Any article about exercise for pain needs to cover one important fact before it goes on:
The body will tend towards self-correction/health/resolution, if, and that’s a big if, the right conditions are present.
The biggest challenge facing an osteopath, or any other therapist, is finding, or more likely, stumbling upon, the right conditions for the individual seeking help.
Whilst there are general guidelines to abide by, every one of us has a unique set of experiences, thus different stories, explanations, treatment techniques and movements are required to facilitate a recovery; not to mention all the environmental factors that come into play.
This article intends to discuss the general principles that should underpin your actions when exercising for/with low back pain.
Where Most Back Pain Exercise Programs “Go Wrong”
Most back pain exercises or exercise programs are based on the notion that pain is the result of specific factors, and that these factors can be specifically identified and then specifically addressed.
There are a variety of factors that can contribute to low back pain, but aside from a history of previous episodes of low back pain, nothing drastically stands out as being identifiable. (1)
As an aside, this perhaps points the finger at us, therapists and rehab professionals, who are not doing a good enough job in the first place (on a population, not individual level).
It is also highly important for sufferers of low back pain to understand, as many people decide to cease treatment/rehab as soon as their pain is gone, rather than concluding the full course of treatment and restoring “lost” function.
Unfortunately, it is very difficult to specifically assess and as a result, address them with targeted exercises.
So knowing that specific factors may be hard to identify and treat, it seems more important to build resilience with a complete mobility, strength and conditioning program.
Take home point number 1: exercise programs for low back pain should not attempt to be specific, but rather improve all physical qualities.
There Are No ‘Good’ And ‘Bad’ Exercises
Another misconception surrounding exercise for low back pain is the concept of ‘good’ and ‘bad’ exercises.
Generally, if you are reading a fitness article, the concept of “neutral spine” is mentioned quite a lot. Lifting should always take place with a neutral spine, regardless.
If you are reading a rehab article, limits might be imposed on external loading, as in, any lifting above 10 kg is bad, and must be avoided.
Or you might read a medical article which mentions you should simply avoid things that hurt.
All of these comments have a place, and are neither right or wrong without any context to define them.
A ‘good’ exercise is one that you can do safely, is suitable for your current ability, is able to be gradually progressed and fits in with your needs and wants (aka your goals).
Take home point number 2: blanket statements and absolutes do more harm than good. There are times when a moderate approach doesn’t work and more extreme action needs to be taken, but it is rarely either or. Exercise selection is based on your needs and wants, not an arbitrary definition of good and bad.
This is a concept that was popularised by American physical therapist Gray Cook, in his book Movement.
Self limiting movements/exercises are those that have an inbuilt “coaching mechanism”, meaning doing them forces you to increase your awareness with movement, and often times with these type of movements you can only perform them correctly, or not at all.
Utilising self limiting movements as part of an exercise program for low back pain allows you to safely challenge your body and brain, leading to improvements, without the risk of overdoing it.
There are many different examples of self-limiting exercises. The specifics are not as important as being able to move with increased awareness and a low risk. This is a big focus of our exercise programming for low back pain, especially in the early stages.
Take home point number 3: a good exercise program will provide both a challenge and the option to “fail safely” – thus reducing the fear associated with facing more demanding movement challenges.
Our Approach To Programming
There is no one way to program exercise for low back pain. As long as the programming is underpinned by sound principles, and not “technique based”, then it should be sufficient.
We strive for more than sufficient, we strive for optimal.
As such, over the years our approach to exercise programming for low back pain has been refined to what it currently is. Chances are, in another 5 years it will be further refined, but the vast majority will be consistent, as it is all principle based.
First, we consider the body as a whole. We don’t only do “low back” or “core” exercises, but rather we devise a total body program. This is the underpinning principle of osteopathy, and is also applicable to exercise programming.
Second, we ensure that of physical qualities are developed in the right sequence.
If we start with osteopathic manual treatment in the consultation room, we then progress to mobility and flexibility exercises.
These will usually start on the ground, as this provides the most stable environment, thus is the least threatening.
Considering pain occurs when there is a perception of threat by the brain (if you haven’t already, have a read of Pain Basics), this is one of the best ways to regain movement and avoid inefficient compensation patterns taking over.
From there you are looking to build “motor control” – this is simply the ability to control movement well.
We can call this stability, but that implies static positions and discounts the movement component. This is actually achieved simultaneously with improving movement/mobility/flexibility.
We can consider mobility as “end range strength”, and we are simply progressively challenging you so that both qualities improve.
Once you have achieved adequate movement and control (adequate is based on your individual needs), if you want and/or need, we would add load. This might be in the form of external resistance, increased leverage challenge or even changing the tempo.
Only when you are moving competently under load do we add a conditioning component – that is, more volume of work. This is the challenge of fatigue to your new found movement abilities, and if done correctly, is the difference between breaking down when the going gets tough and being able to withstand (almost) anything.
Take home point number 4: whole body, principle based programming that utilises appropriate methods of progression yield the best long term outcomes (based on clinical experience and research) (2) for sufferers of low back pain.
There is a well worn quote:
Methods are many, principles are few. Methods always change but principles never do.
This served as inspiration for this post – there is no point showing you how to do an exercise with no context as to whether it is appropriate for you or not.
Rather, it is important to have an understanding of why you are doing something – even if you only care about the “what”.
This understanding means you will not chop and change based on the latest article in your newsfeed.
It means you will take the time to get things right, knowing that making progress is all the matters, even if it is “slow”.
It also means that you have a better chance at a good outcome and are less likely to become a statistic of low back pain recurrence.
Reducing the article to four sentences, we would end up with something like this:
- Do something you enjoy doing, that has intrinsic reward – there are no “good” or “bad” exercises.
- Ensure you take a “whole body” approach to exercise. Don’t simply focus on “low back exercises”.
- Start slowly, progress gradually.
- Vary the stimulus over time, but not too much or too often (or you won’t elicit adaptations).
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.
This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.
(1) Incidence and risk factors for low back pain: http://www.ncbi.nlm.nih.gov/pubmed/24462537
(2) Resistance training and low back pain in active males: http://www.ncbi.nlm.nih.gov/pubmed/20093971