Enhancing Low Back Health through stabilization exercise

Stuart M. McGill, Professor (Spine Biomechanics), University of Waterloo

Note: Dr McGill has recently authored the text book “Low Back Disorders:
Evidence based prevention and rehabilitation” published by Human Kinetics
publishers, (www.humankinetics.com), 2002, ISBN 0-7360-4241-5. This textbook
synthesizes the material introduced here and is recommended as much more
complete and authoritative resource material.
Background Perspective:

Appropriate exercise design for the low back cannot be achieved with pamphlets showing
suggested exercises. Some people with a history of back troubles desire pain relief and spine
stability (a health objective) while others may seek a performance objective (which may be
counterproductive to optimal back health). Some people need more stability while others may
need more mobility. Some exercises will exacerbate the back troubles of some people but the
same exercises may help others. Because each individual has different needs, various
assessment approaches can be utilized to aid in subsequent decisions for exercise design.
Further, proficient exercise professionals will need an understanding of the issues, and of the
myths and realities pertaining to each issue to form a foundation for the decision process.
Obviously assessment tools and the many issues cannot be discussed in this short article. The
focus here is to briefly introduce just a few selected issues followed with an example of a
quantified and evidence based exercise program.

Rather than provide thin background material that will not be robust enough to assist the
exercise design process (the book is necessary to serve that purpose) I have decided to offer
some initial food for thought. There is no shortage of manuals and books offering wisdom on the
topic of low back health. The authors of these have a wide spectrum of backgrounds, ranging
from formal medical or rehabilitation training through to lay people who found an approach to
alleviate their own back troubles and have become self-proclaimed prophets “believing” that
others will benefit. Their intentions are honorable but their advice is rarely based on a sound
scientific foundation. In my opinion, too many of these books offer inappropriate
recommendations or even harmful suggestions. Years ago, as I began to develop our scientific
investigations into various aspects of understanding low back problems, I would ask my graduate
students to find the scientific foundation for many of the "common sense" recommendations I was
hearing both in the clinic and in industrial settings. To my surprise, they would report that the
literature yielded no, or very thin, evidence.

Examples of such "common sense" recommendations include -- if you are to perform a

It is widely believed that stretching the back, and increasing the range of motion is
beneficial, and reduces back problems – however the scientific evidence shows that, on average,
those who have more range of motion in their backs have a greater risk of future troubles. Clearly
there is a tradeoff between mobility and stability where the optimal balance is a very personal and
individual variable. Indeed, the “stability/mobility balance” may shift during a progressive exercise
program as symptoms resolve, or with advancing age, or as rehab/training objectives change.
Another generally perceived goal of training the back is to increase strength, believing in the “no
pain-no gain” philosophy. Strength has little association with low back health, in fact, many hurt
their backs in an attempt to increase strength. It could be argued that this is an artifact, in that
exercise programs intended to enhance strength contained poorly chosen exercises such as sit-

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ups. Performing situps both replicates a potent injury mechanism (specifically posterior disc
herniation) and results in high loads on the spine. On the other hand, muscle endurance, as
opposed to strength, has been shown to be protective for future troubles. Further, for many,
it is better to train for stability rather than stretching to increase range of motion.

Recent investigations into injury mechanisms have revealed that many back training
practices actually replicate the loads and motions that cause the parts of the low back to become
injured. For example, disc herniations need not have excessive loading on the back to occur,
rather repeated forward flexion motion of the spine is a more potent mechanism. Thus, if full
flexion or deviation is avoided in the spine, the risk of herniation is remote. But for most exercise
professionals the link between injury and exercise needs to be better developed. Injury is caused
by damage to supporting tissues. This damage reduces the normal stiffness in the spine resulting
in unstable joints. Thus, while injury results in joint instability, an event characterized by improper
muscle activation can cause the spine to buckle, or become unstable. There is no question that
excessive loading can lead to back injury, but instability at low loads is also possible and
problematic. For example, it is possible to damage the passive tissues of the back while bending
down and picking up a pencil, or sneezing, if sufficient stability is not maintained. Some people
recommend that during training, one should exhale upon exertion (when weight training for
example, exhaling upon the lifting phase and inhaling on the lowering). In terms of grooving
stabilizing motor patterns for all tasks, this is a mistake. In other words, breathing in and out
should occur continuously, and not be trained to a specific exertion effort – this helps to
maintain constant abdominal muscle activation and ensure spine stability during all
possible situations (of course the opposite is true for maximal effort competitive lifting
where a valsalva manoeuvre with the breathe held is necessary – but performance training
is not the emphasis here). Further, specific muscle activation patterns are essential to avoid
injury but have also been documented to become perturbed following injury. Pain is a powerful
instigator in the deprogramming of normal/healthy motor patterns into perturbed patterns. The
exercises and programs described here are based on the latest scientific knowledge of how the
spine works, and becomes injured. In addition, they have been quantified for spine load, resultant
spine stability, and muscle oxygenation, to name a few. These are only a few examples to begin
a program. The goals are to enhance spine stability through grooving motion and muscle
activation patterns to prepare for all types of challenges. Of course, other exercises may be
required subsequently to enhance daily functioning, but once again, these will depend upon the
characteristics and objectives of the individual.

