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Low back pain: why and what to do about it

by Thommy Chui, PT, OCS, CSCS, TPI CGFI MP2

What does it mean when someone says I threw my back out? Was it spring cleaning and this person decided, I  don’t want it anymore?

As a Physical therapist, all too often I hear the phrase” I threw my back out”, followed by… “all I’ve done for the last week is lie down, take pain medication, and rest.  I didn’t want to make it worse.”

Our human anatomy and physiology was developed to move, however our increasingly sedentary work duties and lifestyles have done quite the opposite. Whether it’s sitting watching TV, sitting in front of a computer station for hours without breaks, sitting in meetings , or traveling by car or airplane to then sit in meetings, we just aren’t moving as much anymore.

Studies have shown that prolonged sitting can contribute to decreased disc height in our lower back.  Additionally, extensive sitting produces overly tight hip muscles and weakness in the low back and gluteal muscles.   The result is an imbalance in our core stability.

The most common non-traumatic ways in which people injure their lower back is by bending, standing from a chair, turning or twisting. This is when we “throw our backs out.” What does this mean? It means that since we have an imbalance in our core stabilization, our muscles are not working in harmony. Specific muscles around our spine end up compensating and can progressively become overworked, setting the stage for injury.  The pain we feel initially is usually  tension or spasms of these overworked muscles.  Remember the root of the problem is weakness and inadequate stability caused by not moving enough.—so the last thing you should to do when your back is sore or in pain is lie down and not move!

Research shows that continued mobility in pain free ranges in combination with modification of activities helps decrease pain significantly.

Below are some recommendations for strength and mobility exercises along with safe techniques for getting in/out of bed and standing up from chairs without exacerbating your back pain. Try these the next time you have back pain and it may help avoid a trip to your doctor’s office.

LOG ROLL (4 steps):

log roll 1 crop

log roll 2 crop

log roll 3 crop

log roll 4 crop


hip hinge crop


squat crop


LTR 1 crop

LTR 2 crop


front plank crop


side plank crop


bridge crop


–          O’sullivan, K et al. “Lumbar posture and trunk muscle activation during a typing task when sitting on a novel dynamic ergonomic chair.” Ergonomics. 2012;55(12):1586-95. doi: 10.1080/00140139.2012.721521. Epub 2012 Sep 25.

–          Zemp, RIn vivo spinal posture during upright and reclined sitting in an office chair.” Biomed Res Int. 2013;2013:916045. doi: 10.1155/2013/916045. Epub 2013 Sep 24.

–          Lee SH, et al “The change of whole lumbar segmental motion according to the mobility of degenerated disc in the lower lumbar spine: a kinetic MRI study.” Eur Spine J. 2014 Mar 28.

–          Kline JB et al. “Core strength training using a combination of home exercises and a dynamic sling system for the management of low back pain in pre-professional ballet dancers: a case series.”J Dance Med Sci. 2013;17(1):24-33.


by Jonathan Ide-Don, PT, DPT, OCS


Cadence is the number of steps (or strides) a runner takes in a set amount of time.  It is often expressed in steps per minute (each foot hitting the ground counts as one step) or strides per minute (one cycle of right foot then left foot hitting the ground counts as one stride).  Other names for cadence include step rate, step frequency, and turnover.  Cadence is also one component that determines running speed:

Cadence  X  Step Length  =  Speed


Cadence is one of the key factors affecting running mechanics.  If a runner maintains a constant speed, but increases their cadence, their step length will shorten as well.  A shorter step length and faster cadence can have effects on muscle activation patterns, joint loading, and the overall movement patterns.

Cadence is one factor that is under conscious control of the runner, and short-term changes can be seen immediately with easily accessible tools or cues.  Making long-term changes stick will require practice over a period of weeks to months.


Key points from the research:

Running with a quicker cadence results in the following:

  1. Shorter step length (Fletcher 2010)
  2. Less vertical displacement
  3. Shorter stance time
  4. Better shock attenuation (Hamill 1995)
  5. Less energy absorption at knee (Heiderscheit 2011)
  6. Less energy absorption at hip
  7. Less braking as the foot hits the ground
  8. Increased gluteal activation (Chumanov 2012)


There appears to be a general consensus that a minimum of 170 to 180 steps per minute is a good cadence to shoot for.  Pose running teaches at least 180 steps per minute, but faster if the athlete is able to perform the proper technique.  Chi running also teaches an ideal cadence of 180 steps per minute.  Blaise Dubois, a physiotherapist based in Quebec City, also advocates a cadence of at least 170 steps per minute.  He recommends increasing the cadence to 180-185+ steps per minute for faster workouts.


