In my recent article about how manual handling instructions in the workplace may be contributing to back problems instead of correcting them I made a reference to an interesting book by Esther Gokhale called 8 steps to pain free back. In this book she provides some fascinating insights into how people in Africa and India move in daily life with much different posture in comparison to people in the Western world. She notes how these people are almost completely free of back pain and musculoskeletal problems that are rampant in modern industrialized society. These observations are the basis for her 8 steps in the book and provide some great ideas to treating back problems at the source. As opposed to most injury rehabilitation methods that focus mostly on the exercise corrections this method concentrates on adjusting the way we move with sitting, lying, walking, and bending. In this article, I discuss how this book helped me personally with a hip and back problem and the key parts that relate to all of us.

One thing I have never stopped doing over the last 18 years as a trainer is continually trying to learn and find more effective ways to become fit and healthy. Many of my best lessons have come from mistakes or getting stuck with a method that was simply not working that led me to look elsewhere for answers and more effective ways to deal with the problem I was facing. One of those times was several years ago when I was working with several clients with chronic back problems that were not showing the results I was hoping for with my exercise interventions.

This is usually where I would be looking for better exercises or different programs for the current one may not be working. This is where you often hear me talk about great methods by Dr Stuart McGill or some other health professional with an interesting exercise but sometimes I can end up over-thinking things and get frustrated and confused with too many changes. I have to remind myself to keep things simple and begin looking at what other things can contribute to preventing the person from improving.

When you talk to people with back pain and you ask them the question, what movement makes your back hurt? Their answer will often refer to some simple activity they do during the day. For example, when they bend over to pick up something, when they try to sleep at night, when the sit at work, or standing for long periods. Sometimes it may even be when they go for a walk that their pain is immense.

This is where we try to find exercises that will make it easier to sit, stand, walk, and bend and this often works. However, sometimes it may be more to do with the WAY THEY sit, stand, walk, and bend that is the problem and until we modify these actions they are going to get stuck in a constant cycle of ongoing pain. The big question is what is the best way to complete these activities?

Well, as you would expect that is not an easy answer to provide. This is sometimes where you can gain insights by observing people who do not have pain and this is where my research led me to a book by Esther Gokhale that changed the way I looked at back pain and posture forever.

Why Traditional Cultures Are Mostly Free From Back Pain

If you ever get a chance to read Esther Gokhale’s book you will find out that she herself hurt her back when she was in college doing a Yoga pose and again later in life after pregnancy. She had back surgery only for the pain to return again in a year’s time and the doctor’s suggested more surgery. She decided this wasn’t the course for her and began her own research into what may be causing her problems that led her to some great discoveries.

She wanted to observe how people without back pain moved and see if there was some hidden answers that she could incorporated into her own life. She learned from an institute in France that industrialized countries do not use our bodies very well and cause all types of pain and damage from moving poorly. Whereas people who lived in traditional cultures could work long days in tough conditions completing laborious jobs completely free of pain as seen in the picture below. Many people would be in all types of pain if that had to do this job for 8 hours a day and 5 days a week.

This book in many ways reminds me of the book by Weston A Price called “Nutrition & Physical Degeneration” who carried out studies on over 16 native tribes all over the world in the 1930’s. He compared the diet of tribes of people living according to their native ancestry to the same race of people who were eating white man’s foods and found a correlation of poor health with modern foods. This book by Esther Gokhale reminds me of those same conclusions and findings.

Esther visited countries in Europe, Asia, Africa, and South America observing, photographing, filming and interviewing people who did not have back pain and this is how she came up with her 8 lessons.

What Causes Back Pain?

Before jumping into what the 8 lessons are it is important to clarify what causes back pain. The obvious thing to state is that there is no one specific thing that can cause back pain. One of the most common reasons and one that I myself have often blamed is sitting.

While sitting definitely has some health problems associated with it statistics show that manual labourers have a higher rate of back pain versus those who are sedentary office workers. Also not every single sedentary office worker has back pain, only some do. Esther noted this in the book and found people in India who sat for long hours completing tasks like weaving, pottery, and basket making but back pain was extremely rare in these populations.

This is where the conclusion is not that sitting is the problem, instead, it is HOW YOU SIT that is.

Another factor that is brought up is old age causing back pain. Once again Esther observed men aged in their late 60’s working long hours digging up clay and mixing it with straw to make bricks. This was intense manual labour and many of the workers would carry the weight on their backs and heads working well into their old age. Their rates of back pain were about 50-75% less than what is documented in industrialized countries with much better facilities and working conditions.

Once again it is not old age, or manual labour and lifting that is the problem it is HOW WE MOVE that is.

