Exercises for Acute/Chronic Low Back Pain/Injury Prevention

Learning home-based therapy for injury prevention or for recovery from injury/surgery.

Low-back pain is very common, and most people will experience it at some point in their lives (1). For most, the cause is a lumbosacral strain that results in an acute episode of low-back pain that lasts 1–2 weeks. Lumbosacral strain is an injury to the muscles and fascia of the low back and can be incredibly painful. Exercise can help alleviate an acute lumbar strain and can help protect your back from future episodes. In this article, we explore exercises that can be used for the treatment of acute lumbar sacral strain, and for the daily maintenance of your back.

The spine is an elegant suspension bridge held together by a complex series of discs, ligaments, and muscles. The muscles—known collectively as the paraspinals—act as the cables that maintain the structure and shape of the spine. Essentially, they stabilize the bones similar to the way cables stabilize a suspension bridge. If they are strained, torn, or become weak, you can experience back pain (2). If the paraspinals become weak or damaged, your spine can be subjected to abnormal, uncoordinated motion which allows degenerative conditions to worsen (3). Thus, it is widely believed that maintaining these muscles is critical for low-back health (4).

Each patient will have a different capacity for doing exercise, so it’s important not to go too fast or push too hard right off the bat. If you have no experience with exercise, it’s also important to work with a trainer or physical therapist initially to learn proper technique and to avoid injury. Each exercise can be modified to fit your experience level. Exercises for the low back generally fall into three categories: flexibility, stability/strength, and endurance. We can also separate exercises based on when they should be used—e.g., during an acute episode of low-back pain or for maintenance and prevention of low-back pain.

In some cases, the pain may be due to more serious and/or chronic pathology. It’s also important to remember that some forms of low-back pain can be caused by conditions that exercise will not help, such as infection, tumor, or fracture. If you are having serious symptoms such as numbness, weakness, fever, or incontinence, please see your doctor immediately.

Finally, before we get into the actual exercises, it’s important to remember there are no hard and fast rules in choosing exercises for you. Typically, you should make choices from each category, focusing on strength, flexibility, and endurance, but if one causes pain or doesn’t work for you, please avoid it. The exercises and stretches depicted here are from a combination of yoga, Pilates, and physical therapy techniques, and represent the ones I personally find useful. If they don’t work for you, please know there are many alternatives. Here, I include descriptions of the exercises for quick reference, but please see the video for visual depictions of the exercises.

Flexibility:

Good flexibility of the spine and core muscles  (paraspinals, quadratus lumborum, psoas, abdominals) will allow you to remain supple and injury free. Many injuries occur because the spine becomes stiff in some areas, putting more stress on others. The discs and joints of the spine are also nourished from motion, so if you do not move enough, they will degrade faster. It is also important that the muscles around the hips are well oiled. These include the hip flexors, quadriceps, iliotibial band (IT band), tensor fascia lata, piriformis gluteals, and hamstrings. Maintaining good hip motion reduces strain on the low back.

Here is a typical series of low-back flexibility exercises. You can do each stretch 4–5 times and hold for 1–2 breaths. Make sure you never force or swing your back. Do each exercise in a controlled fashion. You can use the flexibility exercises to warm up for endurance and strength exercises.

·      Double knee stretch: laying supine, brace the abdominals and bring both knees to your chest. This stretches the erector spinae, gluteals, and multifidus muscles.

·      Single knee stretch: laying supine, bring one knee to the chest; pull it in with your arms. Then alternate to the other side. This stretches the muscles noted above, plus the hamstring of the other leg.

·      Hamstring stretch: from the single-knee stretch position, straighten your leg to the sky so that the foot is pointed into the air; hold onto the back of the knee. This stretches the hamstrings.

·      Tensor fascia lata stretch: from the hamstring stretch, allow your leg to bend and drop down to the floor on the opposite side, crossing over your body and your torso to twist. If this is difficult, you do not need to let your foot touch the ground. This also stretches the obliques, tensor fascia lata, and quadratus lumborum.

·      Piriformis and Gluteal stretch: from the supine position, cross your foot over your other knee, getting into a figure 4 position, then bring your other knee to your chest by pulling with your hands. This will twist the hip and stretch the gluteals and piriformis.

·      Quadricep and hip flexor stretch: lie on your side and pull the ankle closest to the ceiling to your buttocks and hold. An alteration of this is lying flat on the ground with your single knee bent and ankle pinned between your body and the ground. This helps stretch the quadriceps and hip flexor muscles.

