Low back pain is a very common problem, and is a topic that comes up often when I talk with, well people. I have written a couple of articles about this in previous years, but I want to address it again, this time with a more practical approach. I realized recently that I have developed a bit of a template for clients who have low back pain, or who have a history of low back pain. The program for each person is different, but there are six exercises that I include for almost everyone who talks about their back when I first meet them. I am going to share these 6 exercises for low back health with you.
Before I begin though, I must point out the following: If daily living causes you low back pain, I strongly suggest that you look to a health care practitioner as your primary source of guidance for your back health. I won’t suggest what type of professional you see, just that someone who is a doctor, osteopath, physical therapist, chiropractor, athletic therapist, or massage therapist sees and hopefully provides some treatment for your back.
With that said, I’m going to share the 6 exercises that I have found to be most important and effective for helping people improve their low back health. Strangely I feel a need to qualify that again. I think that is because it makes me uncomfortable suggesting that I can help “cure back pain” when I am not a health care professional. I’m a trainer. And before I was a trainer, I was an engineer; not a doctor or a physical therapist. But here’s the thing: I help people’s low back pain by avoiding their back pain, not by working on it.
There are many causes of low back pain, and I’m far from an expert in most of them. But there is one cause in which I am quite well-versed: movement. As it turns out this is a very important one. Whether or not a person’s movement caused their low back pain, improving movement often reduces their symptoms. I help people reduce their low back pain by training their movement: Stretching, strengthening, and ensuring proper form while they move. Considering that, it is probably starting to make sense for a personal trainer to be giving out advice about low back pain.
Before I show you the 6 exercises for low back health, I want to share a bit of the theory behind the approach (To go directly to the exercises, scroll down and stop when you see the pictures). It is based on what I have learned from four great professionals:
- Michael Boyle, a Boston-based strength and conditioning coach, author of Functional Training for Sports.
- Gray Cook, a physical therapist, co-creator of the Functional Movement Screen, and author of Athletic Body in Balance.
- Dr. Stuart McGill, spinal biomechanist at the University of Waterloo, and author of Low Back Disorders
- Dr. Shirley Sarhmann, associate professor of physical therapy and neurology at Washington University School of Medicine, St Louis Missouri, and author of Diagnosis and Treatment of Movement Impairment Syndromes.
Here are the big lessons I learned from them:
- “I don’t care how much you don’t move“. Dr. Sahrmann said this repeatedly throughout the course I attended, referring to the notion that it is usually the place that moves too much that is the problem. Repeated movements and prolonged postures cause movement disorders by causing what she refers to as directional susceptibility to movement and relative flexibility. This is really just an extension of basic physics: movement will follow the path of least resistance. In an ideal body, that path will move in a manner that maintains optimal positioning of joints and activation of appropriate muscles to avoid wear and tear. In a body that has been changed through repeated movement or prolonged postures, the path of least resistance can lead to sub-optimal or even damaging movement. If this altered path of least resistance causes pain, then you probably have two problems to address: the pain, and the altered movement. Often the site of altered movement and the site of pain are different.
- Dr. McGill taught me that, for people with a history of low back pain, repeated flexion is probably not a good idea. Some would also argue this is not a good idea for anyone, and I tend to be in that camp. For those with a history of low back pain, especially if it is disc related, repeated flexion may be a significant contributor to the pain. Here’s why: When our low back bends forward (flexion), the load we are carrying (including our body weight) is completely supported by the structure of the back (the discs and the vertebrae), not by the muscles. Muscles get stronger from repetitions, but discs do not; they get strained. Is there a way to reduce the risk of low back injury and reduce the symptoms of an already injured back? Absolutely: Stop flexing!
- Another movement that can cause problems in the low back is extension – or more accurately hyper-extension. Frequent hyper-extension of the back can cause spondylolisthesis, which is a stress fracture of the pars (part of the vertebral column). Spondylolisthesis is common in cricket bowlers and gymnasts who require repeated extensions to perform their sport. The training concept here is similar to the approach for flexion: minimize the extensions. Think about exercises that strengthen without hyper-extending.
- This “anti-movement” approach does not stop with flexion and extension; it also applies to rotation. Think of a golfer or tennis player. There is a lot of potential rotation in every swing or stroke. I mention “potential” rotation because ideally these athletes will have enough hip and thoracic spine mobility to provide all of the rotational movement for their swing or stroke. In fact hip mobility is an important variable in preventing and managing low back pain for everyone. The reason this is important is that limited mobility in the hips usually results in the back being recruited to take over. If you are unable to properly rotate through the hips, then your spine will need to absorb the forces from your swing. And how many times in a tennis match do you swing your racket? Probably more than a few!
