Foundation activities are the building blocks of a better back. Without completing this section you will always be at risk of another flare up – and always wonder why… If you don’t stand, sit, and lie well, you’re potentially spending most of your time aggravating your back.
Remember to always apply the “Use it or lose it, but don’t abuse it” principle. Don’t push into pain, but initially establish what you can do without making the pain worse, and slowly build this up.
This is the active X set-up for standing well. For more details on standing, go here.
- Stand with your feet shoulder width apart, and toes pointing straight forward.
- Screw your heels down into the floor, as though they were moving toward one another.
- Take a deep breath in as you reach up and out with your hands, looking straight up at the sky, lifting your chest upwards.
- As you breathe out, bring your hands down to your sides, relax your shoulders back, and look straight ahead. Keep everything else (legs, chest, belly) as they were, with muscles lifting belly up away from hips. Think of lengthening your spine, with someone pulling a hair straight up from the back of the top of your head.
- Keep your shoulders hunched up
- Push your chest out
- Push your chin up or forwards
Knowing how to stand well is fundamental to recovery and long-term prevention.
Bear in mind, we are all built differently, and so there is no one perfect way to stand. The below is offered as an approach to standing which will improve alignment for the vast majority of people. But play with it. Try standing like this and see how it feels. It may feel like hard work. Don’t stress about it. Changing postures takes time, and is something you might want to play with for a while before finding what’s most comfortable for you. Don’t try to change your posture overnight – you’ll just overload your brain and may just cause more stresses and strains. So, I think it’s worth you exploring, but don’t go crazy with it.
- Stand with feet hip width apart, feet parallel and pointing forwards
- Knees straight, not locked back
- Pelvis and lower back in “neutral”, with arch in lower back
- Lift ribs up away from hips at the front
- Relax shoulders
- Think of someone pulling a hair straight up at the top of the back of your head
- Stick bottom too far out
- Tuck bottom too far under
- Push chest out
- Stick chin forwards or up
3. Abdominal Bracing
When you brace your belly muscles, your back muscles tighten up to protect the joints and control your movements better.
Abdominal bracing is great for preventing those sharp jabs of pain when you turn over in bed or get out of a chair for example. When you’re recovering from a bout of back pain it’s something a lot of people find prevents sharper jabs of pain on effort – as can happen when standing up from a chair, or turning over in bed.
Imagine someone is about to punch you in the stomach; or you’re about to lift something heavy – you tense your abdomen. That initial tensing up is what you’re trying to achieve – but lightly. You may have to start learning how to do this by lying on your back with your knees bent up and feet on the floor; put a hand on your tummy and lift your head up – that hardening of your belly you feel with your hand is abdominal bracing. Practise it a lot lying down and then try to do it standing and sitting.
Use those hips! If bending has you tensing up at the prospect, then you’ve come to the right place. But if you haven’t all ready, please read about fear avoidance and the 3 ways of damaging your back.
The ability to bend over is an essential part of living for most people, but it’s also an activity which frequently results in sharper pains. The Hip Hingeing sequence is designed to minimise the risk of this in the short term, and help you to develop a less stressful more fluid way of bending in the longer term.
In order to minimise the load on your lower back when you bend, you will benefit from re-programming the way you bend. DO NOT avoid bending entirely – this gives your brain all the wrong messages and suggests you’re fearful, and that will cause more muscle tension, and weakness in the muscles that you’re not using, which causes a lack of coordination in your movements, which in turn actually increases the risk that you’ll damage something. Healthy bending is essential in the rehabilitation of your back. If bending has caused sudden worsening of LBP in the past, remember it may only be a trigger, but it could also be due to cumulative and sustained load. But if you avoid bending due to fear, you’ll almost certainly cause yourself more pain and disability. You have to get back to bending – gradually.
But there are different ways to bend, and the most mechanically-efficient follows. This is a five-step bending process; do not move on to the next step until you’ve mastered the one before, and it is painless to do.
- Start with good standing posture
Set yourself up well with good standing posture.
- Abdominal brace
To prepare for bending, you should tense up all your abdominal muscles – just a little, about 10-15% of your maximum effort. Imagine someone is going to punch you in the belly… you tense up. Now, just back off to the point where you have a little bit of tension there – not a huge amount.
- Hip Hinge
Put one palm against your belly and the back of the other hand flat in the small of your back. Push your hips backwards as you lean your trunk forwards, keeping your back flat – you should feel no change in the relative positions of your hands. Maintain the alignment between your lower back and the crown of your head, so you’re not looking down at your feet, and as you go forwards, your eyes roll up to keep looking straight ahead. Stop when the backs of your thighs won’t allow you to go further.
Practise this movement repeatedly – at whatever level you can achieve. So, if you can only go as far as a small amount of hip hingeing, but adding the squat would be agony, then only go that far. But repeat it many times (sticking to the “graded exposure” advice). Remember, you can’t expect to be good at bending (or anything) if you don’t practise. As you practise this, it will become second nature, and you’ll stop being afraid of bending too! A great time and place to practise is when you’re brushing your teeth. Stand with your back to the toilet, and practise hip hingeing, while brushing your teeth. Move on to heel-squatting when you’ve mastered hip hingeing – “brush your teeth and heel-squat”!
Use this technique for sitting down and standing back up again.
Having reached a comfortable and painless hip hinge, now keeping your weight over your heels, squat down; keeping your bottom out behind you and maintaining a flat back. Your knees should not hang beyond your toes – look down briefly to check this; keep your weight back over your heels. Neither of your knees should drop inwards either – if one has a tendency to do so, then consciously push it out as you squat.