·      Rectus abdominis stretch: turn over onto your stomach so you are prone and push up from the waist, arching your back. This will stretch the abdominals and obliques.  

·      Quadratus lumborum stretch (child’s pose): from the prone position, draw back onto your knees so that you are kneeling; reach your hands forward across the floor.

·      Cat and camel stretch: get on all fours and arch your back up and down, gently oscillating between “cat” (arched) and “camel” (slumped). This helps move the individual vertebrae.

In addition to the stretching program noted above, rolling the back with a foam roller or balls are excellent ways to break apart stiff and crusty fascia that may be bound by fibrous adhesions and improve muscular blood flow (5). Foam rollers, consisting of firm cylinders of various materials, can be purchased online or at fitness stores. It takes some balance skill to use a foam roller, so I recommend starting with one leg at a time. Ask for help and supervision if you are doing it for the first time. For each position, perform, 6–7 back-and-forth motions.

·      Gluteal roll: From the sitting position with your arms behind you, put the roller under your buttock and rock back and forth, balancing with your arms.

·      Hamstring roll: From the sitting position, move the roller down to the back of your thigh and roll back and forth.

·      Calf roll: Move the roller farther down under your calf, holding yourself up with your arms, and roll back and forth.

·      Quadriceps roll: Turn prone and hold yourself up with your forearms; put the roller on the front of your thigh, and roll back and forth.

·      Oblique: Lying on your side, holding yourself up with your forearm, put the roller under your torso and roll back and forth.

Endurance:

The prototypical endurance exercise for the low back is walking. It is easy, safe, and can be done almost anywhere without any equipment. However, there are several modifications we need make to improve its effect for low-back health. We generally need to walk at a brisk pace to elevate the heart rate to or above 120 beats per minute. (A casual stroll will not do, so please check with your doctor before performing exercise if you have heart conditions.)

An easy way to ensure you are getting cardiac activation is to walk up a steep grade or incorporate stairs into your walking course. Walking on flat ground is important so that you do not suddenly contort your back to balance yourself on rocky ground. Furthermore, as you walk you should be very conscious of your low back, and brace the abdominal muscles—meaning contract your abdominal muscles to stabilize the spine. An easy way to conceptualize this is to walk around as if you are expecting someone to jump out and punch you in the stomach. You also need to focus on good posture as much as possible, meaning you walk upright looking forward, not down. Your shoulders should be back and not slumped forward. Good posture keeps the back in neutral anatomic alignment, reinforces habitual body mechanics, strengthens the core muscles (see below), and protects your spine as you walk.

A walking program should take place for 30–60 minutes per day, 5 days a week. If you cannot do this, start where you can, but do not overexert yourself and cause pain or injury.

Strength and Stabilization: Core exercises.

What is the core? The core consists of a “box” of muscles that surround the low back and include the rectus abdominus in the front; transversus abdominus and internal and external obliques on the sides; and quadratus lumborum, multifidus, and erector spinae in the back. It also includes the diaphragm (the large muscle that allows breathing) and pelvic floor muscles that make the roof and floor of the “box,” respectively. All these muscles connect to a layer of dense connective tissue known as the thoracolumbar fascia, which allows the transfer of power between different areas of the torso and the bones.

The core acts as the suspension wires holding the spine upright and in the correct position. Imagine the Golden Gate Bridge with the long suspension wires holding it up. If any wires go down, increasing stress is put on its neighbors. This is why it’s critical to maintain a strong core, because if the muscles become weak, stress increases on the bones, ligaments, and remaining muscles of the spine. Without your core, your spine would not be able to keep your torso upright, and it would collapse (6). Patients with chronic low-back pain avoid using their core muscles because it may induce pain, so those muscles become even weaker, promoting a vicious cycle. This is especially true after spine surgery when you are recovering. Thus, part of the recovery process from surgery is rebuilding and strengthening these muscles. Core strengthening programs have been shown to reduce chronic low-back pain (7). 

A core strengthening program focuses on building the strength of these muscles and is done through a combination of dynamic (motion) and static (motion-free) exercises. It is critical to realize that both control and coordination play as important a role as repetition. Unconscious reps are an easy way to be injured. Better to pay close attention to your movements and perform them in a correct and controlled manner rather than trying to do as many reps as you possibly can. In this way, you not only improve strength but also increase your neural coordination and avoid injury.

