Low back pain - the ‘big three’
There are many ways of improving low back endurance and stabilisation through safe and effective exercise.
Personal trainers will be familiar with these exercises, but to use them safely with clients experiencing low back pain you need the Level 4 qualification, Low Back Pain Exercise Specialist.
However, McGill (2007) identified the ‘big three’ exercises which have been shown to sufficiently challenge muscle, spare the spine of high load and ensure sufficient stability to improve normal ADL functions and quality of life. The ‘big three’ are:
- The curl-up to train rectus abdominis and the oblique abdominals
- Side bridge (side plank) to train quadrates lumborum, oblique abdominals and transverse abdominis
- Exercises in the 4-point kneeling position with alternate arm/leg raises (also known as ‘bird dog’) to train the back extensors
Abdominal bracing and neutral lumbar spine should be emphasised throughout each of the exercises
Beginners (modified) curl-up
This exercise is ideal for the very de-conditioned and those wishing to reduce the load on the spine.
Lying supine (face up), assume neutral alignment with hands supporting the lumbar region. It is important not to allow the lower back to flatten to floor, as this takes the spine out of neutral and increases the stresses in the passive tissues. One leg is bent with the knee flexed to 90° while the other leg remains relaxed on the floor. This adds further torque to the pelvis to prevent the lumbar spine from flattening to the floor. The head and neck should be neutral and rigid on the thoracic spine. It is important that no cervical motion occurs, either poking or tucking the chin. Clients should place their tongue on the roof of their mouth behind the front teeth and push upward, which helps to promote stabilising neck patterns. Leaving the elbows on the floor, contract the abdominals to elevate the head and shoulders up from the floor whilst maintaining, focusing on flexing the mid thoracic spine. Remember the intention is to activate the rectus abdominis and the obliques, not to produce a lot of spine motion.
Beginners (modified) side bridge
The client lies on their side supported by their elbow and hip, with their knees flexed to 90°. The client’s free hand should be placed on the opposite shoulder. Pulling down firmly will help to stabilise the shoulder. The client straightens and lifts their body until it is supported on the elbow and the knee, with some assistance from the lower leg. This position can be held for a short period of time then lowered back to the floor. If this exercise is too difficult for some clients, it can be adapted by using a wall in an upright position.
‘Bird dog’ exercises in a 4-point kneeling position
From a 4-point kneeling position, the client is asked to maintain a neutral spine and mild abdominal activation throughout. Initially the client can lift alternating arms off the floor to shoulder alignment whilst limiting pelvic and lumbar movement. This can also be done with individual leg movements extending the hip and knee backwards to a comfortable height using the back extensors to stabilise, progressing into a combination of both arm and leg extensions. As limbs are lifted from the floor, the body becomes less stable and the stabilising muscles must work harder to maintain correct alignment and balance (Norris, 2008). Exercises in this position can also be used to safely condition the trunk extensor muscles as they have shown to sufficiently challenge the musculature while sparing the spine of high load (McGill, 2007).
Some of these positions may sound fairly basic, but the key point is that there is very limited lumbar spine movement throughout, allowing both local and global stabilising muscles to increase in endurance and relieve stress in this problematic area.
Get the right qualifications
With more and more clients suffering with low back pain and new approaches to treatment embracing exercise, there are big opportunities for personal trainers with the right qualifications. Find out more here >
McGill, S. (2007) Low Back Disorders: Evidence-Based Prevention and Rehabilitation second edition Human Kinetics, Champaign, Illinois
Norris, C. M. (2008) Back Stability 2nd Edition Human Kinetics, Champaign, Illinois