The following article will feature information from a number of sources, including but not limited to world renowned back pain researcher Dr. Stuart McGill. It will culminate with what we believe is one of the most effective basic programs for the average individual regarding back pain and rehabilitation. It is NOT intended to replace a consultation with a medical clinician / physical therapist, but hopefully some of the thinking in this article will get you on the right track. As always, we do recommend that you are medically cleared for exercise before implementing Dr. Stuart McGill’s Big 3 exercises for back pain into your daily routine. Without further ado:
Low back pain is fairly common – and increasing in prevalence
It seems that back pain is an almost universal experience in our current culture. It is well known that back pain is the sixth most costly condition in the United States. After some basic digging on the topic, I found a number of peer-reviewed studies discussing an increase in back pain’s prevalence in our society. One study in particular from 2009 discussed phone surveys of North Carolina households in 1992 which was repeated in 2006. The study found that the incidence of chronic back pain had risen dramatically, from 3.9% in 1992 to 10.2% in 2006. Keep in mind that this is only representing the individuals who were experiencing back pain at that moment. The New England Journal of Medicine notes that about two thirds of adults will experience chronic back pain at some point in their lives, and less than one third of those cases will resolve within a year.
Another fairly old article from 1989 had the following to say:
“There is not even any evidence that a symptom which affects most people at some point in their life is any more common in recent times. What is new is chronic low back disability due to simple backache. There were probably isolated cases in earlier times. But it only became a common problem in the nineteenth century and has increased dramatically since World War II.”
All this is to say that – if you’re experiencing a persistent or chronic back pain, it is fairly normal, common, and treatable. This leads to our first point on the topic:
The first step is to stop panicking!
As noted above, back pain is common. It is also extremely annoying and can make basic tasks difficult and cumbersome. One thing it doesn’t have to be, however, is fear inducing. We recommend you stop here and go back to Jeff Petersen’s Video on “Why Do We Experience Pain?” Note the discussion on the emotional nature of pain.
This 2017 study further illustrates that pain is deceptive:
- The study gave participants a standard dose of a pain stimulus and asked the participants to rate the pain they experienced from 0 (no pain) to 100 (the worst pain they’ve ever experienced).
- As you can see from the graph below, the respondents rated the pain for the SAME STIMULUS anywhere from 4/100 all the way to 100/100. The mean pain rating was 71.8:
- The point here is that pain is a highly individual experience – they found that genetic factors (gender, ethnic group, etc.) interacted with psychosocial factors (stress, pain catastrophizing) to produce a “perceived pain level” in the participants. This perceived pain level varied wildly and didn’t necessarily correspond with the severity of the actual stimulus.
It has been known for quite some time that if we don’t catastrophize our pain, the pain response lessens. It is often our beliefs, and our perception of threat that actually leads to the worsening of pain, not the physical harm itself.
But, you only get one spine, right?
While the above statement is true, it is also true that we only get one of many body parts. Think about it – you don’t panic every time you get a headache, do you? Well … you only get one head! If you get tendonitis in your elbow, most of us will simply rest the area and if it doesn’t get better, we’ll seek medical advice. But elbow tendonitis doesn’t carry the same perceived threat that low back pain does. We often believe that pain in or around our lumbar spine is going to lead to a cycle of suffering we may never recover from. The clinicians at Petersen Physical Therapy often help patients recover effectively from back pain or back injuries. They also note that this fear and catastrophizing about back pain is not only unnecessary, it is counterproductive and can actually make your pain worse. We recommend you relax and realize that the back is just another body part that may need some attention.
We are not saying that low back pain isn’t a big deal. Depending on the severity, it can range from a minor annoyance to a debilitating experience, and everything in between. We simply want to impress upon you that, like most other forms of pain, back pain is modifiable by manipulating risk factors and engaging in treatment.
The purpose of the Big 3
Dr. Stuart McGill, a world renowned Canadian spine researcher and specialist, has come up with what he calls the “Big 3” exercises for spinal stability. If you are unfamiliar with his work, Dr. McGill has made quite a name for himself in the strength and conditioning world by rehabilitating olympic level athletes and professional fighters. However, the bulk of his research pertains to the average individual. In his own words,
“The Big 3 came from experimentation converging on the very best exercises to address the mechanisms of pain.”
The purpose of these exercises is to create stiffness in the spine and torso. This includes the front of the spine, sides of the spine, and rear of the spine (you’ll find the exercises below follow this format). He also notes that doing the Big 3 is not a suitable replacement for an assessment. He believes that the first thing to do when rehabilitating back pain is to stop or modify the activity causing the pain. Note that it is impossible to precisely hone in on the activity causing your pain without a proper assessment.
