Exercise for rehabilitation

One of the keys to recovering from an episode of back pain or surgery, and to help avoid future recurrences of back pain, is to undergo proper rehabilitation and exercise in terms of stretching, strengthening and aerobic conditioning of the back and body. This requires a basic understanding of the types of muscles that need to be conditioned.

There are three types of muscles that support the spine:

Extensors (back and gluteal muscles): used to straighten the back (stand), lift and extend, and move the thighs out away from the body.
Flexors (abdominal and iliopsoas muscles): used to bend and support the spine from the front, they also control the arch of the lumbar (lower) spine and flex and move the thigh in toward the body.
Obliques or Rotators (side muscles): used to stabilize the spine when upright, they rotate the spine and help maintain proper posture and spinal curvature.

While some of these muscles are used in everyday life, most do not get adequate exercise from daily activities and tend to weaken with age unless they are specifically exercised.

For all forms of exercise, it is advisable to see a trained and licensed physical therapist, occupational therapist, chiropractic physician or physical medicine and rehabilitation physician (also called a physiatrist). Depending on your specific diagnosis and level of pain, the exercise program will be very different, and these specialists are trained to develop an appropriate exercise program and provide instruction on correct form and technique.

Stretching
Any form of inactivity, especially where an injured back is involved, is usually associated with some progressive stiffness. Therefore, it is necessary to push the range of motion as far as can be tolerated (in a controlled manner). Patients with chronic pain may find it takes weeks or months of stretching to mobilize the spine and soft tissues, but will find that the increase in motion provides meaningful and sustained relief of their back pain.

Stretching exercise should focus on achieving flexibility and elasticity in the disc, muscles, ligaments, and tendons. Additionally, it is important to activate and strengthen muscles not directly involved with the injured area, such as the arms and legs. For example, the hamstring muscles play a role in lower back pain, as it is clear that hamstring tightness limits motion in the pelvis and can place it in a position that increases stress across the low back.

Specialized equipment is available that helps repetitions to be done in the same manner so that progress can be identified and the level of exercise regulated.

Strengthening
It is thought that re-injury is less likely to occur if back strengthening is accomplished than if mere pain relief is achieved with just stretching. An episode of back pain that lasts for more than two weeks should be treated with proper strengthening exercise to prevent a recurring cycle of pain and weakness.

There are two primary forms of exercise for strengthening and/or pain relief that tend to be used for specific conditions. When appropriate, the two forms of physical therapy may also be combined.

McKenzie exercise, in general focuses on extending the spine to reduce pain generated from the disc space. Theoretically, extension may also help reduce a herniated disc and reduce pressure on a nerve root. For patients who are suffering from leg pain due to a herniated disc (e.g. sciatica), extending the spine may help reduce the leg pain by "centralizing" the pain (moving the pain from the leg to the lower back). For most people, back pain is usually more tolerable than leg pain. Sometimes, based on the structured evaluation, flexion exercise are appropriate.
Lumbar stabilization exercise focus on finding the patient's "neutral" spine, or the position that allows the patient to feel most comfortable. The back muscles are then exercised to teach the spine how to stay in this position. Performed on an ongoing basis, these exercises can help keep the back strong and well positioned. Special attention is paid to the extensor muscles of the lower back with resistance exercise.

Additionally, a strengthening program that involves progressive loading and unloading of the lumbar spine by means of flexion/extension exercise can reduce pain and increase the perception of improved back strength. This training, called facilitation, is best accomplished when the muscles to be facilitated are isolated in some way so that other muscles cannot take over the job. Often specific equipment is required to achieve that goal.

Low-impact aerobic conditioning
Finally, conditioning through low-impact aerobic exercise is very important for both rehabilitation and maintenance of the lower back. Aerobically fit patients will have fewer episodes of low back pain, and will experience less pain when an episode occurs. Well-conditioned patients are also more likely to maintain their regular routine, whereas patients with chronic low back pain who do not work on aerobic conditioning are likely to gradually lose their ability to perform everyday activities.

Examples of low impact aerobic exercise that many people with back pain can tolerate include:

Water therapy (also called pool therapy or hydrotherapy). For people with a great deal of pain, water therapy provides a gentle form of conditioning as the water alleviates gravity and provides buoyancy as well as mild resistance.
Walking. Many people think that walking as part of their daily routine (e.g. at work or while shopping) is enough. However, this stop-and-start type of walking is not adequate for aerobic conditioning. Instead, continuous walking at a sustained pace for a minimum of twenty to thirty minutes is required to provide aerobic conditioning.
Stationary biking. Riding a stationary bicycle provides aerobic conditioning with minimal impact on the spine. This is also a good exercise option for people who are more comfortable positioned leaning forward.

Depending on your injury and exercise preferences, you may prefer a different form of exercise. It may be helpful to discuss your options with your physical therapist, or physician to identify an appropriate form of aerobic exercise for you and incorporate it into your exercise routine.