit of rotation using the right side, but just another fun fact on that.

You know, it occurs to me that one activity that puts you in this position that you said is not advantageous is golfing, right?

For sure. Yeah.

You're flexed and you're twisting and rotating. And I did an episode with Graham Claytor on it, and we'll put a link to that in the show notes as well. But how do golfers avoid injury or do you see a higher rate of disc herniations in people who golf?

Perfect. I mean, I will actually tell people, golfing may be the hardest activity on your back because of that position, but then we have to... now we know when we flex forward, we should be doing it with our hip. Number two, now we have to control for that rotation. And your low back only has 10 degrees of rotation. So when you see a golfer and they swing and they get 90 degrees of rotation, it is not coming from their low back. It's coming... you got 45 degrees of rotation through your thoracic spine, which is above your low back, and you got 45 degrees of rotation from your hips. So when a golfer is rotating, they were doing a really awesome job of rotating through their upper back and their hips to get that swing. And what they're hopefully doing is using their abdominals and then actually training and research goes to thinking of the abdominals as more preventing motion than actually causing motion. So when they're rotating, they're trying to brace their abdominals to keep any rotation out of that low back because your low back doesn't want to do it and cause motion at the other segments or other areas of your spine or hips.

And so now if we can make that happen, then you have a probably good idea of trying... or what's the word? You have a good possibility of not hurting your back when you're swinging that golf club.

Excellent. Excellent. Now let's transition to the second kind of category. All right. Let's say middle aged male comes to you with complaints of low back pain with standing. What thoughts kind of go through your mind with that clinical presentation?

Yeah. Now I'm starting to think a little less disc. Well, going back to some other highlights where people with disc, usually people with disc will have more pain with sitting, more pain with getting up from a sitting position and actually, most of the time say I feel better when I walk and stand. So I got someone coming in who says I got pain with walking and standing, I would bet that... our spines can handle a lot of load through the spine. It's actually kind of what they were meant to do through that disc and through those facet joints. But now we probably have a little too much load going through a facet joint. There's probably a little too much hyper extension. So now you think of maybe going the other way, we can go too far into flexion. Well, heck we could probably go too far going backwards.

And so I would actually start to look at that person who has having trouble walking and standing when they get up and they stand, is their back slightly maybe in a little bit more extended position? On top of that, we also want to look at maybe some other things like you might have mentioned before SI joints in their hips as some other sources of pain, but depending on high up or how low that pain is, now let's start looking at, well maybe they're spending too much time in a hyperextended position when they're running, when they're standing, even when they're going to lift weights. Are they arching their back when they're pushing that weight overhead? Are they arching their back when they come back up to a standing position, maybe from a squat or a dead lift again?

Exactly. And I tend to see this type of presentation more in adults. And when I have someone who comes in with increased back pain with standing, the next question I ask automatically is does it affect your legs and does it get worse when you're walking particularly associated with numbness? So I'm concerned about developing spinal arthritis and spinal stenosis, and we've talked about this as well. I did a great podcast interview with Joe Cheatle on spinal stenosis and the surgical side, and we can link to that. But back pain with standing, now of course, there also can be just muscle ligamentous, fatigue and back pain in that position, but I think more about maybe there's a little bit of arthritic back pain, and if you get a little relief when you lean over, that can be the sign of it versus like you said, a disc issue. How would your rehab approach change for someone who's coming in with maybe disc-related pain with flex versus arthritic-related back pain?

Yeah. And you kind of said it, usually I'm thinking of more of that pain, middle age is probably a little different how I would also treat someone who's older in their 60s and 70s, given that I'd have to... we want to look a little bit more at their abdominals and their hip function when they're walking and standing. When I think about my older population, now I'm starting to think even more so about flexing the spine. So you kind of mentioned that maybe they got this kyphotic thoracic spine and it causes their low back to be a little bit more hyperextended. So that kyphosis again, for everybody who maybe not know what that term is, is like when we sit at a computer all day, our back's all rounded. Well, when we get up from that computer, your back's still rounded, but in order for you to stand up straight, you kind of have to hyperextend everything. And so as we see people get older and older, well man, that becomes a lot bigger issue And then their low back starts to hyperextend even more.

So going back to, we would spend some time in some flexed positions, taking some pressure off of those facet joints, trying to open up that spine, and that's more like bringing both needs to your chest. That's more of a child's pose position or maybe like a happy baby in yoga. And so we're trying to create some flexion, but then we also want to figure out what muscles are not necessarily working to help maintain a flexed posture, and that goes to back to your abdominals help kind of brace that spine and kind of push you back into a little more neutral position. Maybe it's a matter of stretching out that upper back because that kyphotic position is also kind of playing a little bit of a role. And then maybe it's your hip flexors.