Two other concepts must be emphasized at this point. First, training approaches intended
to enhance athletic performance are often counterproductive to the approaches used when
training for health. Too many patients are rehabilitated using athletic philosophies, or worse yet
“body building” approaches designed primarily to isolate and hypertrophy specific muscles, and in
so doing thwart progress. Many bad backs are created from using inappropriate performance
philosophies. Identifying the training objectives is paramount. The emphasis here is on enhancing
spine health – training for performance is another topic. Second, many of the training approaches
that are used at joints such as the knee, hip, shoulder etc are mistakenly applied for the back.
The back is a very different, and complex structure, involving a flexible column, with complex
muscle and ligamentous support. The spine contains the spinal cord and lateral nerve roots, and
whose musculature is intimately involved in several other functions including breathing
mechanics, to give just one example. Many of the traditional approaches for training other
joints in the body are not appropriate for the back – either they do not produce the desired
result or they create new patients.

A daily routine for enhancing low back health

The following exercises have been chosen to spare the spine, enhance the muscle
challenge, and enhance the motor control system to ensure that spine stability is maintained in all
other activities. Each one has been quantified for these metrics. Having stated this, they are only

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examples of well designed exercises and may not be for everyone – the initial challenge may or
may not be appropriate for an individual nor will the graded progression be similar among all
people. These are simply examples to challenge all of these torso muscles.

Cat-Camel:

We recommend that the routine begin with the cat-camel motion exercise (spine flexion-
extension cycles) to reduce spine viscosity (internal resistance and friction) and “floss” the nerve
roots as they outlet at each lumbar level, followed by hip and knee mobility exercises. Note that
the cat-camel is intended as a motion exercise - not a stretch, so the emphasis is on motion
rather than “pushing” at the end ranges of flexion and extension. We have found that 5-8 cycles
is often sufficient to reduce most viscous-frictional stresses.

The cat and camel exercise is a motion exercise and not a stretch. Good form includes the
integration of the cervical spine with the lumbar and thoracic spine. All three sections of the
spine should be flexed and extended together.

Curl-up:

The cat-camel motion exercise is followed by anterior abdominal exercises, in this case
the curl-up. The hands are placed under the lumbar spine to preserve a neutral spine posture. Do
not flatten the back to the floor. Flattening the back flexes the lumbar spine, violates the neutral
spine principle, and increases the loads on the disc and ligaments. One knee is flexed but the
other leg is straight to lock the pelvis-lumbar spine and minimize the loss of a neutral lumbar
posture. Alternate the bent leg (right to left) midway through the repetitions.

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 The curl-up is performed by raising the head and the upper shoulders off the floor. The motion
takes place in the thoracic spine – not the lumbar or cervical region. To begin, the hands are
placed under the lumbar region to support a neutral curvature. The exercise is made more
challenging by raising the elbows off the floor. Even more challenging is first performing an
abdominal brace (activating the abdominal muscles), and then curling up against the brace. Hold
the posture for 7-8 seconds. Do not hold the breath but breath deeply. Do not increase the
challenge by increasing the intensity of the abdominal brace. This will groove desirable motor
patterns. Choose the most appropriate level of challenge.

