My first article in this series [December 2017] introduced Stuart McGill's concept of maintaining the lumbar spine in neutral to enhance recovery and performance. McGill asserts that the repetitive microtrauma of lumbar flexion in activities of daily living and while exercising accelerates degenerative changes in the lumbar discs. This can be averted by training our patients to move while keeping the lumbar spine in neutral.
"Grooving" these movement patterns with progressive load is the key to successful lumbar spine rehabilitation. The goal is to enable the patient to maintain lumbar spine stiffness with minimal disc compression during ADLs and sport.
Training the Lumbar Spine Stabilizers
McGill has three main exercises to train the lumbar spine stabilizers: the curl-up, bird-dog and side bridge. Each has progressions from entry-level to advanced by modifying the lever arm, as well as incorporating dynamic movement patterns, liable surfaces and adding resistance.
Regardless of the exercise and progression, maintaining a neutral spine is essential. Only allow the patient to progress along an exercise progression if they can perform it properly with lumbar spine stiffness and in neutral. If they cannot maintain neutral spine while exercising, provide an easier version of the exercise or change it out altogether.
Exercise #1: The Curl-Up
The curl-up is done with the patient supine, one knee bent and the hands placed under the lumbar spine. Next, pre-brace the abdominals, keeping the lumbar spine in neutral. Finally, lift the head and shoulders off the ground as one unit with the fulcrum of movement at the bottom of the rib cage, engaging the rectus abdominus. Done properly, only the thoracic spine will flex slightly.
Only elevate the shoulders so they are just off the floor, 1-2 inches, and do not flex the cervical spine. This is not a sit-up! (Remember, as discussed in my previous article, McGill's research measured the force on the lumbar discs in a sit-up to be 3,350N.) Hold for three seconds and repeat. Build to three sets of 15.
The progression for the McGill curl-up is as follows:
- Remove the hands from under the lumbar spine, actively maintaining lumbar neutral.
- Raise the elbows 1 inch above the table, shifting more load to the rectus abdominus.
- Add a pre-brace – be sure to maintain good technique; no cervical flexion or elevation over 1-2 inches.
- Add deep abdominal breathing.
If the curl-up creates discomfort in the cervical spine, and cervical flexion is not occurring with the exercise, incorporate cervical isometrics separately to strengthen the region, as it is most likely deconditioned. Another technique is to forcibly push the tongue against the roof of the mouth while performing the curl-up. This activates the strap muscles.
Exercise #2: The Bird-Dog
The bird-dog (quadruped) is done with the patient on their hands and knees and the spine in neutral (including the cervical spine). Pre-brace the abdominals. Extend alternate arms and legs while maintaining neutral spine at all times. The only body parts that move are the arms and legs; the whole spine stays stiff for the entire exercise.
Be sure not to reach up; reach out – the arms and legs do not go above the plane of the spine. Hold 6-8 seconds, build to three sets of 15.
The bird-dog progression is as follows:
- Move one arm and one leg individually, without any extraneous motion.
- "Sweep" the floor with the hand and knee as they return after each repetition – no weight bearing – and return directly to the bird-dog position.
- Abduct the elevated arm and leg approximately 20 degrees, return to neutral and recover to the floor.
- Abduct the elevated arm and leg, do small circles with the limbs, return to neutral, recover.
- Repeat the same progressions while on foam stability discs.
Exercise #3: The Side Bridge
The side bridge is the third of McGill's "Big Three." The patient lies on their side in three-point, position propped up on their forearm with the free hand supporting the opposite shoulder. Brace the abdominals. Rise up to the side bridge position with a hip hinge; there should be no lateral bending of the torso. Patients with shoulder injuries may need modifications to spare their shoulders.
The side bridge progressions are as follows:
- Legs straight, split-stance side bridge – top leg in front.
- Split-stance side bridge, roll into a front plank, roll to opposite side.
- Single-leg side plank.
- Add an unstable surface such as a foam stability trainer.
Note: Remember, it is essential to maintain lumbar spine stiffness in every exercise and with every progression.
Chiropractic rehabilitation is different and gets exceptional results because we integrate CMT, soft-tissue work, nutrition and active care. Be thoughtful in your approach: assess the patient's needs, instruct in the proper execution of the exercises and do not let them progress until they have mastered the current level. Application of these exercises involves breaking down the patient to simple movement patterns so we can ultimately build them up for recovery and long-term protection.
McGill's "big three" are safe core stability exercises that spare the lumbar and can be easily incorporated into any practice style.
Author's Note: Videos of each of these exercises and their progressions can be found on my YouTube channel (www.YouTube.com/DrDeFabio) and my patient tear sheets are also available upon request.
