It’s a slumped, flexed over, bad posture world. Our lifestyle as a society and our resulting posture is a major contributor to spine pain, as all of our sitting in our cars, at our computers, and on our sofas at night, as well as wasting time staring down at our phones deconditions us and weakens our spinal extensor and hip muscles, all very important for holding us upright. Many of my clients who come in with a history of low back issues, however, have been led to believe that strong abdominals alone will prevent all back pain. They may be performing dozens of crunches and multiple planks per week in their exercise routine. They have strong abs but are reinforcing that flexed posture in their exercise routine, and are baffled that they still have low back pain. These people frequently exhibit weak, low tone back extensors and glutes so lacking in strength that I can push a leg down with my pinky finger when they try to hold it up against gravity while lying in a face down position. Truly, I marvel that these people are able to stand up at all! But there is one particular exercise that can fix it all for many people. Behold the bridge!

 The bridge is one of my favorite exercises. The basic bridge is an easy exercise for beginner low back/gluteal strengthening that we can progress over time to quite advanced, challenging forms. Please click on the video below to watch me perform a basic bridge, so I don’t have to bang out a giant paragraph of complicated instructions:

Seriously, once you have the technique down, you can perform this exercise while watching TV or while half asleep. But I will say that I am quite particular on a few points regarding how it should be performed.  I don’t dish out exercises for fun, or as optional things to do when you have some free time on your hands. Blow off your program and I’ll discharge your ass. I’m not into wasting time, yours or mine, so I try to teach my clients a couple of exercises to perform correctly and diligently in order to nail specific muscles, rather than a whole host of exercises that leave people texting me at 10 pm complaining that their program is too long.

So when you give this exercise a try, you must be sure to: 1) keep your spine neutral, which means no arching or flattening your low back; 2) pull in your belly button to help hold your spine in neutral, as you’ll find you can’t flatten or arch your spine while doing that; 3) squeeze your glutes to lift, and lift only as far as your glutes will take you, no arching or pressing your feet into the floor to lift; and 4) put your fists on your anterior superior iliac spines, aka hip bones, with your thumbs up to make sure that one hip bone isn’t dropping lower than the opposite side. If it is, give the glute on the lower side an extra squeeze. I explain it all in the video.

But all of that is just a lot of backstory for the plot twist of what happened when four people, who are all supposedly exercise experts, tried to teach one client the simple, beautiful bridge. Here it is: Imagine my surprise when, upon completing my little basic bridge lecture to a new client, a fit woman in her 70s with back pain who fit the flexed posture described above, she sat up and laughed at me. “So now I have to perform FOUR different kinds of bridges. Honestly, I’m going to be bridging all day long, and I still have back pain!” She looked rather displeased, with a “so that’s all ya got” kind of expression.

I asked her to please explain. “Well, my personal trainer told me I should do bridges on my heels, with my toes up, to strengthen my hamstrings. My yoga instructor wants me to arch my back and go way, way up”—and here she did a demonstration that made me shriek and cover my eyes and beg her to stop, as she put all of her upper body weight on the back of her head! “And the woman who teaches my exercise class just has us pulse. Up, and down, up, and down, up, and down.” (In my mind I could hear the bass of Salt-n-Pepa’s “Push It” pumping along with her demonstration.)

So at this point it was evident that what I had on my hands here was a classic case of TMCSTS (Too Many Chefs Spoil The Soup) Syndrome, a dangerous disorder that frequently befalls highly active, highly motivated people. They get an ache or pain, get on Google, find different suggestions for eliminating the pain and try to do all of it at once. They throw everything including the kitchen sink at the pain in an effort to make it go away, and then we can’t tell what’s what, what’s helping and what’s hurting. The trick here is to convince the client that she should perform the exercise MY way, if indeed my way is the best. So first I needed to know the rationale of the different instructors for the different forms of the exercise. Why, I asked her, did each instructor tell her to perform the exercise a certain way?

“Oh, just, you know, for strengthening,” She replied.

Okay. But what are we strengthening, specifically? Why did the personal trainer, for example, want her to perform the bridge to strengthen her hamstrings? What was he seeing that made him think she needed to do that? Because I was seeing the opposite. Her hamstrings were much stronger than her gluteals, and a factor which I believed was contributing to faulty spinal alignment and contributing to her flexed position due to the pull on her pelvis from the hamstrings. In fact, when I asked her to perform the bridge according to my instructions, she yelped, dropped back to the floor and grabbed the back of one thigh, which was knotted up in a hamstring cramp. Hamstring cramping happens during this exercise when you aren’t using the glutes properly and overfacilitate the hamstrings by pressing your feet into the floor. Pain is a good teacher and people learn the correct form quickly!

My client replied that she honestly wasn’t sure why he recommended strengthening the hamstrings except that maybe he thought it would be good for her knees. Further questioning revealed that he had not done any strength testing, or he would have seen that one of her quads was not as strong as the other, the result of a knee surgery with complications. The normal quad to hamstring ratio is approximately 3:2, meaning that the hamstrings, which are primarily a stabilizing muscle for the knee joint, should be 60ish percent as strong as the quads. To build their strength to exceed that of her quadriceps on the surgical knee would be doing her a disservice and set her up for patellofemoral pain.

