A Critical, and the Complex, Aspect of Lumbar Spine Management: Mitigating Position Forces

Article written by Tim McGonigle, PT

“We are surprised over and over again at the symptom control and tolerance for activity people can have even with significant disc and bony spinal pathology when they have a good ergonomic situation, their soft tissues are supple, their muscle function is optimal and directed at mitigating position forces, and they learn to pace their activity with rest and self-care.” – Tim McGonigle, PT

Introduction

Keeping position forces within the tolerance and remodeling capacity of the lumbar spine’s support structures is critical in the prevention and management of low back problems. Healthy joint structures tolerate end-range positions fairly well for short periods of time, but position forces are a key mechanical contributor to back problems as tolerance wanes following sprains or as degeneration sets in.

As you know, the spine can move in multiple combinations of four primary directions:

– Flexion (bending forward)

– Extension (bending backward)

– Side-bending

– Rotation

Position forces are minimal when these movements are kept in their mid-ranges. Keeping slack in the support structures protects them from the escalating tensile and compressive forces that accompany end-range positioning. Damage to support structures occurs when their slack has been taken up and they are either subjected to a ballistic or prolonged force that exceeds their capacity. Examples are easy to come by: 

– Everyone can feel the minimal stress freedom-of-movement available in the joint between the hand and the first finger when in its mid-range, and the escalating tension/compression that occurs when the slack is taken up and pressure is applied at the end of motion.

– Ankles and knees tolerate years of vigorous use during athletic activities as long as they are mostly positioned in their mid-ranges and the intermittent end-range forces are within their tolerances. The ankle sprain or torn knee ligament never occurs when the joints are in their mid-ranges. They only occur when the slack has been taken out of their support structures and an excessive ballistic force is applied.

– Even moderately forceful end-range stresses can overpower the tolerance of support structures if applied over time, such as sitting in an unsupportive chair, sleeping on an unsupportive mattress or bending over too long while pulling weeds.

Once a previous sprain or aging has occurred it takes less end-range pressure to overcome the tolerance of support structures, making spraining episodes easier to facilitate and longer to recover from. An ankle with a history of a bad sprain can function pain free for long periods of time if kept in its mid-range, but re-sprains more easily when the ankle twists. A degenerative spine will be the same, capable of being pretty pain free if kept in its mid-range but will sprain more easily with end-range forces once some form of damage or degeneration has occurred.

As with mitigating axial loading (weight bearing compressive forces as discussed in the May 2025 FPT newsletter), once people become aware of the simple concept of mitigating end-range position forces they start to see contributing factors to the perpetuation of their symptoms and solutions everywhere they look. 

A great deal of position force control can be achieved through ergonomic means. As with mitigating axial loads, once a back-friendly environment is created through adjustments in the set-up of one’s car seat, desk, reading/watching TV chair, support from a mattress and getting items which are frequently handled during common activities at belly button height and in the near reach range, improved back pain management occurs without much thought. It turns, “Oh no, not the car seat (or bed, desk, reading chair) again” into “Oh great, the car seat again! Time to rest and recover!” Simple adjustments can turn an activity that was quite a “check” into an easy energy-preserving “deposit” for the “back account”, resulting in enhanced functional capacity without ongoing extra effort.

Even with a perfect ergonomic environment, the importance of movement and muscle action cannot be overstated in back management. Toned shoulder girdle, trunk and hip girdle muscles along with frequent, controlled mid-range movement and cardiovascular exercise are critical. Passive structures in the body need pressure changes to promote the fluid exchange so essential for cell and tissue health. Also, back pain doesn’t just come from the passive structures of the spine or nerves. A lot of discomfort comes from the local muscles and their associated fascia, both which require use, movement and tensile stresses to be healthy. The exercises and movement necessary to facilitate these aspects of tissue health will be a positive for the passive lumbar structures if performed in their mid-range, especially if axial loading is mitigated, and a negative if performed at end-range under axial loading.