What the Big 3 will do, however, is build stiffness in the spinal discs which are proximal to the joints doing the movement causing pain (hips, shoulders, etc). By strengthening the muscles around the spine we create a stable spine – where our limbs move around a stable spine instead of the spine flexing and bending with activity. McGill points out that the muscles of the core are designed for stabilization – or to prevent too much motion from occurring. This is why many traditional “core” exercises like Russian twists and situps tend to exacerbate spinal issues, rather than solve them. As opposed to traditional core exercises, all three of the exercises below emphasize keeping the spine motionless while under load.
Frequency: A common recommendation for this program is to complete all three exercises twice per day while symptoms persist. Once the pain subsides, we recommend completing these exercises as often as daily and as infrequently as three times per week. We believe you should continue to use this program regularly even when you’re not experiencing pain. It should only take a couple minutes per day.
Without further ado, here are the exercises:
The McGill Big 3 Exercises
The Side Plank
The side plank (otherwise known as the side bridge) is a crowd favorite in the core strength and functional fitness world and will probably be a familiar exercise to most people. If you find this exercise too difficult, we would suggest doing the exercise from the knees to start.
How to do the side plank: Lie on your side as shown with your elbow down below the shoulder. Place your opposing (top) arm on the opposite deltoid. Brace your core and stiffen yourself up into a “plank” position, with the body from head to feet positioned in a straight line. McGill offers a slight twist on the traditional side plank by having practitioners place the top leg foot on the ground in front of the rear leg foot.
Side plank regression: Follow the same instructions as above, but stack your knees on top of each other, bend the knee, and then stiffen through the core just like the regular side plank.
Sets and reps for the side plank: McGill recommends that you hold the position at the top for 5-10 seconds and repeat for 5-10 repetitions per side. You may immediately notice that this is quite a large range. We recommend that you start with five repetitions for five seconds each. Over time, progress to five repetitions of 7-8 seconds each and then finally 10 seconds each. Once you are able to complete 5×10, then add repetitions, shooting for seven or eight 10 second holds and finally 10 holds for 10 seconds each.
Advanced variation: Over time, work up to a single repetition of a 60 second hold.
The Curl Up
The curl up is presented as an alternative to the traditional sit up or crunch exercise – working the rectus abdominis (six pack) and other frontal core muscles without the drawback of flexing and extending the spine repeatedly.
How to do the curl up: Lie down flat on your back with one knee bent 90 degrees and the other out straight. Place your hands under the small of your back for lumbar support and lift your shoulders and head slightly to contract the core musculature.
Sets and reps for the curl up: Hold this position for 10 seconds and repeat five to 10 times per side. As with the side plank, we recommend that you start with five repetitions and progress to 10 over time. Don’t rush it! Progress is what matters, and progress takes time.
The Bird Dog
The bird dog is an exercise aimed at creating stability while engaging the muscles that extend the spine. You will notice that the force of gravity on the raised leg causes the lower back muscles and glutes to engage – this is the point of the exercise.
How to do the bird dog exercise: Set up on all fours as pictured, with the arms straight and the legs bent. McGill recommends that you find your spine’s neutral position by first flexing and extending the spine a few times. Attempt to curl the spine up by raising your abdomen and stop when you encounter resistance. Reverse this by lowering your abdomen towards the ground and stopping when you encounter resistance. The halfway point between the two positions should be “neutral” and should feature a natural curve in the spine as shown. Without changing the position of the spine, raise the right hand above your head while simultaneously raising the left leg. Maintain your hand and foot position on the floor and hold this position for 10 seconds. Bring your arm and leg down without putting your weight on them, and then raise them again and hold for 10 more seconds.
Sets and reps for the bird dog: McGill recommends that you complete 5-10 repetitions on each side, and that you complete all repetitions for one side before switching to the other.
Optional advanced variation of the bird dog: Once this exercise becomes easy, McGill offers an advanced variation. Simultaneously perform “circles” or “squares” with your arm and leg while maintaining the neutral curve of the spine. You’ll notice the core demands of the exercise increase as soon as you introduce this movement.
What if these exercises actually trigger my pain?
Stuart McGill does note that sometimes these exercises (notably the side plank) will actually trigger pain in either the spine or other parts of the body (knees, shoulders, etc). While he does provide some alternatives to work around any pain induced by the Big 3 exercises, we recommend that if you note these exercises actually increase your pain, that you just set up an appointment for an assessment with a physical therapist or your doctor.
Moving beyond the McGill Big 3
One thing of note is that this exercise program is not intended to be comprehensive – it is intended to be a good start for those who need to develop spinal stability to alleviate back pain. McGill and others have noted that there may be other exercises to add to the program based on an individual’s needs. Additionally, we’d recommend against making core stability exercises your ONLY form of resistance training. Learn more about what we recommend for exercise here.
Good luck, and please let us know how this program works out for you!