Back pain 3: Exercises for low back pain

Here are just a few tips and ideas for low back pain rehab and prevention exercises. If you are prone to LBP then I recommend including these as part of your regular workout program. Again, other great exercises can be found in Robin McKenzie’s book Treat Your Own Back and Stuart McGill’s Ultimate Back Fitness and Performance. I also recommend bellydancing, yoga, and Pilates. Anything that gets the back moving, strengthens it, and makes you conscious of that area is good. Some folks may find that including stretching of hamstrings and hips, especially the front of the hips, is useful. See my article on squat stretches for ideas.

When training for rehab, aim for endurance rather than heavy resistance and a maximal strength focus. As I mentioned in Part 2, low back pain is correlated with reduced endurance of spinal musculature. This means you want to work on longer sets with lighter weight rather than shorter sets with heavier weight. For example, hold the plank for 1-2 min, or do 20 quadrupeds.

Always, always let pain be your guide. Your aim is to find the pain free range of motion and work within that range, gradually expanding it as you improve. A little discomfort may be felt, and it’s up to you to judge how much is okay. Do not do any exercise, no matter how good it is, if it causes you a great deal of pain. Assume the usual disclaimer: when in doubt consult with your doctor and/or a physiotherapist.

neutral spine

Neutral spine is the position in which the spine is evenly balanced, and the top of the pelvis is neither tipped too far forward (resulting in an exaggerated low back arch and protruding lower belly) nor too far back. It’s not a single position per se, but rather a dynamic state in which the spine is able to respond and correct itself throughout a movement. Neutral spine is the state in which the spine is most able to tolerate loading and mechanical forces acting on it. A happy spine is never entirely straight, but rather looks like a gentle S-curve when viewed from the side. There should not be excessive rounding of the shoulders and upper back, nor excessive arching of the lower back. It shouldn’t look like the letter C or the letter Z. And if it looks like the letter B, you should probably loosen your belt.

One way to find a neutral spine position was taught to me by my Olympic weightlifting coach. While standing, take a deep breath, and push your chest up and out slightly. The position your back gets into with this action is an approximately neutral spine.

To help alleviate and prevent LBP, neutral spine should be maintained as much as possible during loaded movements. Some people incorrectly misinterpret this as saying that the spine should always remain straight up and down. Then they try to squat and fall over backwards. Rather, the spine should form a generally straight line with slight natural curves, but it can retain this line at a variety of angles. This is achieved by bending from the hip, not the waist.

Below are some examples of neutral spine while sitting, squatting, and picking up a laundry basket.

neutral spine while seated

Here’s an example of improper sitting position. Most of us probably do this at our computers without even thinking about it. Upper and midback is rounded, shoulders are hunched forward, and head is also pushed forward.	In comparison, this is an example of neutral spine while seated. Head is carried further back, in line with the spine. Shoulders are pushed back and the posture is upright. You should be able to do this without back support, but if a lumbar roll or folded towel helps, then that’s fine.

neutral spine while picking up a load

As I mentioned, one of the most common occurrences of LBP is when doing household chores, but this principle applies in the gym as well. This picture shows the wrong way to pick up something from the floor; in this case, a laundry basket. The back is rounded, which effectively removes the assistance of the supporting spinal musculature. I’m cruisin’ for a bruisin’ here.

Here’s the right way to pick up that load. Squat down (see how useful squats and deadlifts are?), and use the legs to drive the load upwards. Also notice that this picture demonstrates neutral spine while squatting, and you can see that again, it doesn’t mean keeping the spine straight up and down, perpendicular to the floor. Rather, it means keeping the back in a relatively straight line at any angle, using the hips as the “hinge”. Don’t forget to hold your breath and tighten your midsection for a split second through the first part of the lift.

pelvic mobilization

Getting the lower back moving around after an injury will help with healing, strengthening, and pain relief. There are many types of exercises aimed at lower back rehab.

One that I recommend, though not shown here, is the cat-cow sequence from yoga. Get on hands and knees on a mat. Round your back, pressing it towards the ceiling, like an angry cat. Try to curl into a ball without moving your hands and knees. Look down and slightly behind you, so you can see your knees. Hold for a second, then slowly and gently relax, and let your midsection sag downward, pressing your belly towards the floor. Look forward and slightly slightly upward. This is the cow position. Hold that for a second, then smoothly and consciously move back into the angry cat position. Go back and forth between these two positions for several reps per set. Don’t forget to breathe deeply and consciously relax throughout. One of my clients who suffers from chronic back pain as a result of a tennis injury swears that this cat-cow sequence is better than ibuprofen for pain relief.

Below is another one I like: the standing pelvic tilt.

I ripped off this movement from belly dancing. Yes, it looks dorky, so let’s all just get past that and agree to do this when nobody is looking. You should be grateful that I was brave enough to look like such a goof for your benefit. It’s quite simple. While standing, tilt the pelvis back and forth as far as it will go in either direction. Do this slowly, consciously, and gently. Hold each position above for a second or two.

Anterior pelvic tilt (left hand photo) means that the top of the pelvis is tilted forward, and the lower back is arched, as in the photo above.

Posterior pelvic tilt (right hand photo) means that the top of the pelvis is tipped back, and the pelvis is tucked under the body, almost like you’re trying to curl into a ball while still standing, or like a dog tucking its tail between its legs. Do as many sets as you like, and as many reps as you like. Something like a couple of sets of 10 to 15 is a good goal.

Once you get comfortable with this movement, try its equivalent from side to side, slowly alternating raising one hip up and then the other.

torso strengthening

A good lower back rehab program should include some work on strengthening the supporting muscles of the torso. This includes the spinal erectors, obliques, and rectus abdominis, as well as the deeper torso musculature. Here are a few exercise ideas.

This exercise, known as a “Superman”, because it looks like Superman flying, strengthens the low back. Begin by lying face down, as shown in the top picture, with arms overhead. Then, raise arms and legs off the floor. The aim is to hold this “flying” position as long as possible. This exercise should be done for a few sets of at least 30 seconds per set. Don’t forget to breathe! And by the way, I don’t recommend doing them on a hardwood floor, as I did. Owie ow. Do them on a nice cushy carpet or mat. One caveat: McGill is not crazy about this exercise, as he feels it puts undue compressive force on the spine. If you are concerned, skip this exercise.

The exercise in the photo above is known as a plank position. Yoga folks will recognize it. It looks like the top position of a pushup. You simply hold this position as long as possible, while maintaining a good, straight, rigid body position. There should be a straight line from your head to your feet. No sagging in the middle! Like the Superman, do these for a few sets of at least 30 seconds, and don’t forget to breathe. These can also be done resting on forearms instead of hands. To get into this position, begin on hands and knees. Then, straighten out your legs until your body is in position.

This type of exercise is known as a quadruped, as it’s done on all fours. Again, do as I say and not as I do, and do this on a mat if you like your kneecaps. Begin on all fours, with a neutral-ish spine, as shown above. Don’t let your body sag in the middle.

Slowly and consciously, raise your left arm and right leg until they’re both out straight. Hold this position for 10 seconds or so, then slowly lower. Repeat for several reps. You can alternate sides with each rep, or do all the reps on one side first, then the other. I’m sort of looking forward here; find a position in which your head is comfortable. You can look at the floor if you prefer.