Exercises to improve posture, Part 2: Corrective exercise for low back pain

The first session with each new client involves two main elements; static postural and dynamic (movement) assessment. These two screens inform my decision-making for everything that follows, from the warm-up and throughout the main workout.

One of the most common things I experience is what’s known as lordosis. More commonly, it’s referred to as an anterior pelvic tilt (APT), or an exaggerated curve of the lower back. My favourite terminology is actually lumbo pelvic hip complex disorder (LPHCD), which sums it up perfectly. Generally, it causes pain for the individual concerned. A quick straw poll, I’d say 70% of clients past and present have suffered with this, and I’m very pleased to say that the protocol I’m about to share here has a 90% success rate when it comes to alleviating the client’s low back pain, with a couple of ‘work in progress’ cases.

So what causes it and why is it so common?

Essentially, a muscle imbalance causes torque on the pelvis, as seen in the diagram below.

The tight muscles at the front (hip flexors) overpower the Gluteus muscles and exert a force that pivots around the hip joint. The big and powerful Psoas muscle attaches from the lumbar vertebrae to the femur, so the lumbar spine is actually rotated forwards (anteriorly). The gluteus muscles are what’s known as phasic, i.e. prone to becoming underactive. Similarly, the Rectus Femoris, part of the quadriceps muscle group also crosses the hip joint and can also exert torque.

The tilt of the pelvis elongates the hamstrings, which then become tight. This, coupled with the fact that they pick up the slack for the underactive glutes means they are working harder whilst already being under pressure. The lumbar spine becomes compressed, the erector muscles that run up each side of the spine become overactive as they fight to keep the torso upright and work against the forward lean.

As you can see, it’s not a great situation to be in and little wonder the result is low back pain.

If you’ve read the Corrective Exercise section of the site and Part 1 in this series you’ll already understand the basic 4-stage protocol of release, stretch, activate and integrate. I’m going to take you through these in context.

Assessment-wise, it can be easy to spot in a static postural assessment. A forward lean in the overhead squat assessment may also lead to further testing that uncovers tight hip flexors, but most often the client will tell me they have low back pain!

At this point it may be useful to provide a rationale for corrective exercise. To paraphrase my associate, Dr Brent Brookbush, before you exercise you can either spend 10 minutes on a treadmill reinforcing all your movement compensations, or you can perform a routine that seeks to address any imbalances in the human movement system.

Performing a corrective routine will not cure a problem in one session, but it will allow the client to perform the subsequent workout in the most effective way possible, and, over time, redress the imbalance.

Stage 1 of the corrective exercise protocol is RELEASE. Here we seek to target adhesions, or trigger points and trick the nervous system into allowing the overactive muscle/s to be stretched. Self myofascial release, as it’s known, desensitises receptors in the muscle, meaning stretching will be more effective.

We are targeting the Rectus Femoris in this case, and you can see my client using a hard foam roller on the front of the thigh. Once a trigger point is located, pressure is held on the spot for between 60 and 120 seconds. Sometimes a palpable release can be felt, as happened here.

Rectus Femoris trigger point release

Rectus Femoris trigger point release with foam roller

Stage 2 of the corrective exercise protocol is STRETCH. Once sensitive adhesions (kinks in the muscle fibres) are toned down, the muscle can be stretched. We are using a kneeling hip flexor stretch here, although there are several variations of Rectus Femoris stretches. The stretch is held for a minimum of 60 seconds, often longer.

Kneeling hip flexor stretch

Kneeling hip flexor stretch targeting the Rectus Femoris

Stage 3 of the corrective exercise protocol is ACTIVATE. In this case, the main muscles to activate are the underactive core and gluteus muscles.

As per the diagram above, the glutes are overpowered by the various hip flexor muscles. The glute max and medius are what’s known as phasic muscles (prone to underactivity), and the hip flexors are what’s known as tonic muscles (prone to overactivity). We need to redress this balance by toning down the tonic muscles and activating the phasic muscles. Activations of the gluteus complex (med and max) and the deep core (transverse abdominus) are shown below.

gluteus bridge with band

Glute complex bridge with mini band

Glute medius activation with band

Glute medius activation with band

Each of these glute activation exercises is performed slowly with full range, 2 sets of 15-20 reps.

The core activation exercise is an unstable quadruped with a ball placed on the back of the client. This is not for fun, although it does add some amusement to proceedings, it’s presence is designed to force the client to keep their pelvis level. This works the core more than dropping the hip. There are progressions to this ranging from single arm or leg, to moving them in and out, to long holds.

q-ped with ball

Deep core activation

Stage 4 of the corrective exercise continuum is INTEGRATE. In this case, the subsystem of muscles we want to integrate is the Posterior Oblique Subsystem. The POS is comprised of the gluteus muscles and the latissimus doors, which are connected by the thoracolumbar fascia. These muscles ordinarily create stability, but this function is compromised where the glutes are not pulling their weight.

squat to row

Squat to row – squat phase

squat to row

Squat to row – row phase

The lats are pulling muscles, and the glutes are extenders of the hip so we reintegrate the functioning of this muscular subsystem using a squat with a simultaneous pulling action. The squat to row movement is performed with a resistance band, as shown here. Form is more important than load, I use a medium strength band, 1 or 2 sets of between 15-20 reps.

There you have it, another protocol of exercises to improve posture and relieve lower back pain. All in all this is a 15-20 minute routine, which, when practiced can be quite pacey and utilised as a nice session warm-up. The stretch, activation and integration phases can be performed as a circuit. It’s an absolute must for anyone with a visible lordosis, or who fails the tests highlighted above, prior to any kind of resistance workout. This routine is not a quick fix, but it will allow someone to perform a workout with the best possible form, and minimise compensations during exercises. Be patient,  it can take a very long time for a visible curvature to correct, although I generally experience a relatively fast relief of pain. It’s important to keep going with it,

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