Exercises to Prevent Recurrence

Many patients who experience anepisode of severe low back pain willhave a recurrence at some time in theirlife. Therefore, it is usually prudent toprescribe a long-term exercise programto minimize the pain and frequency ofrecurrences. Such a program should include3 types of activities:

• Stretches.
• Strengthening exercises.
• Aerobic activities.

In our article on page 348j, we discussedexercise as acute therapy forlow back pain. Here, we focus on exercisesthat can help decrease the severity- and perhaps the frequency-of future episodes.

STRETCHES
Increasing flexibility plays an importantrole in recovery from low backpain and in prevention of future incidents.Many patients with low backpain have tight hamstring, piriformis,iliopsoas, and gluteal muscles. Thesemuscles provide stability in walking,running, standing, transitioning fromsitting to standing, and a variety ofother common movements. Whenthese muscles are tight, they can affectposture. Tight iliopsoas muscles, forexample, can lead to an increase inspine extension, and tight hamstringscan result in a flat back. Thus, lowerextremity stretches, such as hamstringstretches (Figure 1) and piriformisstretches (Figure 2), are an importantpart of an exercise program for patientswith low back pain.

STRENGTHENINGEXERCISES
Exercises to strengthen the trunk,abdomen, and lower extremities alsoplay an important role in both recuperationfrom and prevention of lowerback injuries. Most exercises that buildendurance and strength are based oneither concentric contractions (inwhich a muscle shortens) or eccentriccontractions (in which a muscle lengthens).¹ Usually these contractions produceidentifiable limb movements (eg,a concentric contraction of the bicepsresults in an elbow bend, while an eccentriccontraction of the biceps resultsin straightening of the elbow). In theback, however, there are many musclesthat cross different planes and thatare responsible for a variety of motions(eg, obliques, multifidi); often, manydifferent types of contractions are occurringat the same time. Therefore, itis important that patients be taught exercisesfor the entire trunk region (in-cluding the rectus abdominis, obliques,multifidi, and paraspinals) so that themuscles in all planes of their trunk willbe able to withstand the force requiredto perform daily activities–without becominginjured.

The main stabilizers of the lumbarspine are the multifidi, which allowfor rotatory movements.² Therefore, itis helpful to include exercises for thesemuscles, such as standing back rotations(Figure 3), in any long-term exerciseprogram. It is also important toinclude exercises for the paravertebralmusculature, such as back bends (Figure4) and those done on a back extensionmachine, and exercises for theabdominal muscles, such as abdominalcrunches (Figure 5). Exercisessuch as these will not only build functionalstrength but also improve posture(make it more upright, yet with aslight lumbar curve).

CARDIOVASCULARACTIVITIES
If a patient with low back paincould participate in only one type of exercise,cardiovascular exercise wouldbe the best choice. More muscles areused in cardiovascular activities than inany other type of exercise. In addition,30 minutes of aerobic exercise 3 to 4times a week-at 60% of cardiac-basedmaximum (220 beats per minuteminus one's age)--increases endorphinlevels and improves blood flowand cardiopulmonary status. Theseoutcomes, in turn, lead to an increasedsense of well-being, pain reduction, andan improved ability of the musclesto relax. Finally, many studies haveshown that aerobic exercise helps decreaselow back pain and lessens thechances that it will recur.^3-6 Therefore,be sure to include aerobic activity inthe exercise protocol of any patientwith low back pain.

Walking at a brisk pace is one ofthe best cardiovascular exercises forsuch patients, because it does not causea significant amount of compression onthe spine or knees.⁴ Most patients cantake walks, even if brief. However, thesewalks cannot be relaxing strolls; impresson patients that they must movequickly. It is also important to encouragepatients to walk daily.

Other aerobic activities that are appropriatefor patients with low back paininclude jogging (on a treadmill), swimming,and biking (on a regular bicycleor on a stationary bike). Althoughsome of these activities may increase apatient's pain (because of impact),enough options are available that somethingtolerable can be found. Advise thepatient that pain is not necessarily a signalto stop the workout.

Recommend that patients slowlyincrease their aerobic workout. Althoughinitially they may be capable ofonly 5 or 10 minutes of activity at atime, have them gradually work up toat least 30 minutes, 3 to 4 times aweek, at 60% of the maximum heartrate for their age, weight, and medicalcondition.

References:

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2. Grimsby O. Evaluation Methods, Soft Tissue Work,Mobilization and Exercises. San Diego: Ola GrimsbyInstitute; 2000.
3. Abenhaim L, Rossignol M, Valat J, et al. The roleof activity in the therapeutic management of backpain: report of the International Paris Task Force onBack Pain. Spine. 2000;15(suppl 4):1S-33S.
4. Swezey R. Spine update exercise for osteoporosis-is walking enough? Spine. 1996;23:2809-2813.
5. McCune D, Sprague R. Exercise for low backpain. In: Basmajian JV, Wolf SL, eds. Therapeutic Exercise.5th ed. Baltimore: Williams & Wilkins; 1990:299-308.
6. van Tulder M, Malmivaara A, Esmail R, Koes B.Exercise therapy for low back pain: a systemic reviewwithin the framework of the cochrane collaborationback review group. Spine. 2000;25:2784-2796.