Avoid Low Back Pain with the Right Training Plan

You can avoid low back pain with the right training plan.  IF you have the right strategy.  But do you?  Most of the time, low back pain prevention strategies are limited to general strengthening of the core and the glutes.  Planks, bridges and band walks are the usual protocol.

Sure, we have long been taught that the best strategy to prevent low back pain involves training what we commonly refer to as the core.  It’s actually probably more accurate to refer to the core as the “pillar”, knowing that the lumbopelvic hip complex and shoulder complex are part of it.

But instead of programming core exercises randomly, we should focus on individualizing core training by identifying and addressing the specific behaviors that can lead to low back pain. Even in the absence of pain, the inability to maintain stable behavior of the pillar can quickly overload the low back and result in pain.

Why is this important?  Just one incidence of low back pain can result in fear of movement related to bending or twisting.  The resultant prolonged and excessive bracing by the superficial abdominals and/or erector spinae results in stiffer, guarded movements that don’t lend themselves well to activities of daily living.  This creates behavior that needs to be specifically identified and addressed.

POTENTIAL LIMITATIONS OF CLASSIC CORE TRAINING

Classic core training for the low back tends to have several limitations including bad technical execution.  Bird-dogs and deadbugs are actually very efficient low back health exercises but are typically done wrong.  Because they are done wrong, they get a bad rep as “fluffy” rehab exercises.

The objective of bird-dogs and deadbugs is to limit movement of the spine and pelvis to maintain neutral while moving the extremities, or in the case of low back health, maybe just the lower extremities.  If people are flailing, they’re doing it wrong.  If they’re extending the spine, the pelvis is moving into anterior tilt: wrong.  If they’re “crunching” their abs to flatten their low back against the floor, the pelvis is moving into posterior tilt: wrong.

Planks and side planks are also commonly used for low back pain.  These are also great exercises that have their limitations.  Planks typically have you working in a hollow body position, which is important, but does not cover the entire spectrum of how the core needs to function.  Side planks are great for frontal plane stability but don’t transfer as well to stability in the weight-bearing position.

The main limitation of classic core training for the low back is that it typically does not specifically target the actual behaviors that may result in low back pain.

MOVEMENT BIASES AND LOW BACK PAIN

The use of anti-flexion and anti-extension movements for core control has been around for a while, so intuitively, we understand that controlling the lumbopelvic unit is a crucial component of low back pain prevention.

We can take this knowledge one step further by specifically identifying which of these behaviors needs to be addressed.  The individual who tends to hyperextend the lumbar spine for form closure as a bracing strategy needs anti-extension exercises whereas the person who tends towards flexion probably won’t benefit from them.

With the low back, there are two common movement biases:

With an extension bias, the lumbar spine demonstrates excessive movement into extension relative to the hips and thoracic spine under load.  Often you will see a specific area of extension in the lumbar spine, which we call a segmental hinge.  If there is pain, symptoms are usually provoked by movements and postures that promote extension like walking, overhead movement, prolonged standing.

With a flexion bias, the lumbar spine demonstrates excessive movement into flexion relative to the hips and thoracic spine under load.  Think of those clients you have worked with who automatically round their back when asked to hinge forward.  If there is pain, symptoms are usually provoked by movements and postures that promote flexion like prolonged sitting, bending forward, etc.

If we take the plank as an example of a classic core exercise for the low back, an individual with an extension bias would benefit from a plank, whereas I would be more inclined to program a reverse (or Chinese) plank for an individual with a flexion bias.

One exercise I quite like for reinforcing a neutral lumbopelvic position is the tall-kneeling kettlebell hold.  This exercise can be performed holding the KB in front of the body, or behind the body, sometimes called handcuffed position.  You can make a choice between these two positions based on the observed movement bias:

Holding the kettlebell in front forces you into more flexion and may prevent an extension bias.  Have the client gently push the hips towards the handle of the KB with the intent of leaning ever so slightly forward such that they have to actively push the top of the feet into the ground to maintain balance.

Holding the KB behind you brings you into more extension and may prevent a flexion bias.  As with the anterior loaded version, lean forward ever so slightly.

FRONTAL PLANE STABILITY

Additionally to anti-extension and anti-flexion work, which addresses the sagittal plane, frontal plane stability, or lateral stability of the pelvis, is another important factor to consider for avoiding low back pain.  Low back pain with prolonged periods of standing has been correlated to lack of motor control of the hip in the frontal plane.

We know that the glute med is the main lateral stabilizer of the pelvis.  All fibers of the glute med are activated in hip abduction, regardless of the position of the hip.  Typically, exercises for the glute med involve band walks and shuffles, clamshells, side planks and the likes.  These exercise target hip abduction but don’t transfer quite well to lateral stability of the pelvis.  Let’s not get me started on that subject, but make sure you read my article Monster Walks to Fix Your Weak Glutes?

Personally, I like the variation of the Stork exercise shown in the video below.  I instruct the client to focus on maintaining their weight within the foot tripod, an active arch, the knee aligned with the second and third toe and the torso in line with the pelvis with a slight hinge at the hips.

In regard to the foot, I also consider it as part of the core. Understanding how the foot works on the ground is a key element for the Stork exercise, as well as for all of the lifts.  Refer to my article Foot Stability is the Foundation for All your Lifts for more on this.

LOW BACK ISO-INTEGRATION

Amidst this strategy, we must not forget that direct strengthening of the low back is important for resilience and robustness.  While we don’t want to overwork the back, it needs to be strong to handle loads.  Often times people who have had an episode (or more) of low back pain tend to over-protect the low back making it weak.  Even in the absence of pain, a weak low back is not desirable and will likely get you into trouble in the gym and probably in every day life.

When selecting exercises to load the low back, we often select those that move the torso on the hips, like Goodmornings, RDLs or deadlifts. An optimal core strategy should include exercises that help set the stage to correctly handle and load these exercises.

An interesting strategy then is to move the hips or lower extremities on a fixed torso.  This teaches the low back to work isometrically.  Specifically, it teaches the client to achieve and maintain a natural lumbar arch.  A natural arch in the lumbar spine (not an overextended or flexed spine) is required to efficiently strengthen the low back using the above-stated exercises.

Reverse hyperextensions are largely underused yet are quite a useful tool to teach this.  Have your client maintain a natural arch as they move the hips into extension and back down.  What you don’t want is an overarching of the low back to stabilize the torso.

While we understand that an efficient core and glutes are important for preventing low back pain, we need to do more than program core exercises randomly.  Using a strategy to identify behaviors that can contribute to low back pain and selecting and manipulating core exercises based on these behaviors is key.

The ability to control the pillar is fundamental to build a strong and resilient low back.  As such, your core training strategy needs to address and improve movement control.  Of course, we cannot prevent all injuries or pain.  However, with the right strategy, we can make sure people are moving optimally to prevent overloading the back.

I urge you to re-think the core exercises you program for your clients.  While any well-performed core exercises will work, the key to a more successful client intervention is individualization.  Understanding what behaviors need to be controlled and which need to be instilled will help you build up your clients to their most optimal, robust selves.

Enjoyed this article?  Click the link on the top right-hand corner of the video to share it, we sure do appreciate it!

Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U