Complete rest is never a fix

 

While eliminating what triggers your pain for a few weeks will likely decrease your symptoms, it is never a final solution. Chances are the pain will eventually return because you never addressed why the problem started in the first place.

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Eliminating the movement, posture or load that causes your pain is only half of the battle in fixing any injury. Anyone can tell you to stop doing something that hurts. Eliminating symptoms and building your body to become more resilient to future injury requires a different and more active approach.

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What is core stability?

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The muscles that surround our spine are considered the “core” of our body. It is composed of the abdominal muscles on your front and sides, the erector muscles of the back and even the larger muscles that span multiple joints (like the lats and psoas muscles). It may surprise you that the glutes are also an important part of the ‘core’.

 

Each and every one of these muscles must work together in order to enhance the stability of the spine. But what really is ‘stability’?

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Spinal stability is something Professor McGill has been able to define and measure with his work. First, when muscles contract they create force and stiffness. It is the stiffness part that is important for stability. Think of the spine as a flexible rod that needs to be stiffened to bear load. This is the role of the muscles. Through his research, he has measured athletes who fail to obtain appropriate muscular stiffness around the spine by coordinating muscle activation, and their subsequent injuries and pain.

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When the core fails to meet the stability demands placed on the body during a certain lift or sustained posture, parts of the spine will be overloaded with forces that increase injury risk and performance will suffer.

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In his years of studying the spine, Dr. McGill has found there to be three specific exercises that most efficiently address all of these areas without placing excessive stresses on the parts of the back that may be aggravated or irritated due to injury. This group of exercises has famously become known as ‘The Big 3.’

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• Curl-Up

• Side Bridge

• Bird-Dog

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Another mobility movement Dr. McGill recommends you perform before the Big 3 to reduces low back stiffness and improve motion of the spine is a ‘Cat-Camel.’ Unlike other stretches for the low back that can place harmful stresses on the spine, this exercise emphases mobility in a very spine-friendly manner.

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Curl-up

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A way we can still hone in and focus our attention to improving the stabilizing ability of the anterior core muscles in a more efficient way is to perform a modified curl up.

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Step 1: Lie on your back with one knee bent and the other straight. If you currently have pain that radiates down one leg, flatten that leg out against the ground. Place your hands under your low back (this will ensure your spine remains in a neutral slightly arched position during the next step).

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Step 2: Pick your head off the ground only a few inches and hold that position for 10 seconds. If you’re resting your head on a pillow, imagine it as a scale and lift your head off of it only enough to make it read “zero” on the dial or screen. The goal is to perform this curl-up without any movement in the low back! If you raise your head and shoulders too high (like a traditional curl-up or crunch) your low back will round and excessive forces will be transferred to the spine that could increase your symptoms.

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Step 3: After a 10 second hold, relax your head back down to the resting position.

You can progress this exercise and increase the difficulty by bracing your abs before moving you head or raise your elbows from the ground to decrease your base of stability.

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Side bridge

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After addressing the anterior core muscles, let’s now move to the sides of the body. The side plank is a unique exercise as it activates the lateral oblique and QL muscles on only one side of the body, making it an excellent choice for addressing weak links in stability while placing minimal forces on the spine.  It also engages an important stabilizer of the hip/pelvis on the lateral hip (the glute medius).

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Step 1:  Lie on your side with your legs bent and upper body supported through your elbow. Place your free hand on your opposite shoulder.

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Step 2:  Raise your hips so that only your knee and arm support your bodyweight.

 

Step 3:  Hold this position for 10 seconds before returning back down. Perform the same descending pyramid rep-scheme for each side.

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Bird-dog

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The last of the McGill ‘Big Three’ is the bird dog. This is an excellent exercise to promote a stable core while movement occurs at surrounding joints (either the legs or arms and legs together). The combination of movement occurring at the hips and shoulders while the low back remains stable allows this exercise to have excellent carry over to movements you perform throughout your day and in the weight room.

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Step 1:  Assume an ‘All 4’s’ position (quadruped) with your back in a neutral alignment. Remember a ‘neutral’ position is a very slight arch and not completely flat.

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Step 2:  Without allowing any movement to occur at the low back, kick one of your legs backwards while simultaneously raising the opposite side arm until both extremities are fully straightened. A helpful cue to make sure the leg movement doesn’t create an over-arching of your back is to think about kicking the heel of your foot straight back. Making a fist and contracting your arm muscles as you hold it in the extended position can also increase muscle activity of the core (especially of the erector spinae muscles).

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If you are unable to perform the arm and leg movement together without pain or it is too difficult without losing balance, try the modified version with only leg movement.

 

Step 3:  Hold each extended pose for 10 seconds before retuning back to the starting All 4’s position. You can also ‘sweep’ your arm and leg back underneath your body in between each repetition. Don’t let your back round during this motion but instead maintain the neutral spine position and allow the motion to only occur from the hips and shoulders! Again, perform the same descending rep-scheme as the previous two exercises.

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How many repetitions to perform?

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Unlike training for pure strength or power, the endurance component of stability requires the body to perform many repetitions of an exercise in order to see improvements. Dr. McGill advocates for using a descending pyramid rep scheme with 10-second isometric holds in order to enhance stability without fatiguing and over-working the body.