- Try this experiment: Stand facing a wall with your arms straight and hands on the wall with a mirror to one side; Lean forward slightly and adjust to make sure your back is neutral (very slight arch). Now lift one knee up as if in the start of a sprint stride, then look in the mirror. What happens to your back as you do this? Does it round a bit? For many people, this simple movement causes back flexion (rounding). Now look straight ahead, extend the same leg back and behind you as if finishing a stride and look in the mirror again. is your back very arched (extended)? Think about how many times you do these two movements when you run or play a game of soccer or baseball? Your back is moving all over the place. Is this normal, or is this movement that maybe the big joint below the low back should be doing? If you improve how well your hips move, your back will not have to endure as much stress.
- Michael Boyle and Gray Cook came up with a training theory referred to as Joint-by-Joint approach, that basically says as we move up or down the body, each joint alternatively provides either mobility or stability. This theory is also referred to as the Mobility Stability Continuum. The ankles should be mobile, the knee should be stable, the hips should be mobile, the lumbar spine should be stable, and the thoracic spine should be mobile. If you think about this for a minute, it really makes sense. The joints with the greatest natural range of motion and degrees of freedom are intended to be mobile, while those with limited ranges in at least one plane (knees and lumbar spine) are intended to be stable. It also makes sense in the context of structural anatomy. Next time you see a spine model, take a look at the vertebrae of the lumbar spine and then of the thoracic spine. The vertebrae in the lumbar spine do not move as well, in part because of the alignment of the facet joints (the wing-like bones sticking out to the sides of each vertebra).
- “He who treats the site of pain is lost” is an expression that I have read, and heard spoken many times in strength and conditioning and rehab circles. Since the entire body is connected, the site of pain may not be the cause of pain.
Now, if you put all of this together:
- The site of pain may not be the source of pain. If we look up and down a joint, we will look to the hips and thoracic spine.
- Each joint has a role of either stability or mobility. How well do the hips and thoracic spine move? How stable is the low back?
- The path of least resistance may be altered. When the person bends, extends or rotates, does she do it in the hips or thoracic spine, or is it primarily in the low back?
Now consider that most of us sit at desks for more than 8 hours per day with our hips in a shortened position, and our shoulders rounded over a keyboard. In other words, most people have poor hip and thoracic spine mobility. It’s not surprising that low back pain is such an epidemic.
And so when I see or talk to someone with low back pain, my first thoughts are:
- How well do their hips move?
- Does their back move instead of their hips?
- How well does their thoracic spine move?
- Does their low back move instead of the thoracic spine?
- Can they stabilize their back? Because if their hips and thoracic spine are not moving, they may be able to help their back survive if their low back is stable.
With this thought process in mind, I present to you 6 Exercises for Low Back Health:
1. Hip hinge. This may be the single most important exercise for helping to reduce low back pain. It addresses the altered movement of bending at the back instead of the hips. Our hips are a great big joint with a lot of freedom. Hinging at the hips is such a natural movement, yet it is one that many of us have lost. Learn to bend at the hips instead of the back, and apply it when you bend in your daily activities, and you will take a lot of unnecessary strain away from your back.
How to hip hinge: Stand with your back a few inches from a wall, with feet about hip width apart, and knees slightly bent (10-20 degrees). Keeping your back straight, try to touch your buttocks to the wall without losing your balance (hint: this will require bending your torso forward) and then stand up again. Once you can do this, move very slightly away from the wall and repeat. This time, you will be more bent over when you touch. Continue to do this until you are no longer able to touch the wall and maintain your balance. Go slightly closer and perform repetitions of this movement, each time returning to the starting position without rounding the back. If you are not sure if your back is straight, place your hand on your low back, with fingers outstretched and make sure the entire hand stays in contact with the back the entire time. If you lose contact, your back has rounded.
2. Bird dog. This is such a great exercise. Most people think of stretching when they have back issues, but when it comes to the low back, stabilizing is probably more important. Certainly that’s what the joint by joint theory tells us. So does Dr. Sarhrmann’s “I don’t care how much you don’t move” approach. Dr. McGill’s approach is also heavily focused on stabilizing the core. The bird dog is a great option to help strengthen and stabilize the back because it works it in safely, and can be easily modified to be helpful for someone even if their core and back are not strong yet. Many health care professionals recommend an exercise called supermans instead. I just want to take a moment to share an email that I sent to a client of mine, explaining why I dislike supermans as an exercise.
I thought I’d follow up on the supermans (or prone trunk and leg extension). Here’s what Dr. Stuart McGill has to say about them in his book, Low Back Disorders: “Even worse is the commonly prescribed back extension task in clinics, in which the patient lies prone and extends the legs and outstretched arms; this again activates all four extensor sections but imposes up to 6000 N on a hyperextended spine. This is not justifiable for any patient!”
He notes earlier in the book that “the National Institute for Occupational Safety and Health (NIOSH) has set the action limit for low back compression at 3300 N; repetitive loading above this level is linked with higher injury rates in workers, yet this is imposed on the spine with each repetition of the sit-up!” (and as above with each rep of the superman).
For reference, the bird dog that I showed you is 3000N.
