About seven out of every 10 adults develop back pain at least once in their lives. But despite how common this affliction is, the actual specific cause of back pain remains unknown 85% of the time. And this is still true despite diagnostic advances such as CT scans and MRIs. Given the difficulty in finding the exact cause, it comes as no surprise that you hear about so many ways to treat low back pain. But the reality is that 70% of people with an episode of low back pain will be better in one month no matter what they do. And close to 90% will be significantly improved within three months.
So what roles do exercise and fitness have in the treatment of low back pain? Multiple medical studies have examined this issue and the conclusions are mixed. The types of exercises and when to start them depend upon whether the back pain is acute (meaning that it just started or just flared up and lasts less than one month) or persistent (lasting longer than one month). With a few exceptions, the cause of the back pain does not influence exercise choices.
Acute Low Back Pain
Most acute low back pain is mechanical — meaning that the cause is due to strained ligaments and muscles that support the lower spine. Stiffness often sets in as the muscles around the spine tighten up. The muscle spasms can be main source of pain.
A couple of decades ago, prolonged bedrest was routinely prescribed, with a very slow progression to activity. This advice has been completely reversed — now experts think bedrest should be kept to a minimum, one or two days. Muscles begin to lose tone and weaken after several days of inactivity. This deconditioning of the back muscles may actually aggravate the pain and make them more likely to contract and spasm, perpetuating the stiffness.
Studies to look at how effective specific exercises are for acute low back pain have shown disappointing results — people who performed structured exercises did not experience greater improvement than those who did not perform the exercises. However, getting out of bed, dressing and moving, as much as pain allows, does speed recovery and shorten the time to return to work and one's usual daily routine. Listen to your body — move around as much as you can and stop to rest in a comfortable position when the pain and stiffness intensify. Don't let the rest periods extend for hours, try to stand up and move frequently.
Back to top
Persistent Low Back Pain
Studies on exercises for persistent low back pain show more positive benefits, but the evidence for improvement is not overwhelming. And it is not clear what types of exercises work best — some emphasize stretching with the back extended (McKenzie exercises), while others concentrate on gradually increasing flexion of the back. Of the handful of studies comparing the different exercises, the McKenzie extension exercises appeared to decrease pain and stiffness in more of the participants more than other types of exercises.
Back exercises alone are not enough. You also need to increase your aerobic capacity to improve your overall conditioning. By using all your muscles, not just your back muscles, you can recruit abdominal and thigh muscles to help support your back.
Back to top
An Exercise Prescription
You will need to find a program that works best for you. Here is my prescription to get you started:
Begin with isometric exercises. Lying flat on the floor or in bed, flex your knees. Concentrate on tightening the abdomen and buttocks while pushing your spine towards the floor. Hold it for 5 to 10 seconds, and then relax. Repeat this 10 times. You can perform these multiple times per day.
Once the back is a little less painful and more flexible you are ready to try extension exercises. Lie on your stomach and slowly push yourself onto your elbows to support your upper body. Hold this for 15 to 30 seconds. Keep your hips on the floor. Gradually increase the time your hold yourself up to a few minutes, no more than 5 minutes at a time. If it begins causing pain, let yourself down and try again. If it causes pain each time, you may need to switch to flexion exercises.
A simple flexion exercise: Lie on your back with a towel or low pillow under your head and neck. Bend your knees. Grasp your right leg below the knee and gently pull toward your chest. Hold the position for about 20 seconds and slowly release. Alternate with the left leg. Repeat 10 times. This can be repeated often throughout the day.
Once your back is a little looser, you are ready to start a low-impact aerobic exercise routine, such as walking, cycling on a stationary bike, or water exercise. Water exercise is especially useful for patients with marked pain and stiffness because the water helps provide support to the spine. Begin with 10 minute sessions daily and gradually increase to 40 minutes every day. If daily aerobics is too exhausting, change to an every-other-day routine.
More advanced exercises include abdominals with modified sit-ups. Lie flat on your back with knees bent. Support your head with your fingers and raise your head six inches off the floor, concentrating on pushing your lower spine down and tightening the abdominal muscles. As you advance, you can start to add a slight twisting motion to one side and then the other at the top of the lift. If your back begins to hurt, stop immediately. Take some slow deep breaths to help the muscles relax.
Stretching needs to be included in your exercise program. You should stretch immediately after your aerobics while your muscles are warm. If you just plan to stretch, you should still warm up for 10 minutes prior to stretching. A good stretch of any muscle group consists of a slow change in body position until you feel some tension but not pain. Hold the stretch for 30 seconds, do not bounce. If you are very stiff, just go part way for 15 seconds, come out of the stretch, and then go back into it for another 15 seconds.
Back to top
Keeping Back Pain From Recurring
Now that your back is improved, do not stop your exercise program. You probably want to intensify it with a combination of aerobics, strength training, and stretching. Ideally you want to aim for 60 minutes of exercise most days of the week. At all times be aware of your posture, making sure that your back is well positioned during a lift or stretch.
Back to top
Howard LeWine, M.D., is chief editor of Internet publishing, Harvard Health Publications. He is a clinical instructor of medicine at Harvard Medical School and Brigham and Women's Hospital. Dr. LeWine has been a primary care internist and teacher of internal medicine since 1978.