Stretch and Exercise
There is no question that the two most helpful things that you can do to relieve your back pain is to stretch and exercise.
Unfortunately, there is not just one set of exercises that works for all problems, and this is because different people will have pain in different positions. Some people will have pain when they flex forward and some will have pain when they lean back and to the right.
The different movements that generate the pain suggest that different structures in your back may be injured, but most of the time, it is the intervertebral disc and annulus that are injured. Remember that this pancake-shaped structure has 360 degrees of circumference to be injured, thus accounting for the fact that there will usually be one really painful direction of motion. These structures are hurting because a comfortable position of the back cannot be maintained. Therefore different exercises or stretching routines are necessary to correct each posture problem and assume a more comfortable position or posture.
The main purpose of the exercises is to not to strengthen the muscles, but to be able to maintain a more comfortable position of the back.
At this point, I cannot emphasize enough the point that a skillful medical professional, who can examine and watch you move, may provide the best stretching and strengthening program for you. Exercise has been shown to be the most successful treatment of most painful low back conditions, and it is common for back pain to return when the exercises are stopped. Most people don’t consider low back exercises that fun to do, so when the pain goes away, many will quit the exercises only to have the pain start to return.
In this section I will discuss what might be hurting in your back, and why the pain just won’t go away.
We will also discuss the concept of core strengthening, McKenze exercises and why stretching can really help. I will also make mention of 4, relatively rare, problems that are not going to respond to exercise and need further medical evaluation.
Lets talk a little about your pain and why it’s there. Some structure in your back is likely out of place, wearing out, tearing, being pinched, stressed, compressed or chemically stimulated. The pain generating structures are typically the annulus or covering of the disc, a pinched nerve, facet joint, or any of the muscle-tendon-ligament structures that support the back and pelvis. Once this pain-generating structure in your back gets into a painful position, the body wants to avoid any position change that might give rise to more pain. Keep in mind that the deep structures of the back (disc, annulus, ligaments, facet joint capsules, and deep ligaments and tendons) were not meant to be the primary restraints (or stops) for excessive motion of the back. Instead, the muscles and tendons that wrap around the spine are the primary stabilizers to control movement and not let things get to the point to hold the spine steady so powerful motions can be generated be the shoulders and hips.
Your Core and it’s Function
The loss of core strength means a weaker primary restraint system for spine motion. If the movements of the back are not restrained properly by the core musculature, then the deeper and more sensitive structures are left to stiffen the spine. These deep and sensitive structures shout pain when they are injured or stretched too much.
Think of the spine like a mast on a ship. In order to create power for the boat, a sail must be attached to the mast (think arms and legs instead of sail). The mast would be pretty worthless by itself, so ropes or stays have to connect the mast to the deck of the ship to provide stability and stiffness for the mast and allow the sail to harness and transmit power. The mast will only work if there is support from the ropes or stays, otherwise it will just break with any significant pressure. The spine is similar to the mast and the stays and ropes attached to the mast are like the core muscles. Without the large core muscle groups to protect and control spine motion, it’s too easy to get in the wrong position. A wrong position can result in pain from the injured disc/annulus and surrounding muscles that are in spasm. Things can just spiral down from there.
Your Hamstring and Gluteus Muscles
The problem is when big muscles like the hamstrings or gluteus muscles that are just too tight. You might ask how tightness of these muscles can cause back pain. The answer is that over a period of time, they can cause abnormal posture that is compensated by abnormal positioning of the spine. The tight muscles causing back pain are insidious for a couple of reasons.
- It is not easy to see a tight muscle, so some type of physical exam must be done by someone who knows what they are looking for.
- The person evaluating must think to look for tight muscle groups that are causing abnormal postures contributing to your back pain.
The idea that your back might be hurting because of tight muscles elsewhere is just not that logical at first and is another great reason to have a skillful medical professional evaluate you for persistent back pain that doesn’t respond to regular treatment. This muscle tightness may occur for a couple of reasons. One is just a naturally tight muscle, in other words, that’s just the way you are built (these might respond to stretching). A second reason is because of some tightness or spasm in response to some type of injury or abnormal posture, and this tightness may occur is any of the muscles that control the spine, hips and pelvis.
What causes a back to “freeze up”?
