Low back pain is nearly universal
80% of adults experience LBP at some point. Most resolves within weeks regardless of treatment. The minority that becomes chronic is the population most trainers will work with.
Red flags — refer immediately
Pain with any of these warrants medical evaluation before training:
- Recent significant trauma (fall, car accident)
- Cancer history
- Unexplained weight loss
- Fever
- Loss of bowel or bladder control
- Saddle anesthesia (numbness in groin area)
- Progressive neurological deficits (weakness, numbness worsening)
- Pain at night that doesn't respond to position changes
Common LBP presentations (non-red-flag)
Mechanical LBP: the most common. Hurts with certain movements (often flexion or extension), gets better with movement. Often muscle/joint origin. Disc-related pain: radiating down a leg (sciatica). Worse with sitting, flexion. Better with extension or walking. The "McKenzie" extension protocol helps many. Stenosis: narrowing of the spinal canal. Worse with extension and walking. Better with flexion (sitting, leaning forward). Sacroiliac (SI) joint pain: localized over the SI joint. Often unilateral. Can be reproduced with specific provocation tests. Facet joint pain: worse with extension. Often local, not radiating.What works for non-red-flag LBP
Movement, not rest. Bed rest worsens outcomes. Stay active within pain limits. Progressive loading. Strong cores and strong posterior chains protect against LBP recurrence. Avoid pain-provoking movements. During acute flares, modify or skip the movements that worsen pain. Address the cause. Sedentary lifestyle? Move more. Weak posterior chain? Train it. Poor breathing/bracing? Coach it.Programming for chronic LBP clients
General principles:- Build core endurance before strength (planks, side planks, dead bugs, bird dogs)
- Train the hip hinge pattern with light loads
- Strengthen glutes (often weak in LBP clients)
- Improve thoracic mobility (less compensation by lumbar)
- Avoid loaded spinal flexion under fatigue
- Dead bug
- Bird dog
- Side plank
- Glute bridge
- Hip thrust
- McGill curl-up (instead of crunch)
- Goblet squat
- Trap bar deadlift (lower shear than conventional)
- Suitcase carries
- Conventional deadlifts (technique-sensitive)
- Heavy back squats (good for some, bad for others)
- Loaded spinal flexion (sit-ups, weighted crunches)
- Roman chair hyperextensions at end range
The McGill Big 3
Stuart McGill's "Big 3" — proven to reduce chronic LBP and build resilience:
1. Modified curl-up — head and shoulders just barely off floor, hands under low back, hold 10 sec. 2. Side plank — full or knees down, hold 10-30 sec. 3. Bird dog — opposite arm and leg, hold 10 sec.
Done daily, builds spine resilience without provoking pain in most clients.
When to refer
- Pain that doesn't improve with 2-3 weeks of intelligent training
- Pain that worsens with training
- Any red flags
- Symptoms beyond what a trainer's scope handles
TL;DR
Most LBP responds to movement, not rest. Screen for red flags first — refer if any present. Build core endurance, strong posterior chain, and hip hinge pattern. Use McGill Big 3 daily. Modify pain-provoking movements during flares. Refer if pain doesn't improve with 2-3 weeks.