There are also many other factors to consider that play a part such as nutrition, stress, and modern lifestyle influences with fashion and role models from movies and social media. All of these can play a part in losing touch with how to look after our bodies correctly. I won’t go into too much detail with these factors to keep this article relatively short to focus more on the movement based habits. However, I do encourage you to check out the book and see how easily we have lost sight of what good posture and movement is over the last 100 years.

What Are The 8 Lessons?

As alluded to in the introduction the 8 lessons are really quite simple and in the book she provides great step by step illustrations for you to follow. While I am not going to list all the steps in detail I will provide you with a link to one of Esther's You Tube videos. You can also visit the Gokhale method website to reference any of her other videos or courses so you can try this out for yourself.

I wanted to explain how I find these steps useful and the lessons I found made a big impact for me personally and also with many other people I speak to with regards to help with back pain. You will find that almost of the information and philosophies are very similar to what I have spoken about for many years. Many of the concepts with Dr Stuart McGill are also very much on the same page even though they come from a very different perspective.

One last thing before I discuss each of the steps is that the following lessons are structured in a specific order that helps to improve the efficiency of the next one. Many people may want to rush to the specific lesson that is painful to them and focus only on that particular problem, but they may find it difficult to learn this way and they may lack the skill required for they skipped the previous steps. When you understand the various skills and demands of each you can see why following the order in which they are set out.

Okay, let’s get started.

1. Stretch-sitting

This first lesson is something that was quite surprising to me as to how helpful it was when you are in pain. This is something I had never thought of as I was always trying to encourage a perfect posture while sitting but after experiencing back pain during sitting myself I found how useful this could be.

At first glance it seems to go against your logic of this being useful for it does not appear to reinforce a good posture during sitting. However, this is not trying to strengthen the postural muscles but in fact relax them and decompress the discs in your spine. This is similar to applying a gentle traction in your spine which can be extremely therapeutic when you are in a lot of pain or muscles are stuck in a spasm.

It is also different to simply trying to stretch the muscles of the lower back which is what many people try to do which only serves to irritate the discs in the back and create tremendous amount of damage to the ligaments supporting the spine. You can read more about this in the article Back pain myths busted

One interesting part of the emphasis on good foot positioning. With all the sitting and standing postures the impact of poor foot stability can create problems up the kinetic chain making it impossible to achieve good pelvic and spinal positions. This is something that I discuss all the time yet it is very rarely discussed by mainstream medicine or health practitioners who devote all of their attention to treating the area in pain. Another big reason why I find I relate so well to this method. To see more about how foot stability affects how you move make sure you read the article – Exercise solutions for weak feet

The last important point to this and one that comes up a lot throughout all of the lessons is the importance of maintaining a good neck position. You will see how vital this is in the later lessons that demand a lot more strength and stability and this is something adopted by observing the postures of people carrying loads on their heads. The impact of hunched shoulders and a poor cervical spine can lead to problems lower in the back as much as the neck itself. By addressing this postural position you give your body every chance of restoring optimal stability of your joints and ultimately efficient movement.

2. Stretch-lying

Anyone who has chronic back pain will tell you how hard it can be to get a good night sleep. Trying to get comfortable sleeping can be very difficult when you have back pain and if you are unable to get quality rest your body will not be able to effectively heal itself as this at night is when the body activates its rest and repair hormones. In addition to this is that a poor sleep position can even be partly to blame, or contribute to making your pain worse, so it is important to find a position that enables your body to fully relax.

As with the previous step this position tries to encourage your back muscles to lengthen to decompress the nerves and discs. Using pillows in specific positions helps your body to relax into the position of good alignment while remaining free from tension and compression.

I know from my own experience over the last year and a half where I had some problems with my SIJ and lower back this specific tip was fantastic in helping me to relax the muscles in my lower back. For a while when my back was so bad I would lie down like this on the lounge room floor in the afternoon before I went back to work later in the night. It would be enough to help me get through the day without my back seizing up on me. I often tell people to try and find that relief position for when things are bad so you can get your body to calm down. This position for me was great.

3. Stack-sitting

This is another version of adjusting the sitting position. As opposed to the first step which was more about finding a therapeutic way to relieve the back using a backrest, this version is all about learning to sit upright without any backrest. This means you need to learn how to use the muscles in your body to achieve a good position without creating too much tension.

For many people this can be quite difficult and once again our thoughts on what is the best position may actually be the problem. Sitting in a good posture should not require a 110% effort from our muscles, it should be effortless. The key to this is sitting a position is where your pelvis is held in a slight anterior pelvic tilt. This is the exact opposite to what many people have been taught who believe it is better to tuck your pelvis under in a posterior tilt.

