Most Effective Exercises for Low Back Pain

This question came to us via Facebook. The response is a bit too long for FB, so here is the response…
Beyond developing a strong core, which exercises are most effective for strengthening an injury-prone lower back?

BTW, it has been awhile, but out of sight is not out of mind! Always grateful for the excellent, expert care you have given… Straightening out my sideways…to keep me in the classroom and gym!

Great question.  The ideas of “core stability” and a “strong core” have been widely misinterpreted and abused and thus have come under great scrutiny lately (see here, here and here).  I think the idea of “the core” is highly misunderstood and is confusing for many people for a number of reasons:

  1. First of all, how do we define “the core”.  Does it include the gluteal muscles, the diaphragm (a very important muscle for lifting), multifidus, the psoas and other hip flexors, the hamstrings (they do attach to the pelvis)? There are many different interpretations.
  2. It has been misinterpreted that “pulling in the belly”, bracing before movement and/or doing a lot of sit ups and variations of the plank will create “core stability”.  I think this has succeeded in making people think they need to become more rigid and stiff when they move, which would be detrimental.
  3. Many trainers and fitness gurus have taken to training abdominal and low back muscles individually instead of as a group.

So back to your question regarding which exercises are most effective for an injury prone back…

Unfortunately, it’s a seemingly simple question without a simple answer, other than the answer of, “Whatever is appropriate for you.”  I hope this doesn’t seem like a cop out answer.  Let me explain.

There is no one cause of low back pain.  It may be biomechanical irritation, spinal stenosis, discs, arthritis, referral from another organ, muscular, cognitive and many others.  The appropriate exercise rests on what the source is.  For example, in someone with pain from a disc, we generally want to avoid compression initially.  Therefore, exercises which cause a lot of compression such as deadlifts may not be a good idea for those people.  On the other hand, many people have great fear about their low back pain despite an absence of significant structural pathology.  Those people need to be taught that hurt does not equal harm and they need more cognitive therapy where we reassure them that they will be OK and gradually expose them to more and more spinal loading as they realize they won’t get hurt. Ultimately, this may include a lot of deadlifting.  In other words, exercises that will be great for one group may not be for another.  Some people have poor control and/or mobility with rotation, some people have poor control with sagittal plane movements.  Some people are exposed to heavy squatting when they can’t control a squat properly because they have really bad mobility in their ankles.  The causes are multifactorial.

My point is, we are all individuals needing individual evaluation and then we need to address these issues.  Often it’s biomechanically based, but it is also very often cognitively based.

Patients sometimes get upset when we talk about cognitive issues with low back pain.  We must understand that this doesn’t mean patients are “making it up”.  I frequently hear from patients that they have been told by another healthcare provider that they should avoid certain exercises or activities because they basically were deemed to have a fragile spine.  This ultimately does more harm than good.  It has been shown over and over again that “catastrophizing” a patient’s pain ends up causing the patient to actually feel more pain (here, here, here and here).

Essentially, the spine can be thought of as a movement system in 3 dimensions.  Within that system are a variety of mechanisms that control intra-abdominal pressure, timing, mobility and stability.  What we want to avoid is the idea that the back is fragile, or that you need to be rigid and stiff in order to avoid flare-ups.

I think the key is variety;  Do a variety of different exercises and challenge your body in different ways.