When dealing with lower back pain, don't over-emphasise the abdominals - other muscles are equally important. Try this lower back injury prevention programme
In recent years, one of the main developments in treating lower back pain has been the understanding that the abdominal muscle group plays an important role in supporting the spine, and that strengthening this region is valuable in all prevention and treatment programmes for lower back pain. In particular, the transversus muscle has received a great deal of research attention. It is now accepted that the transversus muscle is key to the development of core stability and that learning to use the transversus abdominis muscle correctly to support the spine and maintain good posture is very beneficial.
For these reasons, abdominal-strengthening exercises and transversus abdominis co-ordination exercises are now becoming standard practice for lower back pain prevention and treatment programmes. This development marks an advance in standards, since in earlier times there was little or no attention paid to abdominal strength in lower back pain programmes. However, the problem now may be that, whereas the abdominals were historically neglected, they currently dominate to the extent that the lower back musculature and other movements of the spine have become the neglected elements in lower back pain programmes.
Walters 1 writes about the fact that the majority of exercises in lower back pain programmes are for the abdominals, and that most practitioners and students now believe that the abdominals are the most important for the lower back. He raises the question of whether the pendulum has now swung back too far the other way and that we should be remembering to include lower back muscle and extension movements along with the abdominal work in our lower back programmes.
This argument does not downgrade the importance of abdominal strengthening, but merely suggests that we should be striving for a comprehensive programme of exercises that effectively strengthens all the muscles and movements of the spine. In any event, lower back pain has a variety of causes, and while weak abdominals and the poor posture that is associated with this will increase injury risks, they are not the only factor that has to be considered.
Back movement and function
Any back movement is a combination of the basic flexion, extension and rotation movements. Flexion is when the trunk bends forward and to the side, e.g., leaning over a sink or sitting up in bed. The rectus abdominis, internal and external obliques and hip flexors perform these movements. Extension is when the back straightens from a bent position or extends from an erect position, e.g picking up something from the floor. The erector spinae, quadratus lumborum in combination with gluteus maximus and hamstrings perform this movement. Rotation is twisting of the trunk about the waist, e.g., turning to one's side while sitting down. The rectus abdominis, obliques and erector spinae are all involved in rotation movements.
These are the basic three movements, but the back can move in any combination of these. For example, the downswing of a golf shot is a combination of rotation and flexion, reaching up and to the side to pick something off a shelf is a combination of extension and rotation. Throughout sport and daily life, the back is performing many complex movements involving the muscles in the stomach, hips and low back. What is more, these movements can occur from lying, sitting or standing positions. For example, sitting up in bed is flexion from a lying position, and bending down to tie your shoelaces is flexion from a standing position.
It is also important that the back does not move! By this I mean that during standing, sitting, walking, running, performing a bicep curl, etc., it is important that the spine maintain its ideal posture and alignment. You may have heard the term 'neutral' used in relation to posture. This refers to the low back, or lumbar segment of the spine as neither extended nor flexed, with the pelvis flat and not tilted. Learning to control this 'neutral' position is the focus of most 'core stability' exercises, targeting the correct activation of the transversus abdominis muscle. However it is important to remember that the paraspinal muscles, particularly multifidus, co-contract with transversus to maintain a 'neutral' lumbar spine, particularly in a standing position or while leaning forwards. Research has also shown that poor multifidus activity is found in back-pain patients, again highlighting its importance.
I believe that the most effective lower back programmes need to take into consideration all the muscles of the spine, how they move and function and in which positions these movements occur. Front, back or side and large or small - all the muscles involved in lower back movements and postural control should be trained. This comprehensive approach also takes into consideration that back injury can be caused by various factors, including poor posture, lifting strain, poor stability, muscle strength imbalances, small repetitive stresses and poor flexibility. The more comprehensive and varied the lower back programme, the more likely all these factors will be accounted for.
