A Quick Guide to Exercise as Acute Therapy

Low back pain affects up to 80% of Americans at some point in their lives.1 This common ailment can be mentally and physically debilitating. The cause is often difficult to determine, and precipitating factors vary widely. Back pain can result from work-related activities, weekend athletics, improper lifting, motor vehicle accidents, and activities of daily living. Although the anatomic location of the pain generator is often unclear, degenerative disk disease, strains (muscular injuries), sprains (ligamentous injuries), and osteoarthritis are frequently implicated.^2,3The treatment options for low back pain are numerous. They include various medications (anti-inflammatories, muscle relaxants, analgesics, anti antidepressants that affect nerve transmission, and others), activity alteration (such as short-term bed rest), physical therapy (eg, passive therapies, stretching and suppleness activities, and activation exercises), manipulative therapy, acupuncture/acupressure, and occasionally—although rarely in the acute stage—surgery. Here, we present a rationale for exercise as acute therapy for low back pain; we also offer guidance in the selection of specific exercises for your patient. In a second article, beginning on page 357 of this issue, we will discuss how exercise can prevent recurrence of low back pain.WHY EXERCISE?The Agency for Health Care Policy and Research reviewed many therapies for low back pain and assessed their effectiveness based on a meta-analysis of the available literature. They found little scientific basis for the majority of treatments.¹ This lack of supporting evidence is due in part to the fact that 60% of patients with back pain improve within 1 week and 90% improve within 6 weeks.⁴ Because most patients improve regardless of the treatment employed, it is difficult to evaluate therapies. The optimal therapy for a particular patient is often not easy to determine— nor is it strictly diagnosisdependent. Still, we have a responsibility to provide effective care that has some scientific validity. We also need to work with patients to create a rehabilitation process that they are involved in and that makes them re- sponsible for their own improvement. Considered in this context, exercise is an attractive option for improving function and decreasing pain in patients with low back pain.^1,5 It also encourages independence from medications and health care providers. The drawback is that it is difficult to convince a patient to exercise— because of time constraints, lack of energy or motivation, and/or pain. Injured patients may fear that excessive movement and impact will cause more pain and hinder recovery. To be motivated to participate in exercise and the healing process in general, patients must have a sufficient desire to get better. Your role is first to help patients understand that exercise can be a key factor in their rehabilitation— and then to prescribe a regimen that facilitates their recovery.TYPES OF EXERCISEA variety of exercises—including stretching, strengthening, and cardiovascular activities—can ameliorate low back pain and expedite the return to normal functioning.^5-7 There are several schools of thought as to what types of exercise are most appropriate for rehabilitation of the lumbar spine. Some are flexion-based⁸; others (such as the McKenzie approach) are extension- based or allow for individual variability,^2,3 while still others emphasize rotatory movements.⁹Flexion-based. Exercises of this type, by flexing the spine, take the pressure off the disk and nerves (the latter is especially helpful if leg pain is present) and help decompress the lumbar region. The knees-to-chest stretch is an example of a flexionbased exercise (Figure 1). Another example is sitting in a chair and leaning forward to touch one’s toes. This stretch/exercise allows for lengthening of the lumbar paraspinals and decompression of the disks.Extension-based. The theory behind extension-based exercise is that lying flat on one’s abdomen makes it possible for a disk to move anteriorly as the posterior parts of the vertebrae close down on each other and push the disk forward—similar to squeezing a tube of toothpaste. It is also believed that this position allows overstretched muscles in the lumbar spine to heal.^2,3 The prone extension is an example of an extension-based exercise (Figure 2). Many low back pain treatment regimens are based on the McKenzie approach. At the heart of this approach is the belief that low back pain is best remedied by “centralizing” the pain to the patient’s lumbar spine— primarily through lumbar extension.¹⁰To centralize pain means to move it from the legs or buttocks to the back.^2,3 The goal is to try to move the nucleus of the disk within the disk space with appropriate exercises and maneuvers in order to lessen the pressure between the disk and the adjacent nerve. As the pressure on the nerve is reduced, the pain centralizes to the back. Although “McKenzie” is often thought to be synonymous with “extension,” this approach actually varies with the patient and the cause of the symptoms, and can include flexion-based as well as extensionbased exercises.Rotation. The multifidi muscles are the main stabilizers of the lumbar spine. They are positioned at an oblique angle to the spine and allow for rotatory movements. When a person has been injured, these muscles tend to atrophy because of lack of movement. Rotation exercises, such as the back rotation (Figure 3), are designed to exercise the multifidi muscles in particular. Rotatory movements, in addition to flexion and extension exercises, are important in regaining full and functional range of motion.⁹DESIGNING AN EFFECTIVE EXERCISE PLANThe type of rehabilitation that is most appropriate for your patient depends on the results of the physical examination— and on the history (Box). Listening to the patient is crucial. After you make the diagnosis—and often it may be no more precise than “low back pain”—it is important to ask 2 key questions:

• “What positions are the most comfortable for you since your pain started?”
• “What do you do to ease the pain?”