Lower back pain is one of the most common complaints that I deal with in my work as a Pilates teacher. In fact it is one of the main reasons most people take up Pilates in the first place (myself included!) And yet whilst the issue is so common, and can be extremely debilitating in the worst cases, it amazes me how little it is understood.

If you look at the spine in relation to the rest of the skeletal structure, you can see how the vertebrae of the lower back are relatively exposed. Whilst the sacrum is closed in by the pelvic bones and the thoracic vertebrae articulate with the rib cage, the lower back is not supported by any other structure. At the same time it bares the weight of the upper body and, being more mobile than the thoracic spine, tends to become the pivot point for a lot of spinal movement.

Excessive over-use of joints under load will bring about gradual wear and tear. In simple terms, this is what causes most back pain.

The traditional / standard prescription for lower back pain sufferers is: strengthen the ‘core’, by which most people mean ‘abdominals’. Of course there is some sense in this. If you strengthen the muscles in the lower abdominal area, then you create functional support for the joints of the lower back, reducing strain.

The key core muscle for lower back pain is the TVA. This wraps horizontally around the waist like a corset. Activating the TVA brings about a lengthening sensation through the whole spine. Up the back the spine is supported by a series of layers of muscles. These are relatively weak in the average person because so many of our daily activities tend to involve collapsing into a forward bending position.  A third component of the ‘core’ is the pelvic floor. Postural deviations tend to put more downward pressure on the floor of the pelvis which becomes weak and loses it’s buoyancy. So strengthening these three areas could go some way to reducing back pain.

However, the presence of pain in any joint is a signal that there are restrictions higher up or lower down the chain that are causing the over-use in the first place. What I’ve come to realise is that ineffective use of the musculature around the lower back is the result of poor integration with other parts of the body, and specifically, with the hip joints.

I’m going to give you two examples to illustrate this. These two postural tendencies are ones I know well. I have clients who present with both. I am simplifying by only considering forward / backward movement. Posture is three dimensional, so this clean side on view does not account for compensation patterns in other directions of movement. We’ll leave that out for the sake of this argument.

Doc - 17-03-2016, 10-37The first postural type that I come across in lower back pain is when the pelvis is in a slight backward tilt as illustrated in my sketch. We call this a ‘tucked under’ posture. This is an extremely common postural type and one that, funnily enough, Pilates can actually encourage! I have come across numerous lower back pain sufferers who actually adopt this position to relieve the pain. Actually they’re just de-stabilizing the lower back even more. When someone walks into a matwork class, one of the first preparatory exercises they are told to do is the pelvic tilt. I’ll hold my hand up here: this is exactly how I begin my classes! Someone with this tendency is likely to just press into their lower backs. The second preparatory movement is to take the spine into a bridge, where the cue ‘rolling the spine down bone by bone’ also encourages people to collapse into their lower backs further.

Doc - 17-03-2016

The second postural type is the anterior pelvic tilt. Here the hip flexors are tight, pulling the pelvis into a forward tilt. The lower back becomes shortened creating the exact opposite to the first postural type. Someone in this position may well benefit from the initial pelvic rocks, which will create some traction through the lower back area. However as soon as they begin moving into the bridge their lower backs begin to arch, amplifying the extension (shortening) of the lower back. Another very common problem in this postural type in particular is the loaded flexion exercises like the hundred, single leg stretch, double leg stretch. All of these will just go into the hip flexors making the situation a lot worse.

So whilst the long term effect of abdominal strengthening and traditional Pilates repertoire will be beneficial for the support of the lower back, in the short term they may simply play into the problem and make it a lot worse.  Rather than focusing solely on the ‘core’, both these postural types will benefit more from working on a common area of under-use: The Gluteals.

The buttocks are one of the most misunderstood areas of the body. Some people just think of the butt as something they wish was smaller (or bigger). Some people feel embarrassed about the thought that they have one and most people don’t realise that whilst it can be an area for fat storage, it is also the site of a major muscle group. Gluteus Maximus is the main hip extensor (ie: it opens the front of the hip) and Gluteus Medius and Minimus stabilise the hip (stopping us from falling over when we stand on one leg). When these muscles are under-used the deep hip rotators ( whose aim is primarily to rotate the thigh bone outwards) end up having to do a lot of the work. A lot of people have heard of a tight Piriformis, for example.

In the case of the first postural type described above, the hip remains in a chronically extended position where the deep hip rotators are literally tacking down the back of the pelvis towards the thighs. This tucked under position means that the gluts are unable to perform as an intermediary between the legs and the lower back, so people with this tendency are literally hanging their legs off their lower backs.

If the hip is not taken into extension enough, then it remains in a flexed position, (the second postural type described above). This leads to over-tight hip flexors and the increased lordosis (arch) of the lower back. As a result of the imbalance, the pelvis comes into a forward tilt making lower back articulation very difficult.

The key to a healthy lower back is to have tone and access to the gluts. This is not a question of mindlessly targeting the buttocks in repetitive exercises. It’s about ensuring that there is the right balance of movement around the hip to allow the gluts to fire up in the first place. Every body is different, and I don’t want to start suggesting exercises over blog posts. But perhaps the following points may help you make some adjustments that could help:

For people with a tendency to tuck under the key is: FOLD AT THE HIP! Stop sitting onto your lower back. When you sit down on a chair try to find your sits bones and sit right onto them. Almost imagine the tailbone pointing backwards which will bring the pelvis into a small forwDoc - 29-07-2016ard tilt, reducing the pull on the lower back. Often achieving this is difficult because the deep hip rotators are tight. So doing a seated glut stretch is a really useful way to create space in the hip joint which will allow the spine to lengthen upwards when sitting.

For people with a tendency to tilt the pelvis forward and arch the back, the key is to OPEN THE HIP. Most of us have tight hip flexors, so doing some Hip Flexor stretches like the kneeling lunge will help create some movement here. Once you’ve found a sense of opening the front of the hip, without letting the lower back, arch you can translate this into walking by leaving the back leg in contact with the floor for longer. This has the effect of lengthening your strides and though it may seem like it’s slowing you down initially, you’ll notice that you’re moving much faster in fact.

These are just a few points that you’ll already know if you’ve done any work with me. Next week I’ll talk a little more about how the tilt of the pelvis connects with and is affected by the feet.