So going back to when I think about walking and standing, we'll go back to your back's really not as involved in walking and standing. Let's really look at those hips because as I extend my hip, if my hip flexors are tight and my glutes aren't really working, well now I might cause my low back to hyperextend again. So let's look at the ability of your hips to be able to get out of a sitting position, to be able to extend to that 10, 15 degrees, if possible, especially when people are running and see if the hips are not a cause of probably some increased pressure in that low back as well.

Excellent. And just illustrates how I think it's a failed approach to look at these issues in isolation. Everything's connected. Your biomechanics from your foot up through your knee, hip into your back, and that's why I like the approach that our therapy team, including yourself, takes with our patients here. Moving on, the third kind of group, and I think you may have touched on it earlier and it probably falls in with the first group, is back pain was sitting and driving. You know, I have a fair number of people who drive trucks for a living who come to see me with increased back pain. And do you generally consider that to be more disc-related pain?

I would. I would. although I have had some truck drivers with the stiffest hips in the world. Also, I've had some guys come in and they'll have a car for like 15, 20 years. The only time they get pain is when they're sitting in this car they've had for 20 years and I'm like, man, can we just get a different seat maybe? But yes, if it really was more like driving and sitting with low back pain, I would probably look at the disc. Also going back to the hips have to almost be probably in a little bit more flexed position. Do they sit with one knee up and one knee down? Sometimes it's even looking at the asymmetry of the pelvis a little bit as well. So I still would even maybe, with my truck drivers, going back to my truck drivers, they're some of the stiffest people because... or even just people sitting at a computer all day, because we are a flexed position, the hips get more stiff than you would think.

But what I said that you would see is that a lot of times they even have a hard time bringing their knees up to 90 degrees. And so if their hips can't even go past 90 degrees and then it's starting to affect their back because your knees should be able to go up further. Your hips should be able to flex further. And so it's almost like they're getting this overall kind of muscular dysfunction that where they're again, the pelvis, the hips are just so tight they're having a hard time even just maintaining that position. But otherwise, yes, I would be looking at a disc as well.

Now, I record this podcast near the Charlotte area and many people who listen get to enjoy the drive on I-77 and 45, and the traffic that comes with it. When you are stuck in the car, can you give some tips to people on what an ideal seat position would be? Now, should we have our back upright? Should it be reclined some? Give some tips for people who are maybe listening to this in their car right now.

Yeah. So even with almost the same as a computer position or that driving position where I almost have gotten away from telling people to be so upright. I actually want you to recline back about 10 degrees. I even say just a tiny, tiny bit because now you can imagine that weight no longer is really sitting on your spine that essentially is going to cause you to round forward. You can actually now bring that weight back against the chair and as you recline it backwards, now gravity's kind of helping you a little bit. Also, if you have a little bit more of a disc issue, again, that sitting position is going to be the place where I... this is what I tell people. I'm like, hey, if you could almost avoid sitting, but again, if you're on a drive and you can't avoid sitting, put something behind your back to keep it in that a little bit of extended position, especially in a time that you're trying to heal over the next two weeks, three weeks, four weeks.

Otherwise, when you go back to looking at these hips and this asymmetry, I'm a driver. Where I put my left hip real flexed and my right one's all straight out. I'm like, hey, let's just even things out. Let's put both feet kind of next to each other near the gas. The left foot kind of hits that wall or the bottom of the little car area where the gas pedal is on the left side and sometimes I just stretch that left side out so we can kind of start to even things out.

So those would probably be my main things I would think about.

So you are a fan of the kind of lumbar lordosis or lumbar curvature pillows to put in the car?

For sure. Especially if you're a gal or guy that sits for two, three hours at a time because again, eventually if you just have that little bit of rounded position, it's going to have some effect eventually, and again, especially if you're symptomatic. Now, if you're not too symptomatic and you could probably not be too hyperextended or need too much, but I still would put a little bit in there. And if anything, again, I'd recline that chair back.

Okay. That makes a lot of sense. I also recommend if possible, just my observation for people has been they do much better in higher riding seats versus low bucket seats because I think those low bucket seats in the sedans and the sports cars, they literally create that flexion moment on the disc and the spine versus some of the higher riding than trucks and SUVs. But obviously that's not an easy factor to modify for some people.