Side Bridge:

Lateral and abdominal muscles (called quadratus lumborum, and the abdominal
obliques) are important for optimal stability, and are targeted with the side bridge exercise. The
beginners level of this exercise involves bridging the torso between the elbow and the knees.
Once this is mastered, and tolerated, the challenge is increased by bridging using the elbow and
the feet. Advanced variations involve placing the upper leg-foot in front of the lower leg-foot to
facilitate longitudinal “rolling” of the torso (see figure) to challenge both anterior and posterior
portions of the wall, and further groove stabilizing patterns which are transferable to upright tasks.
These are superior exercises in terms of muscle activation, low spine load, and stabilizing
patterns compared to exercises such as performing a sit-up with a twist, for example, that
produce lower muscle activity levels and higher tissue loads.

The beginners side bridge is performed with support from the elbow and knees (left panel) while the more
advanced variation using the elbow and feet is shown in the right panel. Maintain the abdominal brace, a
neutral spine and breath deeply.

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An advanced level side bridge involves holding the posture on one side for 7-8 seconds and the “rolling”
over to the other, and repeating as endurance is increased. It is critical to lock the pelvis to the rib cage, via
an abdominal brace, so that the spine remains rigid during the rolling. Finally, add deep breathing while in
this posture. The rolling action with the breathing will prepare many people to meet any challenge with a
stable spine .

Birddog:

The extensor program consists of leg extensions and the “birddog”. In general, we
recommend that these isometric holds be held no longer than 7-8 seconds given recent evidence
from near infrared spectroscopy indicating rapid loss of available oxygen in the torso muscles
contracting at these levels - short relaxation of the muscle restores oxygen. The evidence
supports building endurance with increased repetitions rather than holding time.

The back extensors (both the lumbar and thoracic are important) are challenged with the birddog.
But only one half of these muscles are challenged at a time by lifting the alternate arm and leg.
This reduces the spine load to about a half of that produced during traditional spine extension
exercises such as roman chair extensions. Begin on the hands and knees and hold the posture
for 7-8 seconds. Then lower the hand and knee, and “sweep” the floor with them and raise them
again for the next repetition. This motion will enhance the stabilizing patterns. Switch sides as
appropriate. The abdominal muscle are braced 5 throughout.
Caveats for Exercise

1. While there is a common belief among some Aexperts@ that exercise sessions should be
performed at least 3 times per week, it appears low back exercises have the most
beneficial effect when performed daily.
2. The Ano pain-no gain@ axiom does not apply when exercising the low back in pained
individuals particularly when applied to weight training, and scientific and clinical wisdom
would suggest the opposite is true.
3. While specific low back exercises have been rationalized in this guide, general exercise
programs that also combine cardiovascular components (like walking) have been shown
to be more effective in both rehabilitation and for injury prevention. The exercises shown
here only comprise a component of the total program.
4. Diurnal variation in the fluid level of the intervertebral discs (discs are more hydrated
early in the morning after rising from bed), changes the stresses on the disc throughout
the day. Specifically, they are highest following bedrest and diminish over the
subsequent few hours. It would be very unwise to perform full range spine motion while
under load, shortly after rising from bed.
5. Low back exercises performed for maintenance of health need not emphasize strength,
with high-load low repetition tasks, rather more repetitions of less demanding exercises
will assist in the enhancement of endurance and strength. There is no doubt that back
injury can occur during seemingly low level demands (such as picking up a pencil) and
that the risk of injury from motor control error can occur. While it appears that the chance
of motor control errors, resulting in inappropriate muscle forces, increase with fatigue
there is also evidence documenting the changes in passive tissue loading with fatiguing
lifting. Given that endurance has more protective value than strength, strength gains
should not be overemphasized at the expense of endurance.
6. There is no such thing as an ideal set of exercises for all individuals. An individuals=
training objectives must be identified, (be they rehabilitation, specifically to reduce the risk
of injury, optimize general health and fitness, or maximize athletic performance), and the
most appropriate exercises chosen. While science cannot evaluate the optimal exercises
for each situation, the combination of science and clinical experiential Awisdom@ must be
utilized to enhance low back health.
7. Be patient and stick with the program. Increased function and reduction pain may not
occur for 3 months.

References for the fitness leaders

Andersson, G.B. (1991) The epidemiology of spinal disorders. In: J.W. Frymoyer (ed)., The Adult
Spine: Principles and Practice. Ch. 8. New York: Raven Press Ltd.