Many of the tenets of core strengthening are embodied in popular exercise models such as Pilates, yoga, and Tai Chi (6). Each movement should be done for a total of 30 seconds, or as long as you can tolerate, and repeated 4–5 times. It is important to remember to gradually build your tolerance and not expect immediate results.

·      Dead bug: lying supine, with arms raised over your head, elevate your right arm and bend in your left knee. Repeat on the other side.

·      Hip bridge: lying supine, bend your knees and elevate your torso off the ground and hold. You can increase the difficulty by elevating a single leg off the ground.

·      Sit-up: starting from a supine position, bend your knees slightly, and gradually raise your torso. Keeping your neck in line and your low back braced, touch your knees. Caution: sit-ups, if done incorrectly, can place high strain on the discs, so make sure you are controlled and bracing the entire time (6). Sit-ups may be modified by sitting on a ledge such as the edge of a couch or bed, and instead of bringing your torso to your feet, raise your legs into the air. This allows the spine to remain stabilized and still activate the core.

·      Side plank: now turn on to your side and elevate your torso off the ground, keeping your torso straight and parallel to your legs. If this is difficult, you may allow your knees to touch the ground. Difficulty can be increased by either raising your other arm into the air or raising your upper leg into the air.

·      Prone supermans: lying on your stomach with your arms outstretched, elevate your arms and torso off the ground and hold. For increased difficulty, you can also elevate your legs off ground.

·      Bird dog: on all fours, elevate your leg straight back one at a time until it is straight. You can increase difficulty by also elevating the opposite arm straight forward until it is straight, and you resemble a bird dog.

·      Plank: lower yourself onto your forearms and hold your legs and torso off the ground in the plank position.

Practices to avoid:

In the development of a low-back exercise program, it is important to recognize that you will not be comfortable with all movements. If anything causes excessive pain, numbness, shooting nerve pain (sciatica), electric shock or burning sensations, it should be removed from your exercise program. It is best to learn from a professional trainer or therapist if you have no initial experience.

Any movement that causes excessive compression of the intervertebral discs may be harmful to the spine. Such exercises include forced back extensions such as those done on “roman chair” exercise machines. Uncontrolled and forced bending or twisting of the spine may also cause injury to the discs and ligaments. Do not perform spinal exercise immediately after getting up in the morning as the discs are gel structures which may not be totally stabilized and hydrated after a night in bed (6).

At all costs, avoid smoking and alcohol which damage the discs and bones.

Acute Low-back pain program

When you are in the throes of an acute lumbosacral strain, considering exercise is the last thing you want to do. You may be very worried about triggering pain and even worsening your condition.  With an acute lumbosacral strain, the back is very painful, aggravated by any motion, and the pain takes over your life. The pain distorts your personality and takes you from being active and healthy to bedridden. You think you have been struck down and may ask “why me?”

Take a deep breath, for there is hope. Although you may need to reset for several days after an injury, remember that prolonged bed rest is not healthy, as it leads to atrophy. Counterintuitively, motion can also be good medicine for the bones and joints and can help you recover if done properly. Exercise may not be immediately possible, so if you spend the first few days in bed it is important to pay attention to the following:

·      Do not stay in one position in bed; shift periodically from side to side.

·      Exercise in bed by performing quad and calf contractions (tightening your thighs and calves intermittently without producing motion. Brace your abdominals and breathe deeply.

·      If you need to get up, do not perform a sit-up to get out of bed. Roll to your side and push your torso up with your arms while swinging your legs out of bed. This is called the “log roll” and allows your spine to remain neutral (8).

 To be able to tolerate an exercise program, it may be necessary to reduce your pain level first.  The best ways to do this are through massage, transcutaneous electrical nerve stimulation (TENS), icing, and non-steroidal anti-inflammatories. Anti-inflammatory medications and TENS unit use should be guided by a physician. For our purposes we will discuss the acute treatment of lumbosacral sprain with gentle massage, exercise, and icing. A reminder: be sure to check with your general physician to make sure you do not have a more serious condition as noted above.

When you suffer from a lumbosacral sprain the muscles can become sore and spasmed, meaning they are continuously contracting and cramped. As most of the core muscles are paired, this can easily lead to a muscular imbalance where one muscle is strongly contracting and the other is weaker. This can contort the body, leading to more pain. To get a muscle spasm to relax, targeted pressure from massage can be very helpful. This is similar in concept to foam rolling with the goal of getting the tissues unstuck and relaxed. An easy way to do this is with a firm ball, such as a lacrosse ball. Commercial massage balls are also available and can be put in the freezer overnight to help with cold therapy.

