Exercises to Prevent Recurrence

Many patients who experience an episode of severe low back pain will have a recurrence at some time in their life. Therefore, it is usually prudent to prescribe a long-term exercise program to minimize the pain and frequency of recurrences. Such a program should include 3 types of activities:

• Stretches.
• Strengthening exercises.
• Aerobic activities.

In our article on page 348j, we discussed exercise as acute therapy for low back pain. Here, we focus on exercises that can help decrease the severity— and perhaps the frequency— of future episodes.

STRETCHES
Increasing flexibility plays an important role in recovery from low back pain and in prevention of future incidents. Many patients with low back pain have tight hamstring, piriformis, iliopsoas, and gluteal muscles. These muscles provide stability in walking, running, standing, transitioning from sitting to standing, and a variety of other common movements. When these muscles are tight, they can affect posture. Tight iliopsoas muscles, for example, can lead to an increase in spine extension, and tight hamstrings can result in a flat back. Thus, lower extremity stretches, such as hamstring stretches (Figure 1) and piriformis stretches (Figure 2), are an important part of an exercise program for patients with low back pain.

STRENGTHENING EXERCISES
Exercises to strengthen the trunk, abdomen, and lower extremities also play an important role in both recuperation from and prevention of lower back injuries. Most exercises that build endurance and strength are based on either concentric contractions (in which a muscle shortens) or eccentric contractions (in which a muscle lengthens). ¹ Usually these contractions produce identifiable limb movements (eg, a concentric contraction of the biceps results in an elbow bend, while an eccentric contraction of the biceps results in straightening of the elbow). In the back, however, there are many muscles that cross different planes and that are responsible for a variety of motions (eg, obliques, multifidi); often, many different types of contractions are occurring at the same time. Therefore, it is important that patients be taught exercises for the entire trunk region (in- cluding the rectus abdominis, obliques, multifidi, and paraspinals) so that the muscles in all planes of their trunk will be able to withstand the force required to perform daily activities–without becoming injured.

The main stabilizers of the lumbar spine are the multifidi, which allow for rotatory movements.² Therefore, it is helpful to include exercises for these muscles, such as standing back rotations (Figure 3), in any long-term exercise program. It is also important to include exercises for the paravertebral musculature, such as back bends (Figure 4) and those done on a back extension machine, and exercises for the abdominal muscles, such as abdominal crunches (Figure 5). Exercises such as these will not only build functional strength but also improve posture (make it more upright, yet with a slight lumbar curve).

CARDIOVASCULAR ACTIVITIES
If a patient with low back pain could participate in only one type of exercise, cardiovascular exercise would be the best choice. More muscles are used in cardiovascular activities than in any other type of exercise. In addition, 30 minutes of aerobic exercise 3 to 4 times a week—at 60% of cardiac-based maximum (220 beats per minute minus one’s age)—increases endorphin levels and improves blood flow and cardiopulmonary status. These outcomes, in turn, lead to an increased sense of well-being, pain reduction, and an improved ability of the muscles to relax. Finally, many studies have shown that aerobic exercise helps decrease low back pain and lessens the chances that it will recur.^3-6 Therefore, be sure to include aerobic activity in the exercise protocol of any patient with low back pain.

Walking at a brisk pace is one of the best cardiovascular exercises for such patients, because it does not cause a significant amount of compression on the spine or knees.⁴ Most patients can take walks, even if brief. However, these walks cannot be relaxing strolls; impress on patients that they must move quickly. It is also important to encourage patients to walk daily.

Other aerobic activities that are appropriate for patients with low back pain include jogging (on a treadmill), swimming, and biking (on a regular bicycle or on a stationary bike). Although some of these activities may increase a patient’s pain (because of impact), enough options are available that something tolerable can be found. Advise the patient that pain is not necessarily a signal to stop the workout.

Recommend that patients slowly increase their aerobic workout. Although initially they may be capable of only 5 or 10 minutes of activity at a time, have them gradually work up to at least 30 minutes, 3 to 4 times a week, at 60% of the maximum heart rate for their age, weight, and medical condition.