Once again this is something I discuss all the time, especially with those who are training hard in the gym or come from Pilates where they are taught to imprint. I even wrote a detailed article about this several years ago as I was coming across this so often. (See – Understanding anterior pelvic tilt and its importance to hip function)

When your pelvis is positioned in this slight anterior tilt it allows your back muscles to relax and allows you to elongate your spine which prevents the head from adopting a forward head posture. It also allows for good breathing and optimal position of the internal organs.

The only problem with this is that many people are so stiff and tight in their posterior chain muscles of the glutes and hamstrings that they find it near impossible to achieve this position. I am one of those people and while it may be useful to spend time working on your flexibility of these muscles you may never achieve the required flexibility. It also will take considerable time to achieve this which will not be useful to while you are in pain and looking to prevent aggravating your problem. This is where Esther suggest using a wedge or a pillow to help tip your pelvis forward until you are able to improve your flexibility.

I have a cushion placed in the chair I am sitting on while I type this article on the computer and find it helps me to sit in a good posture with very little effort.

Stretch-lying on your side

This is the follow up to the previous lying position that was on your back. Many people find it hard to sleep on their back and adopt the side lying position. Unfortunately, the position they sleep in can cause problems to the spine. Sleeping a fetal position tends to bend the spine into a “C shaped” hunch position which as we already discussed causes trouble to the discs and ligaments.

The other main problem with side lying is letting the spine twist by having the lower leg out straight and the upper leg draped across the body. This is not necessarily a bad thing for all people as a person with a healthy back will find this is fine and it causes no trouble. However, a person with an irritated back this can be a disaster as seen in this picture below.

By placing a pillow under the knee it can prevent any unwanted twisting of the lumbar spine.

I prefer to sleep on my side too but I was finding it hard to find a comfortable position at first. By placing pillows in specific positions and learning where to put my arms helped me find the right spot to sleep allowing me to get a good night's rest.

5. Using Your Inner Corset (Bracing Your Core)

This step was very much the exact same thinking as what I have used for a long time so there was nothing new for me to learn from here but it reinforced what I had been using.

Those familiar with strength training of the core should know all about this point but once again it is another factor that is very rarely taught in mainstream health. Even those who think they know how to brace can make a real mess of this and it can be confusing at times.

Most people will automatically think of some abdominal exercises like crunches and planks for improving the strength of the core. However, once again I find myself relating to the Gokhale method for while she explains that it is important to activate the muscles of the inner unit, you must relate this to how the muscles contract when we move the arms and legs. This means you need to teach the body how to work together with a combination of the inner and outer unit.

The CORE is really a combination of both small stabilizing muscles known as the Inner Unit, combined with large prime mover muscles that operate like a series of complex chains and systems to provide stiffness on a greater scale. This known as the Outer Unit. True core strength requires the use of both.

The inner unit is incorporated in almost every movement of the human body. These muscles can act as an isometric or dynamic stabilizer for movement, transfer force from one extremity to another, or initiate movement itself. The role of the inner unit is to stabilize the spine. These deep abdominal stabilizers (inner unit) are actually quite small and unable to generate much force in comparison to the larger exterior muscles. The stabilizers are mainly concerned with providing joint stiffness and segmental stability. Their work is what you would classify as low level activity needed for long periods of time.

These muscles include:

1. Transversus abdominous
2. Multifidus
3. Diaphragm
4. Pelvic floor

They are also known as "feed-forward" muscles in that they react quicker than any other muscle group, to prepare the body for movement. The only way they can work effectively and influence the integrity of movement is to fire first. The ability of the inner unit muscles to contract prior to force production of the larger prime mover muscles (geared toward movement) is more important than their strength. Research shows that in people with no history of low back pain, the TVA fires 30 milliseconds before arm movements and 110 milliseconds before leg movements.

The OUTER UNIT is comprised of the large prime mover global muscles that are designed to move the body. These muscles are unique in that they mainly concerned with providing movement of the body but at the same time assist in providing stability. This is where muscles like latissimus dorsi, the glutes, the back extensors, and the ever popular (six-pack) muscles rectus abdominous and external obliques provide movement of the body at certain times, while simultaneously working in a stabilizing role.

For example, the external obliques function unilaterally to laterally flex the trunk and rotate the trunk to the opposite side. But they also contract to prevent flexing and over-rotation which is often critical during certain movements.

You can read more about the specifics of the core in the articles below.