This is generally where I start to lose patience. So the bridge on the heels is reinforcing bad back mechanics. Next, the yoga instructor provided no explanation for the overarching of the spine, according to the client, other than that “it’s a heart opener.” It looked like an ambulance opener to me. The position is forcing my client’s flexed spine aggressively into extension. Maybe she did notice that the client would benefit from some spinal extension, but easy does it! The result of aggressively overarching a spine stuck in flexion is that the most mobile segment will give way to compensate for decreased mobility elsewhere, and could pinch a nerve root or worse, create an instability. As for the weight on the back of the head for a client of this age, prone to degenerative cervical conditions, I have no words other than “Eek!”

Finally, the pulsing up and down bridge performed during the class is what I call “Brain Dead Aerobics.” There’s no reason, no particular muscles being activated, no cues, no instruction, no anything, just do it, up and down, up and down, until the instructor thinks of something else to do or until the class mercifully ends, everyone claps politely and she can go get a cup of coffee.

Anyway, after a discussion of the reasons why I believe my particular form of the bridge exercise is the right way to go, I think I’ve sufficiently convinced her to give it a try, or at least she concedes, “All right.” We schedule a follow up and she goes on her way. I realized then that I had worked myself up into a thoroughly grumpy mood. These fitness professionals who meant well, who went into their profession most likely because they love movement and love people, what happened to them? At what point did they stop thinking about the why and how of movement? Maybe I’ve got it wrong and the choice of profession for them is an intermittent stepping stone on the way to elsewhere, but I know the time and hard work it takes to get their certifications, as well as the energy it takes to work with people all day long, and I refuse to believe that they did it just to do something.

Make no mistake: I have the excellent fortune to know some extremely gifted, highly skilled fitness professionals. Some of them have been and are close friends. I would trust my clients and family members with them. And I also know PTs who lost track of the why and how of movement somewhere along the way, who prescribe straight leg raises for every client who comes in the door with knee or hip pain, because that’s what they learned at an orthopedic clinical rotation in PT school, and well, that’s what you do.

I understand job overload, and physical and mental fatigue, and burnout. Truly I do. And I’m sure I sound like I’m making a big deal over nothing. It’s just a silly exercise, how bad can it be, right? I’m prescribing exercise. I’m not prescribing an opioid medication dosage, a beta blocker or COX-2 inhibitor. If it hurts, don’t do it, right?

Many people who come in these days are well-informed, attuned to their bodies, ask the right questions, and view me as an equal partner in their care rather than the expert whose instructions they will blindly follow. These people can be trusted to hold off on an exercise if it doesn’t feel right. But then there are the other people, who want to get better, will do whatever they are told if they are told it will make them better and stronger, no questions asked. They break my heart because they are like helpless sheep at the mercy of people whom they believe to be experts and they often are fragile. They frequently have been told, “no pain, no gain” and instructed to push through excruciating pain because it will make them better. I have had clients come in with a rotator cuff tear after swinging a kettlebell in a personal training session, or a meniscus tear from performing sumo squats with weights during an exercise class. I have had people who herniated a disc or dislocated a shoulder during a yoga class. I have had people come to me who have been injured by brain dead PT, too.

Exercise science is inexact, like much of the world of science. There are formulas for determining work capacity, VO2 max, maximum heart rate for a particular age, and training load, but there is variability based on the individual, and even more so in rehab. Progressing a client who is just starting an exercise program is like a chemistry titration lab: You start with a dilute solution, add the active ingredient little by little, and if it seems like might have been a little too much, you then back off and dilute it again. Not every exercise agrees with everyone. Everyone leaving my clinic to try a new exercise first must perform it correctly in the clinic, and second must agree to add it into their routine slowly, and to hold off if it exacerbates their symptoms or if any new symptoms appear.

Our job in the rehab and fitness world is not to impress clients with our vast knowledge and physical prowess by handing out exercises that we can perform and they cannot. It also is not to power through a session so we can get our documentation done, no matter how late in the workday it is or how tired we are. Our job is to think, about who the client is, what the goals of their program are, why we believe a particular exercise is appropriate, and how it will help the client meet their goal. There is no excuse for sloppiness when we people come to us for assistance with their health and expect safety.

In addition to health and safety concerns, a few sloppy people in our professional arena also reflect badly on the rest of us. I had a client say earlier this year, “Wow! I’ve never had this great an experience with PT. In the past my PTs always seemed like a bunch of failed med students,” which I thought was hilarious, but I also knew exactly what she was saying. My client at the beginning of this story who left my clinic with her fourth bridge exercise from her fourth consultant did not return for her follow up.  I’d like to believe it’s because she followed my directions and her back pain is cured. Seeing the situation from her point of view, however—four different sets of instructions for the same exercise from four professionals, all of whom should have a working knowledge of the musculoskeletal system, is not impressive. I couldn’t blame her a bit if she took my exercise sheet, made it into a paper airplane and shot it out her car window as she sped down Points North Road.

–Kathleen Doehla, M.S. P.T.