  1. Increasing cadence lessens forces at the knee and hip joints
  2. Increasing  cadence lessens risk of stress fractures associated with repeated, excessive loading of the bone
  3. Increasing  cadence increases gluteal activation, which may positively affect alignment of your knees, ankles, and feet during running

If you are looking to prevent future injuries, or to return to running following an overuse injury, increasing your cadence 10% over your preferred cadence may be beneficial.

A specific target for your cadence is largely dependent upon the individual.  However, shooting for at least 170-180 steps per minute may be a good place to start.


1. Running intervals with a metronome

If you have a smartphone, you can download free or really cheap metronome apps onto your phone.  As part of your warm up, run for 30 to 60 seconds with the metronome matching your footsteps to the metronome beat, rest for 1 minute, and repeat 3 to 5 times.  Then shut off the metronome, and go out for your run and try to maintain your goal cadence.  My personal favorite is the Steinway & Sons free app for the iPhone:


2.      Running with music with specific beats per minute

Build a playlist!  Running with music can make some runners feel like they are working less hard to maintain a certain speed (Bood 2013).  Even better, the music can serve as your metronome.  Check out the websites below to search and find songs to build a playlist at different cadences:




3.      Running drills with a metronome

These drills are excellent technique drills as part of your warm up.  Using a metronome while practicing the drills is a great way to practice the rhythm of running at a faster cadence.  Try each drill 3 times each for 30 seconds, matching your footsteps to the metronome beat.




4.      Jump rope

Practice jumping rope with both feet hitting the ground with a quick, light hop.  Jump rope is a great way to teach your body how to quickly get your feet on and off the ground.  Progress from 2 feet jumps to alternating right foot / left foot jumps.  Focus on quickly picking the heel straight up toward your sit bone, hopping just high enough off the ground to clear the rope.   30-60 seconds of jumping with 30-60 seconds of rest for 5-10 rounds is a great way to start.

5.      Use mental imagery

For those runners who work best with a mental image, some of my favorite cues I have heard are “run like you are running on hot coals,” “Hot feet,” or “run like you are running on thin ice.”  Try different mental cues, and find the one that works for you the best.


1.      Keep your speed constant.

Some runners who have tried to increase their cadence told me that their tendency is to just want to run faster.  This point is valid, because as running speed increases, running cadence tends to increase as well.  The challenge is can you run at a constant speed, but increase your cadence?  Running on a track, treadmill, or straight flat pathway with distances marked can help you control your pace while learning the faster cadence.

2.      Practice, practice, practice… and be patient!

A running course I recently attended recommended 6 weeks of running homework with drills 3 days per week, which included a lot of metronome drills.  It takes a long time to make permanent changes in your running cadence, as your body likely has “overlearned” its preferred cadence.


Fletcher et al.  Biomechanical performance factors in pose running and heel-toe running.  International quarterly of sport science 2010/2012.

Chumanov et al.  Changes in muscle activation patterns when running step rate is increased.  Gait and posture.   (36): 231-235, 2011.

Bood et al.  The power of auditory-motor synchronization in sports:  enhancing running performance by coupling cadence with the right beats.  PLOS ONE.   8(8): 1-8, 2013.

Heiderscheit et al.  Effects of step rate manipulation on joint mechanics during running.  Medicine and science in sports and exercise.  43(2): 296-302, 2011.

Hamill et al.  Shock attenuation and stride frequency during running.  Human Movement Science.  14(1): 45-60, 1995.

Romanov, N. (2004).  Pose Method of Running.  USA: Pose Tech Press.

Running Drills: Forward Fall into Run

by Jonathan Ide-Don, PT, DPT, OCS

The primary goals for this drill:

  1. Learn how to fall forward while placing your foot underneath your body

  2. Learn how to take short, quick strides


This drill will train your body how to transition from standing still, to leaning forward, to running forward while maintaining short, quick strides. 

Start by standing with both feet on the ground in tall posture with both knees slightly bent.  Pull one heel straight up to the buttock, and balance on one foot with arms in running position.  Shift your weight forward and lean forward gradually.  Once you feel at the edge of your balance, quickly switch your feet by pulling the heel of your other foot straight up to your buttock.  Continue leaning forward as you run, focusing on keeping your strides short and quick with your foot landing softly underneath your hips.


