Low back pain is a complex, multifactorial musculoskeletal condition that will affect up to 80% of the global population at some point in their lives. Low back pain accounts for a significant proportion of years lived with disability and has a staggering burdensome impact at a societal level and on healthcare systems around the world. We can therefore expect that low back pain exercises are equally complex. Low back pain is treated in a multimodal context, i.e., clinicians use several modalities and treatment options together to provide intervention and prevention programs that account for many of the biopsychosocial factors evident in low back pain. One such intervention widely used that has moderate- to high-quality evidence, as purported in the scientific literature, is exercise in general, but more specifically muscle strengthening and endurance and spinal mobility training.
What is Low Back Pain?
Low back pain can be broadly defined as pain and discomfort experienced in the posterior back, localised below the costal margin and above the inferior gluteal folds, with or without leg pain. Low back pain can be categorised into several types and sub-types (e.g., timeframe, tissue in injury, severity/triage etc.), but here we will discuss effective exercises for uncomplicated, non-specific low back pain. Non-specific low back pain is further defined as low back pain that is caused by by abnormal stress and strain on lumbar musculoskeletal structures in the absence of serious pathology (e.g., radiculopathy, tumor, fracture, infection, etc.) and encompasses a broad range of very common musculoskeletal/mechanical disorders.
Aerobic exercise can be defined as any of the various sustained exercises that stimulate and strengthen the heart and lungs, thereby improving the body’s utilisation of oxygen. Examples include:
- Walking, jogging and running
- Boxing and kickboxing
- Skiing and snowboarding
- Dancing and skipping
Aerobic exercise has shown to improve low back pain as it increases blood flow and nutrients to the soft tissues in the back, which improves the healing process and reducing back stiffness. Furthermore, 30-40 minute of aerobic exercises can increase the production of endorphins, a chemical released in the brain that affects opiate receptors in the brain and spinal cords’ pain control system, which decreases pain perception.
Aerobic exercise also improves functional status and reduces fear avoidance of movement. Fear avoidance of movement is a predictor for functional limitations and is associated with disability in patients with back pain. In a study examining 6-weeks of moderate intensity walking on a treadmill compared to strengthening exercises for the trunk and limbs on 52 patients with low back pain found that both interventions reduced low back pain symptoms.
In another 8-week study on patients with low back pain reciveing moderate intensity aerobic exercise and conservative physiotherapy management compared to physiotherapy alone found that the subjects who underwent the combined management strategy experienced 42% less low back pain. Other similar studies examining intensive aerobic exercise on back pain also concluded that intensive exercise groups reported less back pain.
Muscle Strengthening and Stabilisation Training
Muscle strengthening is the ability of muscle groups to develop maximal contractile force against resistance in a single contraction. Whereas, stabilisation training is an active form of physical therapy that aims to strengthen muscles to support the spine and help prevent low back pain.
Examples of muscle strengthening and stabilisation exercises include:
- Prone/supine bridges and their variations and progressions
- Planks and their variation and progressions
- Crab walks, standing fire hydrants and clams for gluteal training
- Nordic hamstring exercises
- Squats and its variations and progressions
- Balancing exercises, such as wobble-board and Swiss- and medicine-ball exercises with/without weights and focusing on both the trunk and extremities
Poor core muscle strength and control has shown to lead to lumbar instability and this also reduces lumbar spine flexibility. Moreover, patients with back pain often reduce trunk movement and develop antalgic postures in an attempt to avoid pain, but this further reduces core strength thus increasing lumbar instability, which leads to more back pain episodes.
Exercises that aim to activate deep and superficial abdominal and paraspinal muscles, including transversus abdominis and multifidus, are important for patients with low back pain. These core muscles are essential in supporting the lumbar spine. Significant axial forces/stressors are placed on the vertebral column and its surrounding muscles, which can lead to back pain. In particular, transversus abdominis is an important muscle for spine stabilisation that supports posture; however, activation in this muscle has shown to be delayed during movement in low back pain patients. Spinal stabilisation exercises aim to increase the strength and endurance of these muscles, thereby improving spine stability.