• Core training explained
• How to train the oblique muscles correctly
• Core training using myofascial slings

When a muscle contracts, it creates both force and stiffness. Force creates joint torque to support postures and create movement – but sometimes the force will enhance joint stability and sometimes it will compromise stability. It depends on how much force is applied and the relative forces applied by other muscles acting at the joint. In contrast, muscle stiffness is always stabilizing.

A stiff muscle prevents unwanted movements from all directions. Stiffness at one joint provides the development of explosive power at another which is easily seen in the use of plyometric exercises in sports.

When all muscles at a joint stiffen together a “super stiffness” phenomenon generally occurs. The total stiffness at a joint suddenly becomes more than the sum of individual muscle stiffness. For those activities that demand high core or torso stability, all muscles must be activated not just one muscle. In sports you regularly see the use of the brace during high impact and explosive movements where the core is required to fire rapidly and at crucial times to ensure stability and posture is maintained.

You can watch two videos of me explaining how to do this below. The video on the left shows you the brace using basic exercises. The video on the right shows you how to integrate the brace into integrated movements like squats, deadlifts, etc.

I have discussed the technique of bracing the core many times in articles before but you will find the best explanation and several examples in the article – Do you know how to brace the core?

6. Tall-standing

We are now at the point where things start to get a bit harder as you are standing up for the first time. This is where knowing how to do the exercise and being able to do are completely different.

The secret to standing comfortably is being able to maintain good foot and leg alignment in combination with pelvic stability to ensure the spine can effectively stack the bones without straining muscles. This forces the bones to take the stress of gravity allowing the muscles to relax.

A factor that we discussed earlier with poor sitting positions which is also the main problem most people have with standing is, thrusting their hips forward and tucking the pelvis under as seen in the picture below.

Foot stability is another big problem when trying to get the standing position correct and something that Esther discusses in great detail with this step. For any movement you do standing up, neural signalling begins at the feet as they are the first part of the body to feel the ground and tell the system what to do. They tell the brain where you are, if you are balanced enough to move yet and basically instigate movement before it even begins. The better the feet and ankles are functioning, the better the signal all the way up the kinetic chain.

Many of the exercises she suggests are ones that many therapists use for creating better stability with the muscles of the feet such as “short-foot” which was developed by Vladimir Janda.

I have worked on this for a long time with many people and there is no one single exercise I find that works for everyone, just a series of different ones to try. Some people respond well to big toe mobility exercises, others with ankle mobilization, and others using tools like the Sensa mat or balance beam. I like to use a combination of all of these to give them every chance of improving their overall foot stability. You can see some examples of these exercises in the videos below.

The main learning point I got from Esther in this stage is her emphasis on using something on your head to create a vertical axis with the neck. Obviously this is something she incorporated from watching people in traditional cultures carry heavy loads on their head. She noted how they would also hold their arms and shoulders in a much more favourable posture and be able to do this for long periods of time without fatigue or pain. It makes perfect sense when you think about it and is something I will try to experiment and practice with myself to see how it feels. Practice this yourself and see how it feels for you.

7. Hip-Hinging

This next lesson did not provide me with any additional knowledge as such. But it did reinforce everything that I had learned over the years that the importance of using your hips to bend and not your spine is essential if you want to prevent back pain. In the gym we refer to this as the Romanian Deadlift and in every article or video I provide about back pain this is talked about in great detail as seen in the recent article about lifting objects in the workplace.

This is because the bending movement is often the main trigger of many back pain injuries and chronic problems. We cannot avoid bending for we need to do this multiple times during the day to do simple activities like tying up our shoelaces, getting a plate out of the dishwasher, or picking up our shopping bag at the supermarket. Learning the correct way to bend can save a lot of pain and suffering.

While I did not learn anything new from the book I did find it fascinating knowing that many people in traditional cultures did this automatically and did not need to go to the gym to learn how to bend correctly. This is where the impact of culture and passing down of important knowledge from generation to generation. I am sure all cultures had this at some point and somewhere during the evolution of modern living we gradually lost this sharing of wisdom.

Now we need to have specific training programs and books like this to teach us what should have been built into our automatic movement program.

Esther noted how people in the traditional cultures could bend over their rice paddies or gather water chestnuts for long hours and have no problems with their back at all. Many people in the industrialized world would be in all types of trouble if they had to do that. This is another example of bending not being the problem, instead it is HOW WE BEND that is.

Anyway, back to the art of hip-hinging it is not as simple as knowing how to do it like the first few lessons with sitting and lying. This may take a lot more work to be able to execute the technique correctly due to stiffness in the hips and posterior chain. There is no doubt a considerable weakness with many people too that may need simple and less risky exercises to make this easier to do.