Every joint complex has a “loose-packed” position in which its support structures are slackened and there is minimal compression between the joint surfaces or associated discs. In general, the vast majority of the body’s structures are slackened and minimally compressed when positioned like floating relaxed vertically in a pool. The ankles are resting so that the foot is pointing slightly down and in, the knees and hips are flexed between 25 and 60 degrees with slight external rotation, the arms are floating slightly forward and away from the trunk, elbows are modestly bent, forearms are turned slightly down, the fingers are relaxed in flexion and the entire spine is positioned somewhere in its mid-range between flexion and extension. This “floating position” is the starting point for most ergonomic recommendations and in mitigating position forces during function, and during cardiovascular and strengthening training. When coupled with weight bearing control, a magic combination for the spine is achieved in which adverse stresses to its support structures are mitigated during function and fitness activities while supportive muscle action and circulation are enhanced. 

Examples of Mid-Range/Loose-Packed Positioning During Rest, Function and Training

This is not to imply that all end-range stresses are negative. Optimal musculoskeletal health requires the body’s support structures be subjected to some compressive and end-range position forces to enhance their structural integrity. For active people these forces occur naturally throughout the day and don’t need to be encouraged during activities or training unless a person has fallen into a sedentary lifestyle or has been forced into convalescence. Mitigating axial loading and end-range position forces during prolonged activities such as work, sleep, watching TV/computer time and during physical training saves the tolerance in the body’s support structures for these stresses while shopping in Costco, playing with kids, playing a sport, going for a jog, cleaning the house, gardening or purposely performing compressive activities to promote bone health. 

It’s all about knowing your tolerances, respecting limits and balancing stresses with recovery time so stresses do not exceed tissue tolerances and outpace their remodeling capacity so that enhanced tissue health occurs over time. 

Aging comes for all of us. The key to long term health is to push off the aging/degenerative process as long as possible by keeping stresses within the tolerance and remodeling capacity of one’s tissues and systems by mitigating stressors when possible (controlling spending) and enhancing remodeling capacity by facilitating overall health in every category and appropriately pacing stressors with recovery time (making deposits). Life is easier when there is “a cushion in the bank” and it’s always harder when something is running a deficit. It’s good for all of “your accounts” to mitigate spending and maximize deposits when the opportunity arises as life is “expensive” for your tissues and systems.

Practical Application

To optimize lumbar position control when implementing the ergonomic suggestions in the last two newsletters, simply position the angle between your trunk and thigh at about 135˚and explore the available range between your thigh, pelvis and lumbar spine by thoughtfully rolling your pelvis forward and back on your hip (poking and tucking your tailbone) looking for the least symptomatic, least stressful, most comfortable position for your lumbar and lower extremity tissues. Once identified, adjust external supports (pillows, cushions, towels) to support your thigh-torso angle and spine in this position during “passive activities” such as sitting or lying. During upright unsupported activities you must use your abdominal, back and hip girdle muscles to actively support your spine in its mid-range.

If some intermittent end-range positions are required during physical activity, keeping the support muscles engaged during these brief periods of time does help mitigate the tensile forces the support structures are subjected to. 

Learning to Mitigate Position Forces During Exercise to Prevent, or Reduce, Lumbar Pain Takes Understanding and Practice

Identifying the “usable range” as a starting point in hook-lying

If being symptom free is possible, adjust your thigh-torso angle to where your back is symptom and tension free. If the best you can be is a 4/10, place it where it is a 4/10. This process takes a calm mind and can be difficult for back patients if their minds are spinning due to pain or distracting thoughts. Do your best to experiment without prejudice or bias. Just be open to learning.

