Promising technique for managing nonspecific chronic low back pain using multi angular isometric lumbar exercise

Table 1 Multi-angular isometric lumbar exercise technique for lumbopelvic hip complex

Component	Details
Fundamental start position	Four-point kneeling; hands directly under shoulders, knees under hips; arms fully lengthened, avoid locking elbows; chest and shoulders open, neck relaxed, tension-free.
Spinal alignment	Maintain accurate alignment by focusing on: (1) Sacrum: Base of the spine; (2) Thoracic spine: Mid-back between shoulder blades; (3) Back of the head: Neutral, no excessive tilt; and (4) Neutral lumbar spine: Avoid arching or flattening.
Activation and breathing	(1) Steady breathing: Controlled breathing throughout exercises; (2) Abdominal drawing-in maneuver: Gently tighten deep abdominals by drawing umbilicus to spine, engaging transversus abdominis; and (3) Posterior pelvic tilt: Rotate pelvis posteriorly.
Strength component	Isometric hold: Hold activated position (abdominal drawing-in maneuver + posterior pelvic tilt) for 5 seconds; focus on controlled contraction and relaxation.
Power component	Quick squeezes: Perform 10 rapid activations and relaxations of pelvic and abdominal muscles.
Endurance component	Sustained hold: Activate pelvic floor and deep abdominals to 50% of max effort; hold for 20+ seconds to build endurance.
Focus areas	(1) Core stability: Strengthens core and lumbo-pelvic hip complex stability; (2) Spinal alignment: Reduces lumbar strain, reinforces proper posture; (3) Pelvic floor activation: Enhances lumbar and pelvic support; and (4) Mindful breathing: Supports controlled activation and relaxation.
Purpose	Structured progression improves motor control, core stability, and lumbar-pelvic function, addressing chronic low back pain safely and effectively.

Table 2 Multi-angular isometric lumbar exercise techniques in 6 different positions

Position (P)	Starting position	Abdominal activation	Movement and repetitions
MAILE 4-point kneeling exercise (P1)	Hands and knees alignment: Shoulders at 90°, hands below shoulders. Hips and knees at 90°, neutral neck position. Open chest, relaxed shoulders, neutral spine (Figure 1A).	ADIM: Draw navel to spine. Slight posterior pelvic tilt. Engage transversus abdominis and pelvic floor while maintaining neutral spine.	Perform 10 reps per set, maintaining alignment and core activation for a few seconds. Complete 3 sets, with rest between.
Modified MAILE (50° hip flexion) (P2)	Hands and knees alignment: Shoulders at 90°, hands below shoulders. Hips at 50° flexion (hips slightly back), knees at 90°. Neutral neck, open chest, relaxed shoulders, neutral thoracic/lumbar spine (Figure 1B).	ADIM: Draw navel to spine. Slight posterior pelvic tilt. Engage transversus abdominis and pelvic floor while maintaining neutral lumbar spine.	Perform 10 reps per set, holding position for a few seconds. Complete 3 sets, resting appropriately between sets.
Modified MAILE (120° shoulder flexion) (P3)	Hands and knees alignment: Shoulders at 120°, hands slightly ahead of shoulders. Hips at 50° flexion (hips slightly back), knees at 90°. Neutral neck, open chest, relaxed shoulders, neutral thoracic/lumbar spine (Figure 1C).	ADIM: Draw navel to spine. Slight posterior pelvic tilt. Engage transversus abdominis, multifidus, and pelvic floor. Maintain neutral lumbar spine despite extended shoulder position.	Perform 10 reps per set, holding alignment for a few seconds per repetition. Complete 3 sets, taking rest between sets.
Modified MAILE (30° backward pelvic shift) (P4)	Hands and knees alignment: Shoulders at 120°, hands slightly ahead of shoulders. Hips at 50° flexion, knees at 90°. Neutral neck, open chest, relaxed shoulders, neutral thoracic/lumbar spine. Pelvis shifts 30° backward (Figure 1D).	ADIM: Draw navel to spine. Maintain slight posterior pelvic tilt while holding the shifted position. Engage transversus abdominis and pelvic floor without losing lumbar alignment.	Perform 10 reps per set, holding abdominal engagement during the backward shift for a few seconds. Complete 3 sets, with rest as needed.
Modified MAILE (halfway backward pelvic shift) (P5)	Hands and knees alignment: Shoulders at 120°, hands slightly ahead of shoulders. Hips at 50° flexion, knees at 90°. Neutral neck, open chest, relaxed shoulders, neutral thoracic/lumbar spine. Pelvis shifts halfway backward (Figure 1E).	ADIM: Draw navel to spine. Maintain posterior pelvic tilt and engage core muscles (transversus abdominis, pelvic floor). Keep lumbar spine neutral while shifting pelvis halfway.	Perform 10 reps per set, holding the halfway position with core engagement for a few seconds per repetition. Complete 3 sets, with appropriate rest.
Modified MAILE (maximum backward pelvic shift) (P6)	Hands and knees alignment: Shoulders at 120°, hands slightly ahead of shoulders. Hips at 50° flexion, knees at 90°. Neutral neck, open chest, relaxed shoulders, neutral thoracic/lumbar spine. Pelvis shifts maximally backward (Figure 1F).	ADIM: Draw navel to spine. Perform posterior pelvic tilt. Engage transversus abdominis, multifidus, and pelvic floor. Maintain spinal alignment and core engagement as the pelvis shifts back to its maximum extent.	Perform 10 reps per set, holding core engagement at maximum backward shift for a few seconds per repetition. Complete 3 sets, with rest between sets.

MAILE: Multi-angular isometric lumbar exercise; ADIM: Abdominal drawing-in maneuver.