  1. Reaching your foot out in front of your body as you fall forward rather than quickly pulling the heel up to your buttock behind you
  2. Landing hard on your heel , rather than softly landing with your foot underneath your hips
  3. Losing your forward lean as you start to run

Running Drills: The Quick Switch

by Jonathan Ide-Don, PT, DPT, OCS

The primary goals of this exercise:

  1. Teach how to lean forward while quickly switching support between feet

  2. Teach how to maintain a tight core and forward lean


Start by standing just further than arms distance away from a wall.  Lean forward and place both hands on the wall.  Keep a straight line from your ear down to your shoulder, to your hip, your knee, and to your midfoot.  Gently bend both knees.  Pull one heel straight up to your buttock.  QUICKLY switch support by pulling your other heel straight up to your buttocks, and letting your first foot fall to the ground relaxed.  Alternate pulling one foot and then the other off of the ground.

Start switching between feet with a short pause between switches to learn the movement.  As you get comfortable with switching, shorten the pause between switches until you are essentially running in place.

This exercise can be performed for time.  Start with 20-30 seconds and gradually increase until you can perform the drill successfully for 60 seconds.


  1. Driving knee too far forward in front of the body rather than lifting the foot straight up to the buttock
  2. Flicking foot too far out behind you rather than lifting the foot straight up to the buttock
  3. Rounding at the mid or low back as you lift your foot rather than keeping a straight spine
  4. Stomping the ground loud and hard rather than landing softly and quietly
  5. Jumping up off ground when switching between feet rather than minimizing air time


Running Drills: Modified Butt Kicks Moving Forward

by Jonathan Ide-Don, PT, DPT, OCS

The primary goals of this exercise:

  1. Teaching runner how to change speed of running by changing the angle of their forward lean

  2. Combining proper running posture, proper pulling, and a proper forward lean

This drill is a progression from the stationary, modified butt kicks.  This drill is more challenging to the stability of running posture, as it adds one layer of instability:  a forward lean.  Once you have mastered the stationary modified butt kick drill, give this drill a try!


This drill starts by performing stationary modified butt kicks.  Lean forward slightly from the midsection while maintaining proper tall posture and pulling technique.  As you lean forward just a couple of degrees, you will start to move forward.  As you lean forward at a greater angle, you will move forward even faster.

Start with a slight forward lean covering 10 meters distance.  Progress by increasing your angle of forward lean and increasing the distance covered to 20-40 meters at a time.


  1. Breaking  at the hips rather than leaning forward as one unit
  2. Leading with your chin rather than leaning forward as one unit
  3. Reaching your foot forward in front of your body rather than keeping your footstrike underneath your hip as you lean forward

Running Drills: Modified Butt Kicks

by Jonathan Ide-Don, PT, DPT, OCS

The primary goals of this exercise:

  1. Reinforce proper running posture dynamically as you switch from one foot to the other

  2. Teach proper pulling technique of the heel straight up to the ischial tuberosity (sit bone)

  3. Improve endurance, strength, and speed of hamstring contraction in the context of running

This exercise is a slight modification of the traditional butt kick exercise.  The primary modification of this exercise is the cue of how the runner pulls the foot up off the ground.  In traditional butt kick exercise, the runner focuses on keeping both thighs vertical, and firing the hamstrings to lift the foot up in an arc behind them to kick their buttocks.  In the modified butt kicker, the runner focuses on firing the hamstring and lifting the heel of the foot straight up in a vertical line to their ischial tuberosity (ie. sit bone).

Notice in the video how the knee comes slightly forward relative to the body, rather than keeping the thigh vertical and the knee pointing straight down at the ground.


Start by standing in tall posture with feet hip width apart, knees soft and pushed out to the side, elbows bent 90 degrees, and eyes straight ahead.  Imagine there is a rubber band connecting from the heel of your foot straight up to your ischial tuberosity (your sit bone).  Fire your hamstring and quickly pull your heel in a straight line vertically up to your sit bone.  Then, fire the hamstring on your other leg to quickly pull your other heel up to your other sit bone.

When you lift your other heel, let your other foot fall passively to the ground and land soft and relaxed on the ground.

Start with a slow rhythm, quickly pulling one heel up, pausing briefly, finding your balance, then quickly lifting your other heel up.  Once you feel comfortable with the quick pulling of the heel, then you can speed up the rhythm.  Eventually the rhythm should match your running rhythm with a quick turnover.  The exercise eventually turns into running in place.


  1. Keeping thighs vertical to ground and kicking heel up in an arc behind you
  2. Jumping off the ground when switching feet
  3. Flexing the low back and mid back forward as you pull the heel up
  4. Landing loudly, stomping your foot on the ground when switching feet

Running Drills: Falling Forward

by Jonathan Ide-Don, PT, DPT, OCS

The primary goals of this exercise:

  1. Teach how to maintain proper posture

  2. Teach how to fall forward

Running can be viewed as controlled forward falling.  Maintaining proper posture from head to toe as you fall forward will ensure that you maintain proper alignment of all of your joints as you run.  Proper posture also facilitates proper muscle activation patterns and stability of your spine, which will decrease risk of injury. Leaning forward slightly while running encourages proper alignment and assists in preventing over-striding.