Exploring Your Usable Range Towards Extension

Slowly and thoughtfully tilt your tailbone backwards into the floor or bed creating an upwards arch in your low back to explore your lumbar extension range. As soon as you become aware of any increase in stress, strain or discomfort you have gone too far. Move back to the starting point and move 80% to the point of the first increase in stress, strain or discomfort – leaving a 20% safety gap in case you fudge and make an error in judgment. This 80% to the first sign of stress, strain or increased discomfort is your usable range towards extension on this day and in this position. Depending on how angry your back is, the usable range will change. The more you stress your back the angrier it will become and the smaller the usable range will become. The more you take care of your back, the less angry it will become and the usable range will increase. The amount of usable range available will be an indicator as to the direction and rate of change occurring in your recovery.

Exploring Your Available Range Towards Flexion

Thoughtfully repeat the above process by now tucking your tailbone and flattening your back to explore your flexion range. As soon as you become aware of any increase in stress, strain or discomfort you have gone too far. Move back to the starting point and move 80% to the point of the first increase in stress, strain or discomfort – leaving a 20% safety gap in case you fudge and make an error in judgment. This 80% to the first sign of stress, strain or increased discomfort is your usable range towards flexion on this day and in this position.

If it appears full range is possible in either direction without an increase in stress, strain or discomfort, you still must believe us that using 80% of what appears to be the available range will lead to healing and taking all the slack out of tissues is more stressful for them than not. In fact, there has to be increased resistance/strain to the support tissues that are limiting the motion. Becoming aware of this sensation is part of the necessary learning process and should occur as your body sense improves. It is critical that you become aware of the sensations your tissues are relaying to you if you are to truly gain control over your lumbar pathology. Without this awareness, you will not know how to adjust your position and muscle tone to mitigate position forces and will not be capable of identifying your safe limits.

A sustainable situation is created when just 80% of the available range is used during strengthening or cardiovascular exercise, or activities of daily living, as the spine is supported by productive muscle action instead of the passive tissue’s end-range where the wear and tear on it escalates, even in healthy structures. Doing so slows the degenerative process and mitigates pain in an already degenerative spine.

How to Use The Available Range to Mitigate Position Forces During Exercise and Activities of Daily Living (ADL’s)

The way the available range is used is this. Prior to performing an activity or exercise, pause and ask yourself, “Which direction will my back naturally migrate to with this activity or exercise?”.

Once determined, use your ability to:

– Adjust the position between the thigh, pelvis and spine to bias away from the potentially stressful direction.

– Elicit muscle tone in the “stabilizing” muscle groups that can prevent the spine from drifting towards the stressful direction.

– Perform the activity or exercise to the extent possible while preventing the spine from drifting into the stressful range. 

Positioning away from the direction of stress can only be done within the usable range as exceeding it will create stress in the opposite direction. Each exercise will have a limit that if exceeded the participant will no longer be capable of preventing the stressful movement from dissipating through the lumbar spine. One of the main purposes of the routine is to have the participant become aware of this limit during controlled exercises so they become capable of identifying and respecting it during their functional activities. Without this awareness the participant will exceed their safe capacity, strain their lumbar tissues and perpetuate their suffering over and over again during their day. In the examples below, the young man cannot elevate his arms to the floor and still prevent his lumbar spine from extending. There is also a limit to how far he can curl forward during the sit-up while still preventing his lumbar spine from flexing.

Taking the Concept Full Circle: Applying Control Over “Like Activities”

The spine can only move in just four primary directions and the real goal of the exercises is to create a game in which the participant is challenged to identify the direction of spraining force, to learn to appropriately bias away from it, to stimulate the appropriate preemptive tone in the stabilizing muscle group, to identify and respect the limits of their safe performance and to tie the control of activities or exercises that present the spraining risk in the same direction. Doing so translates into more back-friendly body mechanics during activity and into the ability to productively progress to more intense exercise training.

Mitigating Extension Forces

The abdominals and gluteals work as a force couple to mitigate extension forces by facilitating the flattening of your back (curling the rib cage forward and appropriately tucking the tailbone forward) during activities such as picking feet up off the floor when in supine or hook-lying, rocking forward while on hands and knees, carrying something heavy or working with hands above head. Common exercises that train this awareness and control are the supine leg-lift progression, being in the reclining chair position on a gym ball, being at the top of bridging or reverse bridge exercises as the common denominator with all of these is a tendency for the spine to migrate to end range of extension.

