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Introduction

This is not an academic paper. It is meant to be readable and easily digestible. The goal is for you, the reader, to learn new movements which may be helpful for a new or old back injury. This article is completely unable to address all the factors that contribute to and prolong back pain. It would also be a potential disservice to the academic body of work.

If you feel like parts of this article resonate with you and help you reclaim the physical activities you enjoy then that is fantastic! If they do not help, this does not mean you cannot get better. It means you likely need to address OTHER factors or barriers; factors or barriers that are mentioned but are outside the scope of this article series. I encourage you to find a local health professional to help you identify any barriers or factors relevant to you, followed by a thorough plan, orientated to your physical activity goals.

This article series will not provide the means from which you can diagnose yourself. This article series will help you find an entry point to start from the ground up in restoring the skill of using your lower back. Some of the components that make up this skill are flexibility, strength and their combined mobility. These components are but a piece of the pie (albeit in some a large piece) in the contributors to back pain. As such, the information in this series is meant to be informative and hopefully stimulate some exploration. What started as needing to provide clients with exercise videos has grown into the early stages of a progression/regression framework for exercises. Below is the lower back portion!

SO where do we start?

Back pain is the number one cause of disability globally (1). Do we know what is causing the pain? It is hard to say as there can be many different causes for each case. Lower back pain (LBP) is a symptom; not a diagnosis (2). This means that many things can CAUSE lower back pain. That being said, if you have bilateral pain (down both legs), leg weakness, pins and needles at the leg or saddle region, bowel or urinary changes, loss of sensation or function in the genitals then please go directly to your regular health provider for guidance and an assessment (3).

In most cases, there is strong evidence that LBP will significantly improve within <6 weeks of injury (1). However many will report ongoing low level pain for up to 12 months (1). What other factors could be contributing to ongoing pain?

This may be reflected upon within a biopsychosocial framework which includes, pathoanatomical, biological, psychological and social environments (1). What this means is you could have injured tissue that needs to heal and be rehabbed (4). Alternatively, you may have thoughts around movements that stop you from doing the movements; this can correlate with back pain (5). A movement is only bad if you are unprepared for it! Lastly, your environment may contribute to your lower back issue. This could be from your home, work, cultural or social environments. These environments can influence beliefs about back pain or influence how you use your back throughout the activities you perform (5).

Sometimes the issue is structural. Sometimes it's your environment. Sometimes it's an illness. Sometimes how you think about things is associated with back pain. Somethings you are not prepared for the task you are doing. Ultimately, it is usually a unique combination of these factors for each individual and thus each individual will need an individualised approach.

What is a potential solution?

Physical activity reigns King (so far). It has been shown to reduce lower back pain and reduce activity limitations over advice (i.e. just talking about it), a wait and see approach and many other therapies (6-8). This means you’re better off making sure you try some physical activity before trying anything else. Go for the low hanging fruit.

“Nothing happens until something moves” - Albert Einstein

For me, the above quote is simple and obvious. Even at the most micro of layers there must be movement. Something must happen.

So what type of physical activity then? Physical activity can be anything that is movement by your muscles and requires energy. Most choose exercise. There has been debate about general exercise prescription vs. specific prescription. While, we won’t get into nuances of the debate, there is evidence supporting that BOTH are effective at improving lower back pain and reducing activity limitations, particularly in the long term (6–8). More importantly, what you attend to and enjoy as an activity may be the most beneficial (9). As such, the exercises in this series will be mixed in what they ask of you. Some are specific, some are general. The theme is to create familiarity with movement in a direction that is difficult for you, and over time gradually load this movement so you develop the skills of control, strength and endurance.

Typically, on average 15-16 sessions are needed to see a significant effect on your symptoms (6). This means doing the exercises 15-16 different days! Potentially over 2-4 months. Enter exercise prescription. Many overdo it. Many under do it. Just as many, likely do enough! So how much should you do?

Generally, the World Health Organisation recommends 2x sessions of strengthening sessions per week, 150 minutes of moderate aerobic activity and in their most recent 2020 update, exercises that challenge your balance. If you want to read more into the specifics of these guidelines, check out our article here.

So let’s get into some easy to follow guidelines for the type of training we are going to talk about in this article series. These will be something you keep in mind as you browse and attempt exercises that interest you!

What should I do then?

Please consider that each of those topics below have entire textbooks written about them! We will only be skimming the surface with some general principles.

Environment (10,11):

1. Choose an environment you enjoy.

2. Choose an environment that matches your social and cultural values.

3. Choose an environment that encourages independence with exercise. An environment that guides from the side.

4. Choose an environment that is accessible and nearby to home.

5. Choose an environment that does not break the bank. You don’t need to spend money to get active. You need to spend time.