·      Lie supine with your legs bent and raised onto a chair or couch. Place the ball on the tender area in your low back and move back and forth to massage the area.

Low-back pain is easily exacerbated by sitting for prolonged periods of time which allows the discs to deform.  Lifting without proper posture can also exacerbate low-back pain, so maintain a good upright position with lumbar lordosis (curvature of the lumbar spine). Low-back pain can also be precipitated by spasm, which causes the pelvis to rotate abnormally. If you have abnormalities in muscles of the lower extremities such as the gluteal or hamstrings, making them asymmetric, it can also malrotate the pelvis, predisposing you to low-back pain (9). Reset your back with the following exercises:

·      Lie supine and raise both knees. Put your right hand on top of your right knee and cup the opposite knee with your left hand. Push your right knee down while you resist with your right hand. Pull in with your left hand while resisting with the left knee. Hold this static position for 4–5 seconds and reverse.

·      Lie supine and slide your ankles toward your buttocks so your knees are bent but your feet are on the floor. Rock your knees from side to side with a twist.

·      Use a ball or foam roller and roll out your obliques on each side.

Icing directly anesthetizes the spasmed area and can reduce inflammation. A simple way to accomplish this is by freezing water in a dixie cup then tearing off the top of the cup. This allows the ice to have a “handle” for use in massaging in a circular motion over painful areas. Dr. Dawson, an old army general surgeon, taught me this trick, and I have found it incredibly helpful. Icing should be performed for 20 minutes every hour.

Nonsteroidal anti-inflammatory and steroidal anti-inflammatories can be used to help decrease your pain, but are not long-term solutions. They also have harmful side effects if used for prolonged periods. Similarly, many people ask about the use of a brace, which is an external orthosis that helps support the spine. Braces act as a surrogate to your weakened core muscles and can make you feel better in the short term. However, braces accelerate atrophy and are not a long-term solution.

In conclusion

As a surgeon, I can remove disease from the spine and stabilize broken or worn-out areas of the back, but I cannot rebuild your core muscle suspension system. I cannot mobilize scarred and contracted ligaments and muscles. I can unstick nerves, but I cannot keep nerves gliding. (In fact, without motion immediately after surgery they will become stuck again.) It is up to you to become a student of exercise and understand how to care for your back in the same way you should brush your teeth every day.

References:

1.         Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine (Phila Pa 1976). 1987 Sep;12(7):632–44.

2.         Arokoski JP, Valta T, Airaksinen O, Kankaanpää M. Back and abdominal muscle function during stabilization exercises. Arch Phys Med Rehabil. 2001 Aug;82(8):1089–98.

3.         Magnusson ML, Aleksiev A, Wilder DG, Pope MH, Spratt K, Lee SH, et al. European Spine Society--the AcroMed Prize for Spinal Research 1995. Unexpected load and asymmetric posture as etiologic factors in low back pain. Eur Spine J. 1996;5(1):23–35.

4.         Manniche C, Hesselsøe G, Bentzen L, Christensen I, Lundberg E. Clinical trial of intensive muscle training for chronic low back pain. Lancet. 1988 Dec 24;2(8626–8627):1473–76.

5.         Guillot A, Kerautret Y, Queyrel F, Schobb W, Rienzo FD. Foam Rolling and Joint Distraction with Elastic Band Training Performed for 5- 7 Weeks Respectively Improve Lower Limb Flexibility. J Sports Sci Med. 2019 Feb 18;1:160–71.

6.         Akuthota V, Ferreiro A, Moore T, Fredericson M. Core Stability Exercise Principles: Current Sports Medicine Reports. 2008 Jan;7(1):39–44.

7.         Suh JH, Kim H, Jung GP, Ko JY, Ryu JS. The effect of lumbar stabilization and walking exercises on chronic low back pain: A randomized controlled trial. Medicine. 2019 Jun;98(26):e16173.

8.         Schatz MP, Iyengar BKS, Connor W. Back Care Basics: A Doctor’s Gentle Yoga Program for Back and Neck Pain Relief. 1st edition. Berkeley, Calif: Rodmell Press; 1992. 248 p.

9.         Starrett K, Cordoza G. Becoming a Supple Leopard: The Ultimate Guide to Resolving Pain, Preventing Injury, and Optimizing Athletic Performance. 2nd edition. Las Vegas: Victory Belt Publishing; 2015. 480 p.