In terms of muscle activation, the superman does have higher levels for some of the back muscles (extensors and multifidus), so theoretically you’d have to do more bird dogs than supermans, but once you are strong enough, we can load it with a band. The extra compression force in the superman is not worth it in my books. And if you think about it, if you have a hard time with the bird dog, then are you really getting much muscle activation in the superman, or are your muscles giving out early and then putting more stress on the spine.
Here is how to do a bird dog: Position yourself on your hands and knees, maintaining a neutral spine. Engage your core and lift the right arm and left leg without any movement in your core (your hips and shoulders should remain level). If you can look in a mirror take a peak to see that you aren’t lifting one hip or shoulder. If you are having a hard time keeping your core steady, don’t lift your arm and leg as high. If you still have trouble, only lift one limb at a time (e.g. arm only and then leg only). Once you get better at this, increase the height that you lift your limbs. Hold the position for the desired time and then lower the arm and leg and lightly “sweep” the ground with them and raise them again for another repetition on the same side. Repeat for the desired repetitions and then switch sides.
3. Sidelying rotation. This is an exercise that I learned while taking the Functional Movement Screen (FMS) certification. It is great option to improve how well your upper back works. And for those who spend a lot of sitting at a desk (so almost everyone in North America), this will also help stretch out your chest (pectoral) muscles. When your upper back moves better, your lower back does not have to endure as much stress.
How to do the sidelying rotation stretch: Lie on your left side with your right hip and knee bent at 90 degrees. Place a medicine ball or foam roller (or any item that keeps your knee at about the same height as your hip) under your right knee. Maintain contact between your knee and that item throughout the entire exercise. Place both hands out in front of your chest – arms straight. Slowly rotate your upper body as far as you can. Ideally your right arm will be flat on the floor behind you (180 degrees from your left arm).
4. Stability ball figure 4 glute stretch. Now we’re stretching the glutes, or the hip rotators. The glutes are a very big and important set of muscles just below your low back. I suspect you are getting the hang of this thought process, and realize what I’m about to say: If your hips do not rotate well, then your back will have to endure more stress.
How to do the stability ball figure 4 glute stretch: Lie on your back with your right foot on a stability ball and your left foot on your right knee in a figure 4 position. Use your right foot to rotate the stability ball toward you until you feel a stretch in your left glute. Hold this position for the prescribed time and then switch sides.
5. Half-kneeling hip flexor lunge stretch. This one is still a hip stretch, but it’s the hip flexors instead of the rotators. Sitting all day doesn’t just affect our upper back and chest, but also our hips. I’m sure most people reading this can relate to their hips feeling tight – almost as though it is hard to unbend when we stand up. This problem has a double effect on the low back. Like the hip rotator and the upper back, if the hip flexors do not move well, then the back will take on more strain. In this case, that effect is doubled because the hip flexors are actually attached to the low back. So if they are too tight, they will actually pull on your low back. That is not going to feel good if you have a bad back!
How to do the half-kneeling hip flexor lunge stretch: Position yourself in a half-kneeling position with the right foot forward, and left lower-leg on the floor behind you. Lightly squeeze your left glute, raise your left hand and lean your left hip forward, keeping the spine in a neutral position. You should feel a stretch in your left hip flexor. To enhance the stretch, rotate your torso slightly to the left. Hold this position for the prescribed time and then switch sides.
6. Single leg lowering. This is another exercise from the FMS, courtesy of Gray Cook. It helps to work on the abdominals and hip flexors, but with a focus on stabilizing your pelvis while your leg is moving. This is essentially isolating how the pelvis, abdominals, and back respond to every step you take. What should happen is that your leg moves from front to back inside the pelvis. What often happens instead is that your pelvis tilts pulling your back into extension. This may be due to tight hip flexors, but it may just be a pattern that has been developed. The single leg lowering exercise helps you to stabilize that basic stride motion that you use with every step you take (gratuitous tribute to The Police).
How to do the single-leg lowering: Lie on your back with your legs in a doorway. Place one foot up on a wall with hip flexed (bent) and knee straight. Position yourself so that you are close enough to the wall that you can straighten the “up” leg, feeling only a slight stretch in the back of that leg. Place your hands at your sides with palms up. Lift your other leg up and hold it next to the leg that is on the wall. Engage your core (the way you would if you were about to be punched in the stomach) and slowly lower that leg to the floor. If you feel the stretch in your Up leg increase, really focus on keeping the core engaged and keep your back on the floor. If you cannot maintain this position, then place a 6-8 inch box or step under your down foot. As you get better at this, try to use a smaller step, or none at all, and try to move your body closer to the wall.
Add these six exercises and you will likely find that your back bothers you much less. But remember to consult your health care provider before changing how you are addressing your back, and most important, if any of these movements cause pain, STOP. The expression “no pain, no gain” does not apply to your joints!
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Elsbeth Vaino is a personal trainer in Ottawa, Canada, specializing in training people to meet their goals based on their body and their fitness level.