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Axler*, C. and McGill, S.M. (1997). Low back loads over a variety of abdominal exercises:
Searching for the safest abdominal challenge, Med.Sci.Sports.Ex. 29(6): 804-
811.

Biering-Sorensen, F. (1984) Physical measurements as risk indicators for low-back trouble over a
one-year period. Spine 9: 106-119.

Burton, A.K. (1997) Spine Update: Back injury and work loss. Biomechanical and psychosocial
influences. Spine 22: 2575-2580.

Callaghan*, J.P., Gunning, J.L., McGill, S.M. (1998). Relationship between lumbar spine load
and muscle activity during extensor exercises. Physical Therapy 78(1): 8-18

Callaghan*, J.P., Patla, A.E., and McGill, S.M. (1999) Low back three-dimensional joint forces,
kinematics and kinetics during walking. Clin. Biomech. 14: 203-216.

Callaghan*, J.P., and McGill, S.M. (2001) Intervertebral disc herniation: Studies on a porcine
model exposed to highly repetitive flexion/extension motion with compressive
force. Clin. Biom. 16(1): 28-37.

Cholewicki, J., McGill, S.M. (1996) Mechanical stability of the in vivo lumbar spine: Implications
for injury and chronic low back pain. Clin. Biomech. 11(1): 1-15.

Ferguson, S.A., Marras, W.S. (1997) A literature review of low back disorder surveillance
measures and risk factors. Clin. Biomech. 12(4): 211-226.

Hodges, P.W., Richardson, C.A. (1996) Inefficient muscular stabilization of the lumbar spine
associated with low back pain. Spine 21: 2640-2650.

Juker, D., McGill, S.M., Kropf, P., Steffen, T. (1998). Quantitative intramuscular myoelectric
activity of lumbar portions of psoas and the abdominal wall during a wide variety
of tasks. Med. Sci. Sports Ex. 30(2):301-310.

Kirkaldy-Willis, W.H. (1998) The three phases of the spectrum of degenerative disease. In:
Managing Low Back Pain, second edition. Churchill-Livingston, New York.

Luoto, S., Helioraara, M., Hurri, H., Alavanta, M. (1995) Static back endurance and the risk of low
back pain. Clin. Biomech. 10: 323-324.

McGill, S.M., Sharratt, M.T., Seguin, J.P. (1995) Loads on spinal tissues during simultaneous
lifting and ventilatory challenge. Ergonomics 38: 1772-1792.

McGill, S.M. (1997) The biomechanics of low back injury: Implications on current practice in
industry and the clinic. J. Biomech. 30: 465-475.

McGill, S.M., Childs, A. Liebenson, C. (1999) Endurance times for stabilization exercises: Clinical
targets for testing and training from a normal database. Arch. Phys. Med. Rehab. 80: 941-944.

McGill, S.M. Invited Paper. (1998) Low back exercises: Evidence for improving exercise
regimens. Physical Therapy 78(7): 754-765.

McGill, S.M., and Cholewicki, J. (2001) Biomechanical basis for stability: An explanation to
enhance clinical ability. J. Orthop. Sports Phys. Ther. 31(2): 96-100.

McGill, S.M., Low Back Disorders: Evidence based prevention and rehabilitation, Human Kinetics
Publishers, Champaign, Illinois, 2002.

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Saal, J.A., Saal, J.S. (1989) Nonoperative treatment of herniated lumbar intervertebral disc with
radiculopathy: An outcome study. J. Biomech. 14: 431-437.

Vera-Garcia, F.J., Grenier, S.G. and McGill, S.M. (2000) Abdominal response during curl-ups on
both stable and labile surfaces. Phys. Ther. 80(6): 564-569.

About the Author

Dr Stuart McGill is a professor at the University of Waterloo and a world renown lecturer and
expert in spine function and injury prevention and rehabilitation. He has been the author of over
200 scientific publications that address the issues of lumbar function, low back injury
mechanisms, investigation of tissue loading during rehabilitation programs, and the formulation of
work -related injury avoidance strategies. This work has received several awards including the
Volvo Bioengineering Award for Low Back Pain Research from Sweden. He has been an invited
lecturer at many Universities, and delivered over 150 invited addresses to various societies
around the world. As a consultant to industry, he has provided expertise on assessment and
reduction of the risk of low back injury to various government agencies, several corporations,
professional athletes and teams, and many legal firms.