The immediate response of the body to any pain is to hold still or move to a position that reduces the pain. The muscles in the back will do just this. When the body determines it’s best to hold absolutely still, the result will be contraction and muscle spasm. Muscle contraction will hold the spine or pelvis in an abnormal position to avoid more pain. If the pain is really bad, your back will just freeze up to eliminate any further motion. The result of this sustained contraction is muscle spasm and now we have two contributors to the back pain. One, the painful structure in your back causing the problem, and two is the buildup of lactic acid in the cramping muscle that is holding your back still with spasm.
If these muscles stay tight, your posture will begin to conform to these abnormal muscle forces and everything can get out of alignment, leaving you susceptible to further abnormal stresses, strains and compensated posture.
How are you supposed to exercise your back when it already hurts too much to even tie your shoes?
I have had serious back pain and muscle spasm with this exact dilemma and wondered how I was supposed to exercise when I could barely get dressed or tie my shoes. This is why I think starting with a good passive stretch is a great way to begin your treatment before exercising. A good stretch can relax those muscles that are in spasm or that are too tight and allow a more natural alignment to occur. A natural alignment that can be maintained by the strengthening exercises that follow.
Remember that the reason to strengthen your back and core muscles is to maintain a comfortable posture. Start with stretching. Getting stretched out is the first place I usually start to get someone out of pain, whether they have had the pain for a day or a decade. Most pictures that you see are those of active stretching in other words, you are doing the exercises by yourself. I advocate getting stretched passively. This means that you don’t do anything except lay there while someone else stretches outyour tight hip, pelvis and back muscles so they can relax and let the back return to a more relaxed and normal position. Only when these muscles become relaxed and somewhat pain-free can normal alignment be restored and the core muscles be exercised and strengthened.
Tight muscles in spasm are a common reason that a painful back cannot be successfully rehabilitated and stay rehabilitated. In the next Action Steps, I will show you a passive stretching routine. You can show this to your chiropractor, therapist, or trainer so they can see the moves and see if they are appropriate for you. These can take a few sessions to see the full benefits of stretching, but in my experience, the pain relief and improved range of motion were immediate. If good results are had with the Stretch, then it may have to be repeated on a daily or every-other-day schedule till the pain has subsided to a point where the strengthening exercises can be done comfortably.
I also think its beneficial to stay stretched out once you have healed your low back pain, by getting a maintenance stretch every 2-4 weeks, to prevent a recurrence of pain. This is especially true for people who are tight in general. The stretching routine may not have much benefit in flexible people, and there is research available about the problems of overstretching.
In my estimation, stretching is the most neglected part of our life regimen today for those of us who are tight, regardless of activity level. This stretching regimen (Action Steps video) uses your legs as levers to provide the leverage necessary to stretch the largest muscles in your body (hamstrings and quads) as well as the gluteus, pyriformis, IT band muscles and tendons. I have seen pictures of how to stretch by myself and I have the knowledge to do so, but I could not do them by myself, when I had serious back pain to deal with. You must take the video to a trained professional and let them work this magic on you before you start your strengthening exercises. What a difference it can make!
Don’t jump to conclusions!
I have had more than one patient come to my office thinking that surgery was their only option, only to find out that once their rock-hard hamstrings were stretched out, that the low back pain they had was only a minor annoyance that did not require surgery!
A chiropractor, therapist or trainer has evaluated many of you, and there are a few reasons that professional guidance is a good place to start. The first is because the stretching regimen I am suggesting requires another person to stretch you out passively. When another person stretches you out passively, this means that you don’t do anything or try to help, this is called passive stretching. In this type of stretch, another person is using your long bones as levers to stretch outthose large tight muscles, like hamstrings, quadraceps and gluteus muscles. After this stretching routine shown in my video, the appropriate exercises can be started.
Once the pain from tight muscles and spasm has been addressed with passive stretching, then the strengthening exercises can started. These exercises must begin slowly and increasedto pain tolerance, there is no point to working through the pain.
Stretched Out and Ready for Exercise
The main difficulty in approaching back pain with exercises is to figure out what to exercise and strengthen and what to stretch. Knowing what to exercise requires some insight into what position is causing the pain to begin with. If you just look at a list of exercises and try them out, you might get lucky, but just know that one size doesn’t fit all.
