More than 80 percent of people will experience low back pain at some point in their lifetime. This post, adapted from Brian Richey’s Back Exercise: Stabilize, Mobilize and Reduce Pain explores what non-specific low back pain is, what causes it and the exercises you can perform to treat it.
What is non-specific low back pain?
Non-speciﬁc low back pain is deﬁned as low back pain that is not attributable to a recognisable, known speciﬁc pathology (e.g. infection, tumor, osteoporosis, lumbar spine fracture, structural deformity, inﬂammatory disorder, radicular syndrome, or cauda equina syndrome). In other words, there’s no specific source causing the pain – it could be caused by a number of different factors.
Despite being so common, the number of people who don’t go to the doctor when they suffer from low back pain outnumber those who do go to the doctor by two to one. Low back pain affects men and women, young and old.
Low back pain can be acute (less than 6 weeks), subacute (6 to 12 weeks), and chronic (more than 12 weeks). In only about 10 to 15 percent of acute cases does the low back pain become chronic. With medication and time, the matter begins to resolve by itself, often waiting to rear its ugly head another day. It is through proper exercise and strengthening that you can keep low back pain from recurring.
Without carefully orchestrated healing and strengthening, it is usually only a matter of time before low back pain returns; the frequency and duration of these episodes vary. However, strengthening the muscles and stabilizers may shorten the duration of pain episodes and space them farther and farther apart. Instead of experiencing debilitating pain for four to six weeks every few months, it can be reduced to 5 to 10 days every 9 to 12 months. Sometimes the back pain is held at bay for years, to the point that the client forgets about being injured at all.
What causes non-specific low back pain?
Low back pain can be caused by numerous contributing factors. First, there are mechanical factors such as poor posture, faulty lifting technique, awkward movements such as twisting or bending, and repetitive motions like raking or shovelling can all lead to muscle strains or overuse injuries. These are considered accumulation injuries – incidents that have taken place over a long period of time, but, much like the proverbial straw that broke the camel’s back, the moment when your back has finally had enough is what is memorable. That single event didn’t cause the back injury—it just tipped it over the edge.
Another factor that can lead to low back pain is being overweight or obese. Increased weight applies more disc pressure and overweight or obese individuals tend to have stomachs that protrude farther out from the spinal column, increasing the pull on the lumbar spine toward lordosis (arching), and increasing pressure on the discs and the lumbar muscles (erectors, quadratus lumborum, spinal stabilizers) to keep the torso erect. We often see a weakness in an individual’s core musculature (think of all the muscles from the ribs to the buttocks) when someone suffers from low back pain. In this case it may be a question of whether the chicken or the egg came first. Did the weakness of the core muscles lead to low back pain or did the low back pain result in the muscles becoming weaker? The jury is still out on that. Either way, these are the muscles that you will be focusing on during your exercises.
There are lesser known factors that are also shown to have some correlation to low back pain. Smoking has been linked to low back pain, although the “how” remains a mystery. Genetic and hereditary factors have also seen some relationship with low back pain, possibly due to arthritic factors passed down generationally. We also see low back pain among both those who do too little and those who do too much physical activity. Those who don’t do any exercise and live a very sedentary lifestyle are as likely to develop low back pain as those who pursue highly strenuous physical activities, often without enough rest and recuperation before the next workout.
How can I treat non-specific low back pain?
Physicians often treat low back pain with medication first: anti-inflammatories (NSAIDS), and, if needed, muscle relaxants. They may also suggest physical therapy. A physical therapist will teach many of the exercises that you see in Brian Richey’s Back Exercise, and you will get hands-on learning and training that is tailored to your specific issues.
Other suggested treatment methods include chiropractic, acupuncture, and manual therapy (massage). All of these have some benefit depending on the issue, patient, and practitioner. There is no one-size-fits-all cure. Although the science is divided when it comes to nontraditional forms of therapy, there is a lot of anecdotal evidence that supports it.
Exercise plan for non-specific low back pain
The exercises below depict month 1 of Brian Richey’s suggested 6 month training plan. The full plan can be found in his book, Back Exercise.
The exercise program described will work best for those who are not in an acute state of low back pain. If you are experiencing spasms or having extreme low back pain, wait until the symptoms have subsided a bit before starting. If you have already seen a physician or physical therapist, and need a strengthening or maintenance program that will help to prevent future episodes, then these exercises are for you.
Each month, you will either add new exercises or replace some of your current exercises with more advanced ones. The goal is progression. You want to make progress, and the only way to do that is to work a little harder by adjusting one of the variables. Those variables are volume (the number of sets and repetitions, or total number of exercises), load (the amount of weight being lifted), and frequency (the number of exercise days per week). Each month, you can look forward to a change in your exercise program, and as long as you are not experiencing any increased pain, you will keep up with the new exercise program until the next month. If you have increased pain, go back to the previous month for another week, then give the new exercise program another try.
Keep in mind that not all exercises are meant for everybody. There may be an exercise that works well for one person but may cause another person significant discomfort. Simply stop and avoid the exercise that hurts. Return to that exercise later in the month or even the following month to see if you have become strong enough to do it without pain. There may be an exercise that you will never be able to do, and that’s okay. If you cannot perform this one exercise, it will not make or break your success. Do the ones that don’t cause you pain.