Mitigating Flexion Forces

The back muscles (extensors) are the primary stabilizers to mitigate flexion forces by preventing a rounding forward of the spine (keeping the thoracic cage upright and tailbone appropriately poked backwards) during activities such as working with hand below waist, cooking, gardening, sitting, or putting socks on. Common exercises that train this awareness and control are sit-ups, rocking backward while on hands and knees, initiating the bridging or reverse bridging exercises, squatting or being in the “superperson” position on top of a gym ball as the common denominator with all of these is a tendency for the spine to migrate to end range of flexion.

Mitigating Side-bending and Rotation Forces

Mitigating side-bending and rotation forces require asymmetrical use of trunk and lower extremity muscles in an effort to keep the feet, knees, hips, pelvis and trunk lined up while resisting an asymmetrical force or tendency to move. It would require too much instruction to cover here, but the thought process is basically the same as mitigating extension and flexion forces.

The Final Step

Once this basic understanding and neuromotor control has been established allowing a safe entry into our training program, the participant needs to see that performing complex exercises or activities in the real world requires a constant assessment and adjustment of positioning and muscle tone to prevent end-range forces from challenging the spinal support structures. If we do our jobs correctly, the participant will see that each exercise with its multiple variations offers the opportunity to “play the game” and learn, improving their ability to mitigate position forces during more complex and challenging situations. In reality, during most exercises and activities, the participant will need to elicit the appropriate motor action in a host of “core” muscles, not simply one or two to mitigate flexion or extension forces. For example, when in the “superperson” position on a gym ball the primary force the person is resisting is gravity encouraging the spine to flex, which is countered with the spinal extensors. But it is most often necessary for the person to prevent their spinal extensors from overpowering the force of gravity and producing end-range of extension positioning. This is achieved by matching the force of the spinal extensors with equal contraction of the gluteals and abdominals while adjusting their thoracic cage and lumbo-pelvic position so that the spine is held in a mid-range surrounded by a sea of muscular support instead of no protection from flexion or having the spinal extensors produce an aggravating extension force to the spinal support structures. It truly is a body sense and control game requiring education and close supervision to ensure understanding, control and the link to “like activities” if the participant will gain the most out of the program. Without this extent of understanding, people will perform the exercises haphazardly and miss the opportunity to gain optimal control over their spinal futures.

Our Challenge of Getting Full Buy-in

Getting full buy-in to the process of controlling position forces during exercise and tying this control to like activities of daily living (ADL’s) is the critical step that most often determines success or failure of back care programs as it sets the foundation necessary for people to assume the ultimate responsibility in their back care. It delineates the line between mitigating stressors or letting them have their way with one’s tissues. No one on the planet can exert this minute-to-minute control except the spine’s owner themselves. 

This aspect of back care is far too often misunderstood and underemphasized by most practitioners as it has either not been part of their professional education, or they find it just too time consuming and cumbersome to teach to patients. 

It is also often underappreciated by most patients as it is not what they were expecting the focus of the interaction to be. It is also commonly introduced to them early in their time with a knowledgeable practitioner when their minds are spinning with a million thoughts and emotions so that they are not in a position to grasp the significance to their overall management. 

The lack of emphasis and appreciation of how critical position control is to the management of back issues leads to failed treatment as the client unwittingly keeps their tissues irritated by the way they perform their exercise program and carry out their ADL’s. It leads to so much wasted treatment time as until the client truly absorbs the concept they will not really benefit from advancing an ergonomic, self-care and training program, or from any other intervention a practitioner can provide.

Training robustly and getting into great physical fitness does not take away the need to mitigate axial loading or position forces, or to identify and accept limits. If the spine is allowed to drift into an end-range position during exercise or an ADL the integrity of the passive structures will be challenged, weakening already compromised structures and perpetuating the cycle of activity leading to a flare no matter how good the other interventions have been.