Start by facing a wall, standing arm’s distance away

Key point #1 Find proper posture in the running position. 
Stand tall with your feet hip width apart.  Imagine there is a string pulling up from the top of your head to lengthen your body from head to toe.  Soften both knees while simultaneously pushing knees outward.  Bend both elbows to 90 degrees (right angle) with hands and shoulders relaxed.  Eyes should be focused straight ahead on the wall.

Key point #2:  Pull your heel up to your sit bone. 
Imagine there is a rubber band connecting the heel of your foot to your sit bone, and lift one heel straight up to your buttock.  Hold this position for a few seconds finding your balance.

Key point #3:  Lean forward. 
Lean forward slowly, feeling as you shift the weight from the heel of your foot forward onto the ball of your foot.  Fall forward maintaining tall posture and catch yourself on your hands.  Push yourself back up to the start position.  Fall forward again, maintaining tall posture.

Repeat for 1-2 minutes on each leg


  1. Letting your knees dive in toward each other instead of pushing out as you soften your knees
  2. Leading with your head, jutting your chin forward as you fall forward
  3. Bending at the hips instead of keeping tall posture as you fall forward
  4. Letting your back hyperextend as you catch your hands on the wall

Take a Hike!

Great Bay Area Hikes

by Serena Llamera, PTA, CSCS

Enjoy the final weeks of Bay Area sunshine (get your dose of vitamin D) and smell the fresh air!  You don’t have to go far to explore your scenic “backyard.”

Here are some of my favorite places to hike/trail run in the San Francisco Bay Area:


Land’s End:  On a clear day, you can see spectacular views of the Golden Gate Bridge and Marin Headlands.  Park at the El Camino del Mar Parking Lot and take the Coast Trail to the Mile Rock Lookout Trail. You could hike down to the Mile Rock Beach which is about 3 miles out, but remember that you have to come back up a steep slope and climb those 100+ stairs (so you can skip the stair master for the day).  From the parking lot, you can also head down towards the old remains of Sutro Baths and check out Sutro Sam (river otter) who is still at home there.




Point Reyes National Seashore:  This is a moderate 7.5 mile roundtrip hike with some incline, but so worth it because you get to see a rare 40 ft. tidefall, which is a waterfall that flows directly into the ocean.  (1 of 2 on this coast–the other is in Big Sur).  To get to Alamere Falls, park at the Palomarin Trailhead and take the Coast Trail.  Here, watch out for poison oak, which is prevalent in the Bay Area.  Most of this trail goes up and down and passes by 2 lakes.  At the end of the trail, you will end up at top of the waterfall with an amazing view of the beach below.  Caution: it is tricky and slippery going from the top of the waterfall down to the beach, so take your time and have good footing.  http://www.bahiker.com/northbayhikes/palomarin.html


Mount Tamalpais:  ($8 to park in the lot, free to park on the side of the road)

Take the Steep Ravine Trail starting at the Pantoll Ranger Station.  This 4 mile roundtrip dirt trail follows along a little river, so it feels like you are going through a rainforest most of the way.  The trail takes you over the river a number of times through small wooden bridges.  Midway through, you can climb down a wide, sturdy ladder about 10-ft high.   Towering redwood trees provide a comforting shade through most of your hike.   At the end, you cross Highway 1 and you get to a cabin/campsite (difficult to get reservations here by the way) and down to the beach.  Or you may venture another mile further to Stinson Beach.  Staring at the Ranger Station is mostly downhill, so some people opt to start from Hwy 1 and go uphill to the ranger station.  I’ve tried both ways-they’re both fun!  Caution: during certain seasons and during dusk, watch out for mosquitoes (use bug repellant).  The dirt trails may be wet and muddy.  http://www.redwoodhikes.com/Muir/SteepRavine.html


Muir Woods:

This is the only place to hike in the Bay Area that I know of where they charge an entrance fee ($7/person over 16 years  old) but it is also the closest place to see the Giant Sequioa trees in California (others include Calaveras Big Trees and Yosemite).  The fee helps maintain the wood plank main trail which makes a 2 mile level roundtrip loop around these ginormous trees.  This is also one of the few wheelchair-accessible and stroller-friendly trails around.  If you are looking for an adventure in elevation, you may opt for the Oceanview trail which makes a 2.5 mile loop connecting to the Main Trail.