Yeah, you're right about that. Yeah, for sure.

Okay. So we've covered three pretty common clinical presentations of back pain. Now, one of them, this is kind of a wildcard I wanted to get your thoughts on today was the idea of sacroiliac joint pain. And for those who don't know what that is, it's basically where your spine meets your hip in the back in the buttock area and it can contribute to a fair amount of pain in the low back and even some pain going down the legs some. But it's not a disc. It's a joint. Share your knowledge on the sacroiliac joint and maybe presentations that you tend to see and what your PT approach is.

Yeah. And so SI, of course, is probably one of the more debated topics on how much that SI moves, who it moves on. Definitely just because of the difference between men and women, women are probably going to have a pelvis and SI that can move or come out of alignment in a sense more often. And maybe in males it fuses a little sooner. Sometimes it maybe moves just a little bit. I would say it seems to have some movement to it, and one, I say that because of the way we diagnose it and the way we almost can push on it. I had a guy actually recently after a fusion, still have some SI pain. We can get right on that SI joint and just like you mobilize the low back, we can kind of mobilize it, it elicits pain. So bottom line, we know that that thing can elicit pain. We know that it's something we can treat. It's something we can work into and alleviate it.

But going back to the SI, let's think about the reasons that SI joint is now starting to be symptomatic, and that goes back to our favorite thing we've been talking about so far, are these glutes. Your piriformis attaches into it. Even some low back muscles come in, [inaudible 00:24:46] come back and attach into it. You got to imagine when you're walking and standing, when I bring my knee all the way up to my chest, it moves my SI joint. If I extend my leg, it moves my SI joint. And most of the time on people we find, or I find, on the SI joint I would actually work on extending that leg even more so, because that tends to be the one where as soon as I have people kind of let their leg hang off the edge, they can feel that pool on that SI joint. And I'm saying, let's start to work into that because maybe they're sitting at a computer. Maybe on that I-77 right now, and they're sitting in the car, they haven't extended those. When's the last time you extended your legs today?

And so a lot of times we want the same thing, work on those glutes, work on extending those legs. I'll even go a little further on symptomatic. Let's even look at the glutes as a source of pain. One area that I find that often may be looked over that can actually refer pain down your leg are the glutes. And so we can have a radicular pain, probably from a nerve, but we can have a referred pain from more of the glute muscles and doing dry needling and rolling people's glutes out. We also want to maybe even look at the glutes as a source of pain that can radiate down the leg, just like an SI joint can. Let me know if you have any other questions on that.

No. That's great. In fact, I did a podcast interview with Marty Keston, who's a licensed massage therapist here in Charlotte with a lot of experience doing trigger point work, and we talked about that concept as well as literally having a dysfunctional muscle band in the glute that can mimic sciatica pain. So I'm glad you brought that up and that's why I think everyone's best friend could be a foam roller, particularly with the amount of sitting we do. Foam roller or tennis ball. Those are great tools, self-help tools where you can literally sit on them, roll on them and treat yourself. And I guarantee you, everyone who's listening, if you try this, you're going to find something that talks to you and that's sensitive.

There are category that I would add in terms of sacroiliac joint pain that I see particularly working in a neurosurgical practice, and I do see a slight uptick in pain in that area from individuals who have had a prior lumbar fusion and I think it's just physics. You transfer the load into the joint when you're no longer moving through your L4, L5 or S1 segment. So do you observe that as well in your practice?

Yeah, for sure. And I would even say given the history of everything we talked about, it's perhaps that even those glutes possibly aren't working well in the first place as well. So even before surgery, even after surgery, yeah, maybe just a transfer of down to the next segments going down, that maybe there's still a kind of a chronic issue within those hips and glutes that still kind of need to be addressed.

What are some of your go-to kind of simple glute sizes that you recommend?

Oh man. So you're making me happy talking about the glutes again, but the bridge. So you think about a hip hinge. Well, okay. So maybe this person listening to this podcast is like, well, I'm having trouble thinking about how to hinge from my hip. Let's take it a step down, regress it a little bit and let's go into basic bridge. But I will say every time people say I can do a bridge all day. Hey, do you feel that like mostly in your butt muscles? No. I feel it in my legs in my back. Well, already we can infer that when you try to use your butt muscles, use your legs in your back. Well, let's try to get your glutes working. So a bridge is basically a hip hinge on your back. And so then let's start to make sure you know how to work your bridge first, and now let's try to take you up to a standing position.