- Push knees beyond toes
- Allow a knee to drop inwards
Hip hinge, squat then curl
The last step in the bending sequence
Having reached the end of your squat range of movement, and with your bottom stuck out behind you, now curl your head, neck and back forwards and downwards.
Returning from bending
Reverse the steps; so uncurl your back first, then push up from the squat, then use the hinge action to bring yourself up straight, then allow the abdomen to relax.
At this point you should be combining all 3 steps. Remember, it’s vital that you perfect each of the steps in this movement before moving on to the next step. This steps are
- Hip Hinge
Lying on your front to sleep probably isn’t a good idea in the long-run. You will almost certainly get to an age when lying on your front causes lower back and/or neck strain. However, if – at the moment – lying on your front is the least painful position, then it’s OK to lie on your front for
short periods. Try to put the pillow so that it supports the rear half of your head when turned to the side, but not the whole of the side of your head – it’s important not to push your neck into a fully twisted (rotated) position.
Your lower back should not arch down towards the floor – if it does, then put a pillow under your belly to lift your hips up and stop this from happening.
When lying on your back, it’s best to have a pillow which supports your head and neck to keep your spine in neutral – don’t lift the head too high up.
You may feel better with a pillow under your knees to allow your lower back to relax.
Lying on the floor may be the worst thing you could do – be guided by pain. If you’re more comfortable on one surface than another, then stick with it.
7. Turning over in bed
There’s a knack to turning in bed with a painful back.
- Make sure to brace your abdomen before starting to turn over.
- Keep it braced while you do the turning.
- Try to only move one body part at a time, while keeping braced.
Side-lying is often the least uncomfortable position for people with lower back pain. But how to do it well?
Lie on your side, with a pillow that’s thick enough to keep your head and neck aligned with your spine – not pushing your head up, or allowing it to drop down towards the floor.
Have your knees together (although you may find it more comfortable with a pillow between them), and bent a little – enough to keep you stable, but don’t bend your knees right up towards your chest.
Arms in front of you, hands together on the pillow – praying might help 😉
If you have more pain on one side of your lower back, or one-sided sciatica, often lying with this side uppermost is helpful. Have the lower leg bent up, and the upper leg straightened down so that your lower back is slightly bent to one side e.g. if you have left sciatica/lower back pain then try lying on your right, have the right knee bent up and the left one straight down. You may also find a thin pillow under your right side (between hip and lower ribs) helps to arch your back away from the pain on the left. If this makes it more sore, then don’t do it!!
Sitting is one of the most common aggravators for lower back pain. Here’s how to do it well..
The most important thing about sitting is to vary your posture – remember what you learned about sustained and cumulative loading.
Also known as “perching”. This is a good option because it allows you to maintain your pelvis in a slightly forward tilted position, keeping the arch in the small of your back and generally ensuring all your curves are similar to a standing alignment. This does mean holding yourself up without using the backrest on the chair, but your muscles are there to do exactly that.
They may tire, but if you gradually build this up, over time, you’ll reach the point where you can sit like this for 30-40 minutes at a stretch. If you typically get more LBP when sitting you may find this the first sitting posture that your back can tolerate – yeeha! Go with it.
For years now you may have been advised to adopt 90 degrees at ankle, knee, hip and elbow – as though this was the “Gold Standard” of sitting. Unfortunately this may have led to you spending all your time sitting in this position; however, due to the sustained load this causes, you now know this is a bad idea. So, standard sitting posture may be fine for brief periods – just don’t spend any more time in it than is good for you!
As long as you have a support in the small of your back (and higher up), there’s nothing wrong with this position, except that it really isn’t a good position in which to do desk-work. It’s good for speaking on the phone or speaking to a colleague – or gazing at the ceiling. But be aware that this posture can suggest to others that you’re not that interested in what they have to say AND that it can affect your own mood. It’s well-recognised that an upright posture is much more dominant than a slumped one.
Wait until it hurts before you move!
Believe there’s a “perfect” seated posture.
The image shows what’s wrong with sitting in a car. If you sit with your knees higher than your bottom, this is likely to cause excessive strain on your lower back.
- Put a cushion or folded towel under your bottom so that your bottom is as high as your knees.
- Arms at about 120-150 degrees
- Back at 110 degrees to thighs
- Have good lumbar support that doesn’t force you forwards but supports your neutral spine
- Have your knees higher than hips
- Over-reach for the wheel
- Sit at 90 degrees
11. Sitting down and standing up from sitting
(Use the arms on a chair to support you if you like).
- Stand with your back to the chair, heels a few inches in front of the chair.
- Abdominal brace.
- Hinge at the hips, pushing your bottom out behind you, then squat down, keeping your weight through your hels.
- Rest at the front of the seat, before shuffling your bottom to the back of the seat – if that’s where you want it. You may wish to stay perching at the front of the seat.
- Shuffle your bottom to the front of the seat (don’t try to stand up from the back of a seat, as it may involve too much forward-bending).
- Abdominal brace.
- Use the chair arms to push down on if you like, or push your hands down on the fronts of your upper thighs.
- Hinge forward very slightly at the hips
- Keeping your weight through your heels and your lower back flat, push up with pressure from your thighs. Once your knees are straight, then push your hips forward to bring yourself fully upright.
And away you go!!
As with posture, bending and getting into and out of chairs are very common activities – if you do them badly you may cause cumulative strain. Make sure to practise these activities by incorporating them into your plan.
Try to stand up from the back of a chair, or try to sit straight to the back of the chair from a standing position.
Start with the standing set-up (above) and be sure to brace your abdomen before starting your hip hinge. The technique for safe lifting is just as you would see in power-lifting.
If you have to get really low down and your lower back curls under you a bit, don’t worry about it – be guided by pain (as ever)