Tilden Park :  This is an easy 1 mile loop around Jewel Lake which is great for kids by the way, because afterwards  you can drive the kids to ride the Merry-Go-Round and the miniature steam train, and feed  lettuce and celery to the cows and sheep at the Little Farm.  Park at the Little Farm


Another great easy hike is around Lake Anza (roundtrip loop is about 1 mile).  Park at the end of Lake Anza Road.



Crystal Springs Reservoir :

Sawyer Camp Trail:  This is a fairly level, paved asphalt trail so it’s accessible to everyone including wheelchairs, strollers, cyclists, roller skaters, skateboarders so stay to the right if you’re going for a stroll.  You get a view of Crystal Springs Reservior all along this trail.  It’s 3 miles to the set of restrooms, or you may go further and make it 12 miles roundtrip.  http://www.bahiker.com/southbayhikes/sawyercamp.html


Tips for Hiking:
Make sure you plan ahead!

1)      Bring plenty of water.  Hydrate yourself.
2)      Bring a friend or two (or more) for company.
3)      Protect yourself from the sun: hat, sunglasses, and sunscreen.
4)      Wear comfortable, sturdy shoes/boots.  Make sure the shoes have been broken in before taking them for a good hike.
5)      Recognize poison oak (if you see leaves of 3, let them be).  Itchy, red spots on the arms and legs can become blisters and ooze.  Very uncomfortable (my husband had it twice).  Wear long pants and sleeves.
6)      Stretch out before you hike: calves, quads, hamstrings, hips and back.
7)      Plan to go to these places on a clear sunny day for the best views.
8)      Wear layers because weather is unpredictable, especially along the coast.
9)      Pack snacks and a lunch.  There are no places to grab lunch except for Muir Woods.
10)   Arrive early.  Parking fills up by 10AM on weekends.  It’s also less crowded on the trails.
11)   Check the trail map, so you know where you’re going.
12)   Pace self and set reasonable distance goals.  If you are having a hard time carrying a conversation, you may be overexerting yourself.  Take rest breaks.
13)   Use hiking sticks.  Not only do you get an upper body workout, you burn more calories.  When you use hiking sticks while you’re going down hills and stairs, you will also place less stress on your knees.
14)   Bring a camera for those memorable moments and achievements!
15)   Use a backpack with a waist strap to distribute the weight to your hips instead of through your spine and shoulders.


Do This, Not That

by Colleen Morgan, PT, MS, OCS, CSCS

Whether you are a weekend warrior or competitive athlete,

a life-long “gym rat” or exercise newbie, it’s important to know which gym exercises are worth your time and energy.  Learn what exercises most physical therapists would categorize as worthless (perhaps even downright dangerous) and explore some healthy alternatives in our recurring blog column “Do This, Not That!”

Do This!

Not That!

Bird dog may look (and sound) like a weird exercise, but similar to the plank, it’s a great “whole body” exercise.  This is a surprisingly functional exercise: Remember how tired you were after you knelt to clean the bathtub?  Stabilization of your core, upper body, and lower body occurs as soon as you get onto hands and knees.  The exercise becomes progressively more challenging as you lift just one arm, just one leg, alternating arm and leg, and finally same-sided arm and leg.  Keep that tummy tight to support your back! Seated back extensions against resistance.Sitting imposes the greatest compressive load through the lumbar spine.  Forcefully extending your back against resistance creates a compressive force rather than a stabilizing force through your lumbar spine.  Add on the fact that you are sitting and you have a potential recipe for harmful spinal compression!

Do This, Not That

by Colleen Morgan, PT, MS, OCS, CSCS

Whether you are a weekend warrior or competitive athlete,

a life-long “gym rat” or exercise newbie, it’s important to know which gym exercises are worth your time and energy.  Learn what exercises most physical therapists would categorize as worthless (perhaps even downright dangerous) and explore some healthy alternatives in our recurring blog column “Do This, Not That!”

Do This!

Not That!

Side Plank
You thought a plank was challenging?  Try a side plank as well!  It’s another great “whole body” exercise, but it isolates one side of your body at a time as you improve the endurance of scapular/shoulder stabilizers, obliques, and hip abductors.  Start on elbow and knees (with knees bent).  When you can hold that position perfectly for at least 30 seconds, progress to the straight leg version below.  Be sure to hold equally from side to side to ensure symmetry.
Seated oblique twists against resistance 

Sure, we all want rippling abs, but what are the potential consequences?  Studies have shown that lumbar spine compressive forces double from a position of sidelying to a position of sitting.  This machine also increases harmful spinal compressive loads by locking your hips and pelvis in place!  Without appropriate force dissipation, your spine bears the bulk of this load!

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