And then going back onto your SI joints where your piriformis can sometimes be over tight or over elongated, let's look at your hips internal and external rotation. And an easy one for that, going back to my golfer who needs to learn how to rotate from their hips or my person who walks and is still having some trouble with loading through their hips and their SI joint, let's look at your easy clam shell, which would be laying on your side, keeping your feet together and just lifting their knee up. But again, a lot of times when I have this person, they're not really using their glutes and we have to make sure they make it a smaller motion. It should feel heavy. If it feels too easy, you're probably cheating. So try to make sure that again, your glutes are getting engaged or you could do a reverse clam shell, which would be the exact opposite, internal rotation of the hip. Again, trying to get this internal/external rotation of the hip, especially for my golf swing, especially maybe for a walking as well and where you just kind of put some towel roll between your knees and lift your foot up. And so basically you're doing the opposite of a clam shell.

So I have some easy go-tos. Maybe throw in some sidestepping in with that too, just to get these tips working, but those would probably be the foundational ones that if I can get those going, I can almost, hate to say guarantee, but I can almost get you up to a standing position and we can make a [inaudible 00:29:21].

It sounds like regardless of the source of the pain, activating and sequencing the glute exercises and movements is going to be beneficial to most people. Is that correct?

You are correct. And I'll even give you a little secret. Out of all the patients, I've been working here for 10 years, I have never had a person come in here with back pain who could activate their abdominals and activate their glutes. Hasn't happened yet. It's one or both. So I would almost conclude that the most of the people that come in these doors have an issue of one or the other.

Wow. All right. So then I'm going to throw an unfair question at you. If you could recommend only one exercise that if someone did religiously to reduce their risk of disc injury, what would it be? Would it be a glute exercise? Would it be a plank? What would you say is like to the busy executive who says, "I don't have time," although you kind of don't have time not to, but really just wants to say, I want to start with one thing and do it well. What would you think is the most impactful?

Man. I would just have to go two. I have to go two exercises. It's a bridge and it would be a plank.

Okay.

Because I have to teach people how to brace. And so if I can teach you how to brace, remember like we talked about those abdominals, if I can teach you how to control the neutral position of your lumbar spine, but then on top of that, like we talked about, where does the power come from? Power comes from the hips. Walking, standing, getting out of a chair, going upstairs. We all know people come in, as we get older, can't do a lot of those things. They have difficulty. Where does that power come from to do that? It comes from the hips. Where does it come from in my golf swing? Comes from the hips. Where come from, from running? comes from the hips. So I have to throw two. And that's what I tell people, if you could keep... and I tell everybody, if you could keep up a bridge, I almost would bias my bridge over the plank for my patients who are about 70 and older, because most of them, it always comes down to their glutes.

The only asterisk I would put to that is with the bridge, if you have extensive joint arthritis or stenosis, for some people it can be aggravating. So I think this is where it's important to not do it yourself because there are degrees to the pelvic bridge. You do not have to thrust your hips like they're going through the ceiling to get therapeutic benefit.

There you go. And I would almost say, and I will say [inaudible 00:31:45] if you are doing a bridge correct, it will not cause pain. And after all the 10 years I've been here, there's only about one or two people that I could almost say had a hard time with that bridge, but I will say, oh man, most of the people who come in here, if I teach them how to bridge, even with a disc injury, even with stenosis, if we teach you how to do it correctly, it will not cause pain. And I'll say if you are having pain, most likely you're not activating your glutes or yes, you're thrusting up too high. You're using your back. Your hamstrings are cramping up because you're using your hamstrings, you're not using your glutes. So yes.

Awesome. And I've had a great time here with Jackson Bellis, physical therapist with our group, just doing kind of a back pain rehab, potluck Q&A session. It's been awesome. I got one last question and it wasn't on kind of our pregame list, but I want to get your thoughts. There's a lot of debate that I read in the literature and clinically on the role of the hamstrings and disc herniations and back pain. There are some people who say you got to stretch your hamstrings every day. There are others who say well, if you have tight hamstrings, that's because you have issues in your quads. What are your thoughts on this whole issue of tight hamstrings because everyone has... I mean maybe once a week, I'll have someone who's very flexible and limber, but even myself, I'll stretch until I'm blue in the face and I have tight hamstrings. So what does this all mean?