Skill development (9):

1. When possible focus on the task at hand, not your body parts. For example, when squatting, think about pushing the ground away from you (task), versus thinking about straightening your knees (body parts). This enhances motor learning. You will learn faster.

2. Try to do tasks on your own, but with support. This can be in the form of a physio or someone you know providing feedback about your task objective. You might ask, did I do the goals from the video? Look for a summary of your performance.

3. Have 1 task-goal per set.

4. The task must be challenging but achievable. Either you have to think about what you’re doing or it feels effortful or it is challenging to balance.

5. What you expect is important. Think about the satisfaction of being competent in something. This will enhance learning and potentially breed further success.

6. You must choose to do it. But, collaboration helps.

7. Respect your skill level. Rome wasn’t built in a day.

8. If you think about yourself during the task this will likely reduce performance and learning opportunities.

Resistance training (12):

Hypertrophy (make a muscle bigger):

1. Go to fatigue. Not task failure. It doesn’t matter if it is 5 reps or 50 reps. Just go to fatigue.

2. Go a slow to moderate pace.

3. Perform the technique as intended. If you deviate you are only fatiguing other muscles.

4. Minimise exhaustive cardio.

5. Get adequate rest i.e. 48-72 hours.

6. Some muscles may require multiple exercises as they have different functional units. Basically some muscles can do singular movements well, some can do multiple. Train accordingly.

Strength (is specific) (13):

1. Be specific with your workouts. If you want a stronger back, do exercises that challenge your back strength. If you want to be better at bending forward and getting back up again, you must do exactly this.

2. Choose a variety of exercises. This is least important. Just here to keep things fresh.

3. Progressively overload. Progressively overload.

4. This won’t be linear. Everyone progresses at different rates for different reasons. However, if you are new to training, then it will likely be faster.

5. Use heavy weights/loads to get strong. This will be different for everyone. 5kg for you may be extremely heavy in an exercise; while someone else may need 10kg.

6. Full range is not always necessary for strength gains.

7. Work at a 7-8 on the RPE scale. Read more about this here.

Conclusion:

Lower back pain is very common. It is associated with loss of physical function. There are many causes to it. Each combination of causes for each individual will require different approaches. Most acute back pain resolves significantly within 6 weeks. Most back pain reduces with physical activity. Physical activity can be anything you enjoy that involves movement and energy. This can be specific or general exercise. Resistance training is recommended by the World Health Organisation. Today we outlined some general principles to follow depending on your goals. Next week we will discuss forwards and backwards based lower back movements so that you may start implementing the general principles.

Enjoy!

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References

1. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. The Lancet. 2018 Jun;391(10137):2356–67.

2. Cook CE, George SZ, Reiman MP. Red flag screening for low back pain: nothing to see here, move along: a narrative review. Br J Sports Med. 2018 Apr;52(8):493–6.

3. Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020 Jul;50(7):350–72.

4. Ford JJ, Hahne AJ. Pathoanatomy and classification of low back disorders. Manual Therapy. 2013 Apr;18(2):165–8.

5. Darlow B. Beliefs about back pain: The confluence of client, clinician and community. International Journal of Osteopathic Medicine. 2016 Jun 1;20:53–61.

6. Ford JJ, Bower SE, Ford I, de Mello MM, Carneiro SR, Balasundaram AP, et al. Effects of specific muscle activation for low back pain on activity limitation, pain, work participation, or recurrence: A systematic review. Musculoskelet Sci Pract. 2020 Dec;50:102276.

7. Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord. 2014 Dec;15(1):416.

8. Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H, et al. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. Br J Sports Med. 2020 Nov;54(21):1279–87.

9. Wulf G, Lewthwaite R. Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychon Bull Rev. 2016 Oct 1;23(5):1382–414.

10. McCormack GR, Shiell A. In search of causality: a systematic review of the relationship between the built environment and physical activity among adults. International Journal of Behavioral Nutrition and Physical Activity. 2011 Nov 13;8(1):125.

11. Sherwood NE, Jeffery RW. The Behavioral Determinants of Exercise: Implications for Physical Activity Interventions. Annu Rev Nutr. 2000 Jul;20(1):21–44.

12. Beardsley C. Hypertrophy: Muscle fiber growth caused by mechanical tension. 1st edition. Strength and Conditioning Research Limited; 2019. 351 p.

13. Beardsley C. Strength is Specific: The key to optimal strength training for sports. 1st edition. Strength and Conditioning Research Limited; 2018. 328 p.

Copyright Disclaimer - This article is protected by the Copyright Act 1994. The author controls the copyright of this article. Recognition of the author’s right to be identified as the author will be acknowledged and when relevant the author will be acknowledged as the author. You will obtain the author’s permission before publishing any material from this article. For further information you can reference the Act here: https://www.legislation.govt.nz/act/public/1994/0143/latest/whole.html

Part 1: What exercises do I choose for my lower back?