Core stabilisation programmes have shown to significantly reduce low back pain by 39%–77%, and likewise muscular strength programmes have shown to significantly reduce low back pain by 62%. A 3-month study involving 30 subjects with low back pain compared core stabilisation exercises (i.e., slow curl ups, bird dog, the plank and sit ups) to conventional spine exercises (i.e., static stretching of tight muscles). The study found that the core stabilisation exercises significantly reduced low back pain by 77% compared to 63% following the conventional exercises.
Low Back Flexibility and Spinal Mobility
Low back flexibility and spinal mobility refers to the range of motion in a single joint or multiple joints of the lumbar spine, and length in muscles that cross these joints to facilitate movement.
Examples of low back flexibility and spinal mobility exercises include:
- Static or proprioceptive neuromuscular facilitation stretches for the hips flexors, hamstrings, quads and gluteals
- Low back repeated extension in lying exercises as seen in McKenzie Therapy
Stretching the back (erector spinae and deep core stabilisers), legs (hip flexors, hamstrings, quads) and buttock (gluteals, external rotators of the hip) muscles can help to mobilise the spine, and increase in spinal range of motion assisting in reducing back pain. Improved movement increases the ability for patients to complete activities of daily living, such as lifting and bending. Stretching also decreases muscle stiffness as a result of changes in viscoelastic properties, due to decreased actin-myosin cross-bridges and the reflex muscle inhibition.
Flexibility exercises are often used in exercise rehabilitation programmes because they are effective at reducing low back pain. However low back pain patients must be careful not to perform exercises that result in pain, especially when stretching the flexors and extensors of the trunk and hips. A 4-week intervention programme involving 40 low back pain patients included 10 lumbo-pelvic non-weight-bearing exercises in prone, supine and side lying positions, which were completed twice a week with 10 repetitions. The study found a 54% increase in lumbar flexion, a 98% increase in lumbar extension, and a 58% improvement in self-reported back pain.
Lumbar extension exercises, such as those prescribed in McKenzie Method of Mechanical Diagnosis and Therapy, can reduce tension in the posterior annular fibres and lumbar spine discs, and change intradiscal pressure, which allows anterior migration of the nucleus pulposus (i.e., inner portion of the disc). This is important for normal vertebral disc function to withstand compression forces. Furthermore, lumbar flexion exercises stretch the hip flexors and lumbar extensors, and decreases the compressive forces on the posterior disc.
Exercise programmes involving muscular strength, flexibility or aerobic fitness in combination appear to be beneficial for reducing the pain and disability associated with low back pain. This is particularly true in patients presenting with chronic (>3 months) low back pain. Exercises performed 2–3 times per week can reasonably be recommended for prevention of low back pain in the general population.
At Sydney Spine & Sports Centre (S3C) in Balmain, our clinicians are highly trained in sports chiropractic and provide excellent, evidence-based and tailored exercise programs for patients with low back pain and all types of musculoskeletal disorders. Visit our website to book online today: www.s3c.com.au/book-now.
Please visit our website and blog pages for more information on low back pain:
- How Chiropractors Treat Back Pain
- The Effect of Prolonged Sitting on Neck and Back Pain
- Lumbar Extension Exercises in Low Back Pain
- The Role of Gluteal Muscles in Low Back Pain
- 14 Myths and Truths of Low Back Pain
- Low Back Strains and Sprains
- Low Back Pain Overview
- Lumbar myelopathy
- Cauda equina syndrome
- Lumbar spinal stenosis
- Bone Spurs
- Degenerative disc disease (DDD)
- Pinched nerve
- Lumbar radiculopathy
- Lumbar facet joint pain
- Bulging Disc
- Herniated Disc
- Disc protrusion
- Discogenic pain
- Post laminectomy syndrome
- Ankylosing spondylitis
- Reiter’s syndrome
- Psoriatic arthritis
- Enteropathic arthritis
- Sacroiliac disorders
- Foot drop
- Spinal neurofibroma
- Acute low pain
- Chronic low back pain
- Stiff low back
- Trigger points in the low back
- Red flags for low back pain
- Internal disc disruption
- Lumbar spondylosis
- Lumbar facet syndrome
- Lumbar foraminal stenosis
- Lumbar disc herniation
- Lumbar osteoarthritis
- Lumbar osteophytes
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