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An example program would be to perform five reps, then three, and finally one to end (each with an 8-10 second hold). Rest between each set for 20-30 seconds. As this rep scheme becomes easier, it is recommended to increase the amount of repetitions rather than the duration of the holds in order to build endurance without causing muscle cramping. This can be freely modified to suit your current individual level of endurance and goals (for instance using a 6-4-2 or 8-6-4 rep scheme).

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Re-Awaken those Sleeping Glutes!

It is common to see patients with back pain also have an inability to properly activate and coordinate their glute muscles. Simply put, the buttock muscles can fall asleep. When this happens the body naturally starts to use the hamstrings and low back muscles more to create hip extension (both are problematic in creating efficient movement and place excessive stress on the spine).

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Glute bridge

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Step 1:  Lie on your back with your knees bent as shown.

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Step 2:  Squeeze your butt muscles FIRST and THEN lift your hips from the ground. Picking your toes up and driving your heels into the ground can help increase your glute activation during this part of the movement. Squeeze your glutes as hard as you can in this bridge position for 5 full seconds before relaxing back to the ground.

 

If you find your hamstrings cramp during this motion, bring your heels closer to your hips. This shortens the length of the hamstrings and gives puts them at a disadvantage to contribute to the movement (a concept called active insufficiency).

 

Recommended sets/reps: 2 sets of 20 for a 5 second hold. Eventually work your way up to 10-second hold.

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Deep Squat With Isometric Hold

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Step 1:  Hold a weight in front of your body and perform a deep goblet squat.

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Step 2:  Brace your core in this bottom position and drive your knees to the side while keeping your foot in an arched position (this should turn on the outside of your hips or glute medius muscle.)

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Step 3:  Rise a few inches and squeeze your glutes like crazy. Hold this for 5 seconds before sinking back down. This translates the glute activation from the previous exercise into something functional that mimics your squat technique. This should only be attempted if you can perform it without any back pain.

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Recommended sets/reps: 1-2 sets of 5 for 5 second holds

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Final thoughts

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We hope that this brief article was able to give you a better understanding of proper core stability training and how to perform the ‘Big 3.’ We recommend using these exercises not only as a foundation for your rehabilitation from back pain but also as a part of your weekly training program to prevent future injury once your symptoms have resolved.

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The combination of these exercises should be safely performed daily if you are trying to recover from back injury but should not be performed directly after rising from bed in the morning (that is the time at which the discs of your spine are most hydrated and prone to injury).

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The last thing Dr. McGill recommends to couple with the “Big 3” exercises is a regimented walking program. Getting up and walking throughout you day can be extremely helpful in maintaining the health of your spine. Start with smaller bouts of walking (5-10 minutes at first with a fast pace that causes you to swing your arms). The goal should be to eventually reach a 10-minute walk three times a day.

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References

1. McGill SM. Ultimate Back Fitness and Performance (4thed). Waterloo, Canada: Backfitpro Inc, 2009. (www.backfitpro.com)

2. McGill, SM. Back Mechanic: The step by step McGill Method to fix back pain. Backfitpro Inc. 2015 (www.backfitpro.com)

3. McGill SM. Core training: evidence translating to better performance and injury prevention. Strength and Conditioning Journal. 2010; 32(3): 33-46

4. McGill SM. Grenier S, Bluhm M, Preuss R, et al. Previous history of LBP with work loss is related to lingering effects in biomechanical physiological, personal, and psychosocial characteristics. Ergonomics. 2003;46:731-746

5. Indahl A, Kaigle A, Reikeras O, Holm S. Electromyographic response of the porcine multifidus musculature after nerve stimulation. Spine. 1995;20(24):2652-8

6. Cohen SP & Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007;106:591-614

7. Durall CJ, Udermann BE, Johansen DR, et al. The effect of preseason trunk muscle training of low back pain occurrence in women collegiate gymnastics. J Strength Cond Res. 2009;23:86-92

8. Lee BC, McGill SM. Effect of long-term isometric training on core/torso stiffness. JSCR. 215;29(6):1515-1526

9. Cholewicki J, McGill SM, and Norman RW. Lumbar spine loads during lifting of extremely heavy weights. Med Sci Sports Exerc. 1991;23:1179-1186

10. McGill SM, Cholewicki J. Biomechanical basis for stability: an explanation to enhance clinical utility. JOSPT. 2001;31(2):96-100

11. McGill SM. Stability: from biomechanical concept to chiropractic practice. J Can Chiropr Assoc. 1999;43(2)

12. Boren K, Conrey C, Le Coguic, et al. Electromyographic analysis of gluteus medius and gluteus maximus during rehabilitation exericses. Int J Sports Phys Ther. 2011;6(3):206-223

13. McGill SM. Low Back Disorders: Eevidence Based Prevention and Rehabilitation(2nd ed). Champaign, IL: Human Kinetics Publishers, 2007.

14. Olfat M, Perry J, Hislop H. Relationship between wire EMG activity, muscle length, and torque of the hamstrings. Clin Biomec. 2002;17(8):569-579

15. Grenier SG, McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Rehabil. 2007;88(1):54-62

16. Juker D, McGill SM, Kropf P, Steffen T. Quantitative intramuscular myoelectric activity of lumbar portions of psoas and the abdominal wall during a wide variety of tasks. Mec Sci Sports Exerc. 1998;30:301-310

17. McGill SM. The mechanics of torso flexion: sit-ups and standing dynamic flexion maneuvers. Clinical Biomechanics. 1995;10:184-192