Yeah. Right. I'm probably a little biased towards one direction. I do think hamstrings are overly thought of to stretch, and I say that because especially when I have someone who's walking and standing. Your hamstring flexibility has nothing to do with the ability to walk and stand. Now, depending on your ability to bend, the only time I really have someone stretch their hamstrings is, I mean, you got that guy who's got like 20 degrees of hamstring flexion or 40 degrees. But when it comes down to just teaching that person, how to bend properly, I can still work them within that, when they're bending 60 degrees of hamstring length. I'm the same way. I got tight hamstrings, but it also depends on what you're trying to do. If I'm trying to get down to the floor in a deadlift, heck you might want to work your way down to make sure that your hamstring flexibility has the ability to get there.

But I'll throw another caveat just because of more experience with treatment, I've kind started to throw... I will do a hamstring stretch with nerve tension. So if you have residual numbness, tingling, one hamstring isn't going up as high as the other because you've had a recent disc herniation, or you're going through one right now, I will stretch that. But when it comes to just physical activity... maybe before I get to physical activity. When it comes to just treatment in general, I've actually never had really stretch too much of people's hamstrings to get them better. I'll just throw that caveat in there. So I can get them pain free. I get them doing everything they want without really ever having to throw in a hamstring stretch.

But three, going back to your activity kind of depends on what you do. If you're a golfer, your hamstring doesn't really have to be that long, unless you're trying to get down the ground and you can't do it. So it depends on the functionality, what you're trying to get back to as if you're needing to stretch that hamstring, like a CrossFit and toes to the bar. If I got to bring my feet all the way up, well, heck you could probably be more efficient if you had some more hamstring length. So it just kind of depends on what you want to do with that.

So tight hamstrings don't necessarily cause low back pain, but maybe can set up an improper hip hinging mechanism that can ultimately stress your back?

There you go. Depending on how far you want to go with that hip hinge. Whether it's a hip hinge and a deadlift, a hip hinge... again, like in maybe like a toes to bar where you're having to bring your feet all the way up to your hands. So yes, there is that need to be able to hinge as far as you're asking to. But when I'm needing my average person to learn how to bend over into the dishwasher, if I'm asking my average person to bend over into a laundry, I'm not really asking them to bend as far, so I can get that person to learn how to hip hinge, get them pain free, back to normal health without necessarily [inaudible 00:35:36].

And that's what everyone's looking for. Awesome. All right. Before I let you get out of here, I always like to find out what are your kind of personal daily routine health strategies, books, podcast, tips, tools, things that you use to remain a successful, busy, productive healthcare employee and human being? So what are what's one tip, maybe someone's listening that if they add it into their life, it could up level it?

It would be, I mean, I, myself like to make sure that I'm challenging my body because a lot of times we're not really challenging our body to see what it can do. So when I say that in the means of, have you seen if you can push overhead and extend your arms all the way? When's the last time you squatted just to see what kind of squat you get into? And one reason I've gotten into more of a lifting program is it's challenged me to see some of the deficiencies I have in my mobility and what I can and can't do. And so sometimes if you've never really challenged that, maybe you haven't really seen what your body can and can't do, I'll tell you as a physical therapist, one thing my patients always come to say is, "I did not realize how tight I was. I did not realize how weak I was." And so if we never really get to the point where we're trying to see what our body can and can't do, we may not be using it as well and enjoying it to the fullest it can. And so with that said, I work out a couple times a week.

But I'll throw one more thing in there just for general health. Another thing in the last year or two that I've really been looking at is look at your previous injuries. I've really been nice... It's been fun looking at the length of some of these old injuries, like motor vehicle accidents, hip replacements, ACL strain and you don't really realize that they have had an effect because we haven't continued to think about rehabbing them. I have an old ankle injury from high school, but I could tell you year by year, some different injuries I had until I started taking a closer look at it. So I try to bring that full circle and just to saying have you really looked lately at some of these old injuries and the way your body... and what it can and can't do because I would say on that side with my old injury, I realized I don't squat well on the right side with that old injury. So hopefully that was helpful.

Yeah. Love it. You know, definitely pushing yourself and seeing where you are and course correcting. We want perfection, but we'll take progress when it comes to health. So Jackson, I really, really enjoyed the knowledge that you just dropped. That was awesome. If even just one person listening to this is able to improve their life, I'm going to feel really good about it by, I suspect everyone who hears the information you shared is going to gain at least one nugget or two that's going to be helpful for them. So thank you again for your time and look forward to catching up with you soon.

Yeah. Thank you, Dr. Lakhia, and I feel the same way. I really think we can make a big change in back health and I think looking at the way we move and the things that work and don't work, is a big piece of it.

Awesome. All right. You have a good evening.

Yeah, you too.

Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health. On the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.