Are you looking for the 3 best exercises for low back pain? There is no such thing as a “best exercise” for anything. Granted there are exercises that work well for a lot of people, and we could qualify these as “go-to” exercises. However, we should still avoid blindly prescribing them to anyone with low back pain without first checking whether they fit the individual. I always say exercises are tools and it’s always a matter of finding the right tool to do the job.
So, while I can’t give you the best exercises for low back pain, I can give you the best strategic approach to low back pain.
In the initial part of your intervention, pain is the issue of most importance, so understanding pain triggers and movement biases is the most important part of your intervention strategy. Only then can you be confident that you are selecting the “best exercises” for THAT individual’s low back pain.
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LOW BACK PAIN TRIGGERS
An individual with low back pain will typically present with specific movements and postures that trigger pain. They can also be intolerant to specific types of loads. The different pain triggers for the low back include:
-Flexion intolerance: Flexing the torso over the hips, or even passive flexion such as sitting, will increase pain. They will typically be apprehensive about flexion like bending forward to touch the toes.
-Extension intolerance: Extending the torso, or even prolonged extension such as standing for long periods of time, will increase their symptoms.
-Compression load intolerance: You can test this with a heel drop test. Have the individual stand on their toes and then let the heels drop down to the ground. They will typically have pain with impact activities like running, jumping, etc. Often this is in combination with flexion or extension.
-Shear load intolerance: Holding a load away from the body will typically increase their pain, things like putting something into the trunk of a car. They may also have some flexion intolerance.
As you can see, things can get pretty complicated, as people can be intolerant to a combination of 2 or more of these. Flexion/compression or extension/rotation are other common combinations that can trigger pain. Already you can see that trying to find the “3 best exercises” that could fit with all of these different manifestations of pain is a far reach, and we haven’t talked about movement biases yet.
As well, if someone has symptomatic degenerative disc disease (DDD), they may have pain that is increased with a wide range and variety of movement. The most important consequence of DDD we need to consider is that it can generate instability. Disc degeneration results in a loss of disc height which creates laxity between the vertebrae as it changes the morphology of the intervertebral joints. The loss of height also allows results in ligament laxity, which also contributes to instability. This means that a lot of movements can trigger pain.
LOW BACK MOVEMENT BIASES
Individuals also present with movement biases. Dr. Shirley Sahrmann is famous for developing movement system impairment (MSI) syndromes to describe movement-based diagnoses. She proposes that MSI syndromes develop from alignments and repetitive movements that over time induce changes in tissues and joint structures. These changes result in hypermobility of accessory movements (sliding and gliding between joint surfaces) and micro-instability. You can read more about her work here.
Here is brief description of two common movement biases of the lumbar spine:
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. 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. Symptoms are usually provoked by movements and postures that promote flexion like prolonged sitting, bending forward, etc.
PAIN AND MOVEMENT INTERVENTION
By now, you already have a pretty good idea that dealing with low back pain and movement biases is much more complex than prescribing generic exercises for the core and the glutes. The first part of your strategy needs to be about avoiding pain triggers and correcting the movement bias. Let’s take the example of someone who is flexion intolerant.
Dead bugs and Bird dogs have often been deemed the “best exercises” for low back pain. While it is unfortunate that they are mostly done wrong, if done right, I will not argue that they are great exercises to address micro-movement and instability of the lumbar spine.
The dead bug is what I consider an anti-extension exercise, and therefore requires some flexion moment. In the initial stages, you might find that the flexion-intolerant individual is not ready for this.
While I am here, I just want to open a parenthesis on the dead bug. Too often I see coaches cuing clients to flatten their lower back against the floor, but we need to be cognisant of how they are going to achieve this – particularly if someone is flexion intolerant. The goal of the dead bug is to address micro-movement and instability. We are looking for the ability to maintain a neutral spine position with movement of the extremities. We do not want a posterior pelvic tilt and lumbar flexion, something that tends to happen when people are cued to flatten their low back into the floor. I’ve even seen dead bugs done with scapulae lifted off the floor in a crunch position. This defeats the purpose completely. End of parenthesis.
For the flexion-intolerant individual, a bird-dog might be better tolerated. Still, it is not uncommon for people with a flexion movement bias to find themselves in some lumbar spine flexion just in the quadruped position. As such, you may find that the classic bird-dog is not a great fit. You don’t have to reinvent the wheel here, just modify the exercise to fit the individual needs.
Try a modification where the arm is up overhead pushing against the wall and the contralateral leg extends. I have found that this position helps prevent individuals from getting into a flexion position.
Make sure to watch the main video of this article to see how this exercise is performed.
In the same vein, nothing stops you from modifying the classic dead bug exercise using just the legs, or even just the arms initially, instead of simultaneous contralateral.
The Pallof press is another common exercise that gets prescribed for low back pain. There’s an example of an exercise that would not be a good choice for someone with shear intolerance. Pressing a weight away from the body from standing or kneeling usually is what triggers symptoms for people with shear intolerance. Again, nothing stops you from seeing if a half-kneeling position is better. Otherwise, Pallof presses can be done in the supine position as well:
GLUTE FUNCTION
On the list of “best exercises” for low back pain we also find everything glutes. I am not arguing the point that the glutes are important for distributing forces. However, during hip extension, the lumbar spine will typically move more readily than the hip. For an extension intolerant individual, bridges and the likes may not be pleasant. If you get them prone in a torso/hip supported position, then you may be able to bring awareness to hip extension:
This is just another example of how the individual dictates the best exercise, not the other way around. I discuss this as well in my article “Avoid Low Back Pain with the Right Training Plan”.
CARRIES FOR CORE STABILITY
I am huge fan of carries. Carry often, carry all kinds of things in all kinds of different ways.
Unilateral holds and carries are a great way to work on frontal plane stability, and important component of low back pain intervention, as dysfunction in the lumbar spine may result in poor firing and stabilization of the quadratus lumborum. The QL is an important contributor to back extension, and also forms the lateral sling with the contralateral glute med to maintain frontal plane stability of the pelvis. Of course, a unilateral hold also creates an anti-rotation torque. You are trying to keep the heavy load from pulling you laterally and forward. So, if someone was intolerant to rotation, extension, or a combination of the two, this might actually be a bad fit for them. Going with a regular carry, perhaps in a bear hug position, might be a better option.
One of the challenges with doing heavy holds or carries is that you usually need to pick up the object(s) from the floor. This can be problematic for the low back pained individual. Loading and unloading from chest-level is an interesting way around this. Watch the main video to see an example of this.
IT’S NOT THE TOOLS
“It’s not the tools you have faith in – tools are just tools – they work or they don’t work. It’s the people you have faith in or not.” – Steve Jobs
Don’t get me wrong, we need to progress people so that we can eventually get them into positions where they can control their movement bias. Someone with an extension movement bias will need to be capable of getting into a hip extended position without overextending the lumbar spine. But initially when you’re dealing with pain and the movement bias, avoiding pain is the first matter of intervention.
I apologize for bringing you here thinking you would get the 3 best exercises for low back pain. But I hope you got more out of it than that. If you want to be an asset to get your clients from injured to strong, or get them moving pain-free, stop looking for the best exercises. Find a strategy that will help you fit your client with the tools they need when they need them. We have so much accessible to us in training, so many exercise variations. We don’t need to reinvent the wheel, but we do need to be more analytical in how we choose, modify and apply exercises based on the individual.
Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U
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