The following is an example of a progressive lower back pain prevention programme. Any rehab training needs to be specific to the individual patient and you may need to avoid certain exercises to begin with, so I am assuming that what follows is a prevention programme with all movements included.
Four basic exercises to recruit the core stabilisers and train stomach and low back muscles.
Transversus. Lie on your back with legs bent. Find the neutral low back position. Place each hand in and down from the bony prominence of your hips and activate a small amount of tension under your fingers. This is where the transversus muscle is. You should be able to activate transversus without tensing the whole stomach area or moving the spine. Keeping the tension, perform small leg lift movements, using the transversus muscle to maintain 'neutrality' as the legs move. Practise this for a few minutes. Breathe normally as you do so.
Multifidus. Stand upright. Soften your knees and find the neutral lower back position. Maintain that position, lean forward from the hips 10-15 degrees. Do not let your back bend. Hold the position for 10 seconds and then return upright slowly. Repeat 10 times.
Ab crunch. Lie on the floor with legs bent. Find the neutral low back position. Lift the head off the floor and look up. Using the stomach crunch the shoulders off the floor and then lower slowly. Just before shoulders are fully down once more, crunch up again.
Back extensions. Lie on your stomach. Place your hands by your ears. Slowly pull your chest off the floor and squeeze your bum to lift your feet up as you do so. Lift chest and feet a few inches each and slowly lower. Just before your body returns fully to the floor, raise back again.
More advanced core stability, stomach and low back exercises.
The plank. Lie on your front resting up on your elbows. Go up on to your toes forming a bridge from your feet to your elbows. Your low back should be in neutral and perfectly solid as you maintain the static bridge position. Hold for 10-30 seconds.
Bum lift bridge. Lie on your back with your feet on a gym ball. Find the neutral low back position and then lift your hips up by squeezing your gluteals. Hold your hips off the floor for 10-30 seconds and lower slowly. Keep your shoulders and neck on the floor as you lift up.
Standing medicine ball twists.
Stand with good posture, knees soft. Find the neutral lower back position. Hold a medicine ball out in both arms (5 kg for men, 3 kg for women). Keeping your knees facing forwards, rotate from the waist (not the hips) and turn your head and shoulders from side to side. Keep the medicine ball out away from the body and initiate the movement from the waist and stomach muscles.
Twisted crunch. Like the ab crunch
before but with a twist; one shoulder
leads each time.
Gym ball back extension. Like the floor back extension, but performed on the gym ball. Let your trunk flex around the ball and then extend up using your gluteals and low back muscles.
Superman bridge. Kneel on all fours. Find the neutral spine position. Maintaining this as best you can, extend one leg back and the opposite arm forward. Return to the start and repeat for the other side.
Add some more advanced stomach and lower back exercises.
The wood chop. Stand with good posture, knees soft, feet shoulder width apart. Hold a medicine ball above your head. Bending from the waist, pull your body down and bring the ball between your feet, as if you were chopping wood with an axe. Extend back upwards using the gluteal and lower back muscles. Keep your arms straight throughout and initiate the movement from your stomach and low back.
Dead lift. This is one of the best exercises for teaching people to lift with the correct technique. Stand behind a barbell, feet shoulder width apart. Pick up the bar by bending your knees and squatting down all the way, grasp the bar and then stand up using only the legs. Keep your back flat as you squat down and stand up; do not use your arms.
Reverse crunch. Lie on the floor with your knees bent. Keep your hands by your head. Using only your stomach, crunch up the legs so your bum lifts off the floor and your knees come towards your chest. Initiate from the stomach; do not swing the legs. Lower the bum down, crunching up just before it rests on the floor again.
This sample programme is aimed to include core stability exercises that emphasise both the transversus and multifidus, and dynamic exercises for the low back, hips and stomach areas. These exercises have been grouped so that the most basic are performed in level one and then, once core stability and strength are improved, more complex and demanding exercises are introduced into the programme.
1Walters, P. 'Back to basics.' Health and Fitness Journal, 4(4), 19-25.(2000)