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Exercising for Lower Back Pain – Where Do You Start?
by Jason Gruss, MD, FAAPM&R

So you have pain in the lower back, legs, pelvis or trunk area and you’ve heard a lot about strengthening your core and various other lower back exercises but you, like millions of other Americans, iStock_000017269628XSmall.jpghave discovered that it hurts to do those type exercises.

So, if you are like many you are afraid to continue. Questions abound. Am I doing the right exercises? Am I doing the exercises right? Am I starting with the right type exercises for my condition? Should it hurt while I exercise?

Yep, we hear the same questions all the time. So, rest assured, you are not alone with this line of questioning.

The start point of any exercise program begins where you are the least fit. If you want to run a marathon but can’t walk around the block without getting winded or shin-splints, why try to run up and down hills on your first day? You are doomed to failure.

When dealing with back pain most of our patients have been overly protective of their back for weeks, often months and sometimes even years. When you protect yourself from any painful movement you inherently alter normal movement patterns and as a result your muscles become out-of-balance.

The place to start is with gentle flexibility exercises to restore movement and elasticity. Please take note of the keyword in that last sentence GENTLE. Rehab exercise should never be painful. It may be slightly uncomfortable but not painful.
Every muscle in your body has an opposing muscle. In your upper arm your front arm muscle (the biceps) bends your arm at the elbow while the back arm muscle (the triceps) straightens the arm at the elbow. One group flexes and the other extends. This same scenario is repeated throughout your body. Without opposing muscle groups you’d get stuck in one position without the ability to reverse your movement. 

In your lower back your ab muscles pull you forward while your back muscles straighten you out and keep you erect.  With lower back pain victims we usually see weak ab muscles and inflexible back muscles. 

Here’s where most people screw up. They think because they have weak muscles they have to do strengthening exercises. Most often they hear about the CORE so they start doing sit-ups. Whoa! No TRIPLE WHOA!!

That brings us to the first rule in rehab that says before you can strengthen a muscle you have to restore flexibility to its opponent. Sound complicated, yeah I know but it's not really, and it’s one reason so many well intentioned exercisers and even some exercise therapists fail.

When you read about core exercises you most often hear about strong abs, so logic says “let’s do crunchies” (or worse yet full sit-ups) right? Wrong. Here’s where most everyone makes their first mistake: they start by strengthening the weak (their ab) muscles when they should be starting by stretching the inflexible (lower back) muscles. Most often we see tight inflexible back and back-of-the-leg muscles, so gentle hamstring stretches and simple low back stretches are in order.

Depending on the elasticity (or in-elasticity) stretching may last a few weeks before we even think about strengthening.

There are six primary muscle groups that compose your core. Start with very, very gentle stretches to restore flexibility to inflexible muscles. If you ever heard the old cliche “No pain, no gain”, FORGET IT, it’ll make you worse!

Once the stretching part is complete we can start work on strengthening the weak opposite muscles.  This should help balance out the back supporting muscles and add both flexibility and stability.
The typical pattern is as follows:


Inflexible Weak
Low Back Abdominals
Hip Flexors Buttocks
Back Thigh Front Thigh











I feel better thank you, we’re done. Not so fast, we’re only one third of the way home.

"Did you ever wonder why back pain returns?  We’ve just balanced the majoriStock_000016333205XSmall.jpg muscles groups by restoring flexibility and adding some strength and as a result we feel better. However, there are dozens of smaller muscle groups that have to be retrained for the big groups to do their jobs correctly on a consistent basis.

These smaller muscles are often referred to as setting muscles. You’ve probably heard of the Rotator Cuff muscles in your shoulder. Many athletes have shoulder problems related to the Rotator Cuff. The Rotator Cuff muscles DO NOT power the shoulder/arm, they simply put your upper arm joint in the right position so the big powerful muscles can pull or push in the right direction with our injuring the joint.  They set the joint up for proper mechanics.

It’s true about all the tiny muscles that surround and attach to your spine as well. They set the spine up to make it ready for the big guys. If these little guys are out of synch, it’s not a question of “will your back go out”, it’s “WHEN will your back go out?”

Did you ever step off a curb without being prepared and feel a lightning bolt jolt your spine? Yep, it could be a curb, a step or something as ridiculous as picking up a pencil or lifting your infant child. If the setting muscles haven’t set the joint up properly, WHAMMO!

So, how do we train these muscles? There are a variety of ways but basically we start patients performing slightly exaggerated movements similar to those that they would typically do in their jobs and daily lives. Golfers might simulate wood chopping motions, while a dock worker might simulate lifting and bending movements.

The key is start with a portion of the movement and slowly but progressively add more to the movement. After a few sessions we finish with exaggerations of the same movement. We often have patients perform slow structured movements first without resistance (weights, elastic bands or resistance machines), then we begin adding more and more resistance by increasing weights or band thickness.

Well, thank you now I’m done, right? You guessed it: not so fast!  There’s one more important step and it’s called neuromuscular re-education or proprioceptive training.
Watch an infant learn to walk, it’s amazing. They start with a stand and then fall (fortunately they have a low center of gravity and are close to the ground, so there isn’t much damage). Then they step and fall. Then step, step, wobble, fall. Then three steps, a few more wobbles, a couple of falls, and so on. They are learning proprioceptive skills or balance and muscle coordination. Pretty soon they are running from room to room, tearing up the place and you kinda wish for the good old days.

Because you had your back pain for a while (it only takes a couple of weeks), you’ve learned new (very protective but very bad) movements. Your back has to be resynchronized. Just like our cute little blond on the left we have to retrain our muscles to work together - PROPERLY. All the hundreds of tiny parts have to relearn how to work together or one little shift of a vertebra that's not in synch and bam we’re back in a full blown episode, completely discouraged and mentally ready for surgery. 

If you’ve seen people in physical therapy exercising on big exercise balls or balancing on rocker boards, walking toe to heel like taking a sobriety test or on Bosu Balls you are witnessing proprioceptive training.  It’s like the infant first learning to walk. Proprioceptive re-education is vital to your back’s future, skipping it means you are in and out of back pain episodes for years on end.

So now we’re done, right? Yeah we’re done, sort of.

The whole process typically takes 3-4 months depending on your level of deconditioning. There is a caveat, however.  As with all exercise you must keep it up.

While you don’t have to do the boring stuff that heals you, you do have to do exercises that keep your core strong and the small muscles well-toned and synchronized. In our clinic we think this is so important we actually offer past patients weekly group exercise classes that focus on core workouts.

Depending on how bad your back is you may need to add base-line medications and spinal traction techniques during your exercise regime to help speed the process.

Following this routine we have a good success rate and are able to keep most patients out of surgery. Those patients that do end up in surgery typically experience better outcomes and quicker recovery because they are better conditioned.


Exercising for Lower Back Pain - Step One Flexibility by Emery Paredes, PT

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