Conclusion

In the management of lumbar pathology, physical training and exercise is not just a strength and endurance game, it is a body sense and control game. Enhancing the ability to read the direction of force, knowing how to bias away from it within the usable range, knowing what muscles to use to prevent the force from getting to your spinal tissues, identifying and respecting limits and tying it to like activities is the real goal. This concept is hard to grasp and so easily lost once people start gaining control over their symptoms. A good physical therapist should constantly be monitoring a client’s performance and alerting them when their technique is becoming sloppy and their memories of the real purpose of the training becomes short.

Being aware of the position forces your spine could be subjected to during exercise and activity should be part of everyone’s health plan as back problems appear to be a fact of life for the vast majority of people around the world. Doing so not only protects the structure of your back, but it also enhances the benefit of the exercise program as your spinal support muscles and body sense are more challenged in the process. It makes the difference between allowing position forces to get to your back, making exercise “a check against the account” or a win-win-win for your tissues, fitness, and neuromotor control system. The neuroscience professionals would add another “win” as the focus on body sense will clarify your homunculus and reduce your pain sensitivity.

Physical training makes us better at the way we train and there is often little carryover to improving performance for other activities. The long-distance runner who goes to the park for a pick-up soccer game will soon become winded, shocked at their poor eye-foot coordination and quite sore the next day. Training for lumbar health needs to emphasize anticipating direction of position forces to be controlled, adjusting thoracic cage and lumbo-pelvic position to slacken passive lumbar structures, and utilizing muscles to prevent end-range positioning from occurring. To complete the training, this same thought process and position control needs to be applied during activities of daily living (ADL’s). If people train well while in the gym but do not incorporate the same position control during their ADL’s they will have not truly understood the purpose of the training session. 

For training to really be productive, it must train us to be better at what we do. What we do 100% of the time during unsupported activity is control our bodies in space and sometimes we are challenged to control a free object in space (getting the groceries from the trunk of the car into the house). This is why much of the training performed at Folsom Physical Therapy is directed towards these two goals (control of the body in space and controlling a free object in space) while keeping the spine in a mid-range position. In an effort to safely challenge the participant’s ability to control their body in space and/or control a free object in space we often mitigate axial loading by having clients perform exercises pitted against gravity in horizontal positions and on unstable surfaces (gym balls, balance boards, air cushions, etc.). When vertical, we again use unstable surfaces/positions and often use leverage instead of heavy weight to add to the challenge without increasing axial loading. When working clients in more supported positions so that heavier loads can be handled more safely, the direction of resistance will often create a de-compressive force through the spine resulting in a tractioning moment producing lumbar pain relief. This has proven to be a great way of safely challenging clients to exercise position control while “putting money in their back account”.

Remember, there will always be a limit to what you are doing before the task exceeds your ability to prevent position forces from getting to your passive spinal structures. The limit may come because of the range required, the weight handled, the duration of the activity or just how complex the activity is in relation to your skill or fatigue. When performing a task that is beyond your ability to mitigate position forces you do have just four choices:

1- You can do it and pay the price

2- You can find another way to accomplish the task by:

• Moving differently, or

• Creating a more back-friendly environment

3 – You can get someone else to do it

4 – Or, you can leave it alone

There are no other options. You are the one who is steering your ship. See the reality and assume control of the direction and rate of change occurring in your quality of life and tolerance for activity. If you are not happy with your current functional limits, find someone who can help you do something about it by advising you in ergonomic solutions or helping you train to become smarter, stronger, and more flexible to expand your capabilities.

If you live outside of the Folsom area, please feel free to contact us to see if we have trained a therapist in your area. Be the master of your fate and the captain of your soul.

For additional resources, check out these helpful videos from the FPT Video Library:

Back Class 1- BASIC 

Back Class 2- PROGRESSION

The Car Seat Talk