Watch the video below to see what this technique is and the various exercises I might use to help someone learn the correct form.

This is where I find many of my accessory exercises will differ to what Esther suggests and where I find I refer more to the teachings of Dr Stuart McGill. I won’t go into too much detail about this as you can reference everything you need to know about hip-hinging and deadlifts in the articles below.

• How to learn the Romanian Deadlift to protect your back
• What version of the deadlift is best for you?

8. Glide Walking

Out of all the steps this is the most complicated and difficult to learn. Anyone who has difficulty walking due to an injury or disease, or if you have tried helping someone restore a dysfunctional gait pattern will know exactly what I mean. You can read a detailed article about this here – How to improve your walking ability

A gait cycle is a sequence of events in walking or running, beginning when one foot contacts the ground and ending when the same foot contacts the ground again. The human gait cycle is a very complicated, coordinated series of movements. There are so many moving parts within the gait cycle that the use of simple isolated exercises do very little to improve the motor program. But due to this complexity it makes it very difficult to find exercises that are both useful and safe to do.

You can watch a video of the various exercises I might use to enhance the gait pattern.

In this step Esther provides some interesting cues to help restore an efficient walking pattern. She refers to this type of walking as “glide walking” as it encourages a relaxed swing phase with each stride to keep the muscles around the hip from tensing up. Once again a heavy emphasis is placed upon maintaining an anterior pelvic tilt to avoid thrusting the hips forward.

Perhaps the two most interesting points I found in this lesson are.

1. To straighten the leg and keep the heel on the ground when the leg is behind you to help you feel the glutes engage.
2. To imagine walking on a line. She makes the point about the oldest known footprints of humans were found in Tanzania and they show two people walking in sand walked on a line. Their footprints were not side by side by in one continuous single line. The argument is that modern man walks on two lines but this is a recent distortion and devoid of our natural efficient method of walking. Once again this is something she noted in the traditional cultures where people would walk barefoot and do this instinctively.

I won’t go into too much detail about how she teaches this step as it is quite lengthy and difficult to explain so I do encourage you to read the book or click here to watch the You Tube video to get an idea of what she suggests.

Do you Need More Help?

Before jumping straight into a corrective program make sure you have seen a qualified Health professional for an accurate diagnosis and assessment of your condition. I cannot stress this enough as self-diagnosing can potentially lead to more problems. We often refer out to Doctors, Chiropractors, and Physiotherapists before implementing our program to know exactly what we are dealing with. Being certain on where to start is crucial to the success of the program.

If you have seen a health professional and are now looking at implementing a series of exercises and stretches this article will provide you with many great ideas on how to do this. As many people struggle to implement this into a gradual progression I created a detailed step by step program called Back Pain Secrets that includes a 85 page Ebook and 90 minute video with exercises, stretches, mobilizations and in an easy to follow format. This can be done at home or in the gym and we cover everything about your condition in great detail from eliminating the cause to best strength exercises, even nutrition to speed up the healing process! For more information you can watch a quick trailer video of what is included. Click here or on the image below to get a copy.

Summary

I very rarely write articles that are more like a book report but I felt this book contained so much information that is relevant to all of us I thought it was worth writing. The fact that she spent so much time investigating and watching people move in traditional cultures to inherit the wisdom of efficient movement is incredible.

While this article and the book itself seems to refer to people with back pain, it really does apply to every person. It is a shame that so many of us only see the need to apply the learnings of books like these when something bad happens to us. It is so much easier to prevent problems than fix them after they have broken. Many of these learnings provide you with that knowledge, it is now up to you to decide if you are going to use it or not.

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 300 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily. You can also subscribe to our FREE fortnightly newsletter to stay up to date with all of our latest tips and training methods by clicking here.

If you live in Melbourne and feel you need specific help with your exercise program please feel free to reach out to me for help and we can set you up with your individualised program.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 18 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specialises in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

• 8 Steps To Pain Free Back - By Esther Gokhale
• The Vital Glutes - By John Gibbons
• Movement - By Gray Cook
• Corrective Exercise Solutions - by Evan Osar
• Back Pain Mechanic - by Dr Stuart McGill
• Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
• Low Back Disorders - by Dr Stuart McGill
• Ultimate Back Fitness & Performance - by Dr Stuart McGill
• Core Stability - by Peak Performance
• Athletic Body in Balance - by Gray Cook
• Anatomy Trains - by Thomas Meyers
• Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
• Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
• How To Eat, Move & Be Healthy by Paul Chek
• Scientific Core Conditioning Correspondence Course - By Paul Chek
• Advanced Program Design - By Paul Chek