Low Back Pain: Get Started with Abdominal Exercises

Low back injuries usually do not occur from one single incident or event like lifting a heavy box.  Instead, most back injuries occur from small incremental stress or load applied over time.  Sitting slouched for prolonged periods at a desk or repeatedly performing bending and twisting can overload sensitive spinal structures.  These structures include the muscles, facet joints, ligaments, discs, and nerves.   Muscle weakness, poor endurance, poor position awareness, and previous history of injury can make one more susceptible to low back injuries.  Most of these injuries are not serious and do not require extensive testing or treatment.

The core muscles function to spare the lumbar spine and surrounding structures from excessive load.  These muscles include the abdominals, low back musculature, diaphragm, and pelvic floor muscles.  No single muscle is more important than the others.  Human movement and low back pain are more complex than one muscle or structure.  Instead, all muscles should ideally function together in coordination.  Pain interferes with coordination and control.  The specific task being performed determines the magnitude and timing of core muscle activity.  Some tasks require a very low load and level of muscle activity such as bending to tie the shoes.  Other tasks require greater muscle activation patterns at high speeds such as swinging a baseball bat.

Exercises to train the core musculature should begin with low loads focusing on control and endurance.  Exercises performed lying on the back targeting the abdominal muscles is a great place to start.  The following exercises can be performed by those with low back pain or those with a history of back pain looking to prevent recurrences.  Once these exercises are no longer challenging, progression is needed.  Future articles will address proper progressions.

Abdominal Bracing

Begin lying on your back with the hips and knees bent.  Find a neutral spine position by gently rocking your pelvis back and forth.  Your neutral position is somewhere between a fully arched and fully flattened position.  In your neutral position, you should be able to hold a small grape under your low back without crushing it.  Maintain a neutral spine and gently contract your abdominal muscles in the front and sides continuing 360 degrees around to the low back.  This muscle contraction should be gentle and no movement should occur.

Once a neutral spine can be maintained with gentle bracing, breathing is added.  Diaphragmatic breathing is performed while maintaining a neutral spine and gentle bracing.  This involves expanding through the belly and rib cage in a 360-degree fashion.  Minimal or no movement occurs in the upper chest and shoulders.  Five deep slow breathes are performed while maintaining a neutral spine and bracing.  No breath holding or movement of the spine should occur.  It is helpful to place one hand on the abdomen and the other hand on the chest to ensure a proper breathing pattern is maintained.   This exercise forms the foundation for all subsequent abdominal exercise progression to follow.

Bent Knee Fall Out

The bent knee fall out is performed after abdominal bracing and diaphragmatic breathing have been mastered.  Begin with a neutral spine, bracing, and diaphragmatic breathing.   Lower one knee to the side towards the floor in a slow and controlled fashion.  No movement in the spine or hips should occur.  It is helpful to place the hands on the hip bones to ensure no movement is taking place.  With each repetition alternate sides.  To increase the challenges add a resistance band around the thighs.  Perform 10 slow repetitions on each side.

90/90 March

This exercise begins with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate lowering the heels to the floor.  Gently touch the heel to the floor without relaxing.   Perform 10 slow repetitions on each side.

Heel Hover

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate extending of the knee so one leg straightens without touching down.  As you lower the legs, it is important that the low back does not arch away from the floor.  Perform 10 slow repetitions on each side.

Double Leg Lift

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Both knees and feet are then simultaneously elevated so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly lower the legs together.  Do not touch down or relax the feet to the floor.  It is important that the low back does not arch away from the floor.  Perform 10 to 20 slow repetitions on each side.  To increase the challenges add a small ball to squeeze between the thighs.

Closing Thoughts on Abdominal Exercise for Low Back Pain

Pain interferes with how our brain transmits signals to our muscles.  This is especially important when your low back pain has persisted for more than several weeks.  These 5 abdominal exercises re-program the lost connections between the brain and core muscles.  Slow coordinated and controlled movements are crucial for success.  Absolutely no holding of the breath should occur.  Breathe holding increases tension throughout the body and interferes with retraining of the muscles and nervous system.   Practice these exercises, master them, and improve your endurance by increasing repetitions.   Once these goals are achieved, you are ready to build strength and resilience with more challenging exercises.

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Identifying Expert Physical Therapists: Part 2

Previously, I discussed the attributes of expert physical therapists. Experts share an inner drive for continual learning and improvement of their craft. Experts collaborate with patients to solve problems and possess a belief that patients are responsible for their own health. Several other related themes include spending more time with their patients, placing a greater emphasis on educating their patients, being more responsive to their patients needs, and possessing more extensive knowledge than novices1, 2.

A study by Resnik and Jensen3 further explored the characteristics of expert and novice physical therapists based on the outcomes of their patients seeking care for low back pain. From the results of this study, experts were distinguished from novices by a patient-centered approach which resulted in superior results/outcomes for their patients. Within this approach patients are viewed as active participants in therapy (not passive recipients). The primary goal of therapy is the empowerment of the patient. Empowerment is achieved through collaboration between the therapist and patient, ongoing patient education, and the establishment of a positive therapeutic relationship or alliance. The patient-centered approach results from the interplay of the expert’s clinical reasoning, knowledge base, clinical practice style, and values & virtues.

Expert Clinical Reasoning

Successful outcomes from physical therapy can be fostered through the empowerment of patients and interactions which promote self-efficacy. Patients benefit when given a sense of control over their problem. This sense of control and empowerment can be accomplished through education, avoiding passive treatments (ultrasound, hot packs, etc), minimizing unnecessary visits, and assisting patients with developing self-management strategies. Experts collaborate to solve problems and resemble more of a coach, teacher, or guide than they do a “healer”.

Knowledge Base of Expert Physical Therapists

Years of experience do not distinguish experts from the average. Experts obtain knowledge through clinical experiences, specialty education, their colleagues, and continual self reflection. Experts seek out knowledge and consult with their peers about challenging patient cases. They typically practice in supportive environments where professionals learn from each other. Experts emphasize the observation of functional movement constantly evaluating their patient’s movement patterns.

Values & Virtues of Expert Physical Therapists

It is obvious to others that expert physical therapists enjoy their work and have a passion for helping others. Many view the practice of physical therapy as “a calling”. As mentioned, experts possess a drive to continually learn and improve their skills. Experts are humble and inquisitive; both characteristics of lifelong learners.

Clinical Practice Style of Expert Physical Therapists

Experts adapt and individualize their interactions, examination, and treatments to meet patient needs and foster empowerment. Patient education is central to the expert clinical practice. Expert’s value the continuity of care with their patients and are very stringent with delegating tasks to aides or assistants. Most practice without support personnel.

In Closing

Patients receiving the services of physical therapists should seek out experts who possess the attributes and characteristics discussed here. It is appropriate and recommended to visit multiple physical therapist clinics to observe these attributes in action before deciding on a physical therapist to collaborate with. In particular, take note of the style which a physical therapist interacts with their patients. Look for signs of a coach or educator who engages their patients in the decision making process, and ultimately empowers their patients to take ownership of their overall health.

Thank you for reading!



  1. Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy. Phys Ther. 2000;80(1):28-43-52.
  2. Jensen GM, Shepard KF, Gwyer J, Hack LM. Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings. Phys Ther. 1992;72(10):711-722.
  3. Resnik L, Jensen GM. Using clinical outcomes to explore the theory of expert practice in physical therapy. Phys Ther. 2003;83(12):1090-1106.