This differentiation is what makes the treatment of the painful back so difficult, and why a medical professional can be key to getting relief. There are two general low back exercise regimens. The first is referred to as McKenzie Exercises, developed by Robin McKenzie from New Zealand. They focus on strengthening the muscles that extend the back (the opposite of flexing forward) in order to reduce the pressure on a compromised disc space.
See http://www.mckenzieexercises.com/ for a more complete description.
These exercises can be helpful for treating leg pain from a disc herniation or back pain from degenerative disc disease.
The second common exercise regimen is referred to as Lumbar Stabilization Exercises that emphasize strengthening of the core musculature, particularly the abdominal muscles. The core muscles are comprised of large groups of muscles that often span the length of the spine or crisscross the torso. Although there is not complete agreement
of experts of which muscles to include, they often include the Rectus Abdominus, Transverse Abdominus, Internal and External Obliques, Multifidus and Erector Spinae, Gluteus Minimus, Medius, and Maximus, Hip Flexors, Hip Extensors, Hip Abductors and Hip Adductors. Think of these muscles as the ropes or stays that help support the spine (mast of the ship).
The idea of stabilization exercises is to find a position of the spine that is comfortable (neutral spine) and then exercise the back muscle groups to teach the spine how to stay in this position. These exercises are performed on an ongoing basis with the goal of pain relief and a comfortable position of the spine. Stabilization exercises are strengthening exercises that are progressive in difficulty and are aimed at a group of muscles rather than a single muscle. It is helpful to think of the core muscles as a group of support ropes for the mast, rather than a single rope.
There are many descriptive sources of progressive stabilization exercises, but one I like is the Princeton University Lumbar/Core Strength and Stability Exercises (http://www.princeton.edu/uhs/pdfs/Lumbar.pdf).
I like this description because it lists the variety and difficulty of the exercises. The American Academy of Orthopedic Surgeons gives a great pictorial description of back exercises seen at (http://orthoinfo.aaos.org/topic.cfm?topic=a00302).
There are other exercise regimens that can be helpful as strengthening and stretching exercises to maintain a pain-free back such as pilates, yoga or tai chi. Pete Egoscue advocates his technique that emphasizes structure, position and posture to treat and eliminate back pain.
The above regimens emphasize stretching and strengthening exercises to maintain a comfortable posture to avoid back pain. These exercise regimens may become part of your daily routine if back pain recurs when the exercises are stopped. When the back pain becomes manageable or resolves, there is a third, more generalized exercise regimen that should become as much a habit for you, as brushing your teeth is.
In general, these exercises are referred to as aerobic exercises. These exercises provide maintenance levels of fitness for much more than just the back. Aerobic exercises provide benefits to many systems that include cardiovascular (heart), lung, musculoskeletal as well as psychological (elevated mood). Aerobic exercises use oxygen to provide energy and are not too intense, so normal conversation may be had when performing them. Such exercises are usually performed for at least 15-40 minutes at least three to six times a week.
Examples of such exercises are walking while breathing deep, light jogging, biking, or elliptical trainers for 20-30 minutes a day. Rebounding is a very efficient exercise that only requires about 15 minutes a day. Another high-tech and efficient method of exercise with lots of benefits is exercising on a Power Plate or Whole-Body Vibration, which is a spin-off from Russian space technology.
The vibration generates an involuntary muscle contraction in every muscle in the body, putting every muscle in training. They state that a few minutes can simulate an hour of jogging! This first step of stretching and strengthening of your back is the most important step you are going to take to reduce or eliminate your low back pain.
You can do this! Take control of your pain, it might be slow to start but should get better in a short time.
Remember if your back condition does not respond within a few days or gets worse with these recommendations, make an appointment with a specialist for further evaluation!
Start with passive stretching of tight muscles of the back, buttocks and legs. Show this video to your treating practitioner or trainer to see if appropriate, since they will have to do the stretching.
McKenzie and/or Stabilization Exercises to reduce or eliminate low back pain.
Start to notice activities, positions and the time of day that result in more back pain. This may help you get some awareness of what you are doing that increases your pain. You may even have to take some notes (journal) about what you actually do each day to see if you can uncover a pattern.
Start Aerobic Exercises (3-6 times a week) to increase and maintain fitness, when back pain is under control to prevent further occurrences of pain.
In the next session we will look at the importance of sleep and how it contributes to your health and well-being.