Let’s discuss what kind of pain is okay and what kind is not. A little discomfort is acceptable. On a scale of 1 to 10, with 1 being no pain at all and a 10 being the worst pain you can imagine, where would you rank your pain as you perform an exercise? If it is a 1 to a 3, it is okay to work through it. This would include some mild discomfort. However, if the pain is severe, don’t perform the exercise that day. You may feel some pain with the first or second repetition of an exercise and want to immediately stop. It is recommended to do a couple more repetitions and see if the pain dissipates. It often will. However, if the pain continues above level 3, don’t push through.
It is recommended to perform the exercises three to four times per week.
Month 1 Exercises
1. Neutral spine and Kegel
Hold for 30 sec
Lie down (supine) on your back in a position that produces little to no pain, or such that the pain subsides as you continue relaxing on your back. Next, find your Kegel muscles. These are usually described as the muscles that help to hold back a stream of urine. They are your pelvic floor muscles, a muscle group that comprises part of your inner core, and they should be slightly engaged during these exercises. Don’t grip them hard, just a light hold: think 30 percent of your maximum.
2. Bent-knee fallout
2 sets of 10 reps each side
Lie on the back with the knees bent at 90 degrees and feet flat on the floor.
You can place the hands on the hip bones as a feedback device. Slowly drop one knee out to the side and toward the ground, more slowly than you think you should. Let the foot rotate with the knee; it doesn’t need to stay flat on the floor. Most people only get to about 30 degrees to 45 degrees before their pelvis begins to move. That is where to stop, then slowly bring the knee back up to the starting position and repeat with the other side. How far the knee travels doesn’t matter for now. Over time, you will gain a greater range of motion while keeping the spine still. You know you are going slow enough when there is some “chattering” in the leg muscles. This is a good thing. This means that the smaller muscles of the pelvis are firing. If you go too fast, you will bypass these smaller (stabilizing) muscles and only use the larger (mobilizing) muscles.
3. Heel slide
2 sets of 10 reps each side
Lie on the back with the knees bent at 90 degrees and feet flat on the floor. This exercise is best done on a surface where the feet will slide.
Slowly extend one leg forward by sliding the heel along the surface as far as possible without losing a neutral spine. The foot doesn’t need to stay flat on the surface; only the heel needs to remain in contact. You may be able to extend all the way or only get halfway, and that’s okay. When you’ve gone as far as possible without changing the spinal angle, return to the starting position and repeat on the other side.
2 sets of 10 reps each side (alternating)
Lie on the back with the knees bent at 90 degrees and the feet flat on the floor.
Lift one knee so the thigh is perpendicular to the ground. Return the leg to the ground and repeat on the other side. While this seems easy enough, in all my years I have only had a couple of people do it correctly the first time. On the next repetition, be conscious about what the resting leg is doing. It should be resting, yet most people tend to push down with that leg to use the leg muscles to stabilize the pelvis and spine rather than using the core. I want you to focus on keeping the resting leg relaxed and make sure it does not push down as you lift the active leg. If you do it correctly, you should feel additional engagement of your abdominal (core) muscles. You will alternate legs, each time relaxing one leg while engaging the other.
5. Lying overhead reach (single- or double-arm)
2 sets of 15 reps on each side. For low back pain, do either the single- or double-arm version as long as you maintain good posture and don’t arch the back.
Lie on the back with the spine in a neutral position and the arms straight out in front of the chest (think of a zombie from a 1950s movie).
While keeping the spine neutral, slowly move one arm (or both if doing a double version) back over the head without arching the back. Return the arm to the starting position and repeat with the other arm.
6. Pelvic press hold
5 sec hold for 5 reps
Lie on the stomach with the forehead on a rolled-up towel or pillow, and place the hands under the pelvis just below the hip bone in the front of the body. The hands are a feedback device to make sure to push down evenly on both sides.
Press the pelvis into the hands. Hold for five seconds and release. You should feel the glutes tighten during the hold. This pelvic press will be the starting position for the next four exercises.
7. Pelvic press hip extension
2 sets of 10 reps each side (alternating)
Lie on the stomach with the forehead on a rolled-up towel or pillow, and place the hands under the pelvis and press into the hands. As you press the pelvis into the hands, make sure the pressure is equal between the hands throughout the exercise.
Using the glutes, lift one leg slightly off the ground, ensuring that the pelvic pressure stays even between the hands. After the lifted leg returns to the ground, repeat the exercise with the other leg. This is a very difficult exercise to do correctly. Most people will twist slightly from side to side or arch the back making the pressure change as the body rocks more toward one hand and then to the other. You need to make sure to limit the range of motion and only go as high as possible while keeping the pressure even between the two sides. Even if you only lift a quarter of an inch, this is okay. Keeping the pressure even is more important than how high the leg is lifted.
8. Pelvic press shoulder retraction
5 reps of 5 sec hold for 2 sets
Lie on the stomach with the forehead on a rolled-up towel or pillow and the arms at the sides with the palms facing down. Press the pelvis into the floor and hold.
Pull the shoulder blades back and together; squeeze them tight and hold. Then lift the hands off the ground an inch or two. The lift does not have to be high; the hands only need to be slightly off the ground. Hold for 5 seconds and then relax. Work up to 10-second holds.
9. Togu pelvic tilt
2 sets of 12 reps
Lie on the back with the knees at 90 degrees and the feet flat on the floor. The Togu ball is placed under the sacrum (below the low back; it should not be directly on the low back). Being under the sacrum will allow more freedom of movement in the pelvis, making the exercise easier and more effective than lying on the ground.
Using primarily the abdominals, perform a posterior pelvic tilt. If you are unsure of what that means, imagine a neutral pelvis as a clockface with 12 o’clock being between the legs and 6 o’clock being at the navel. At the center of the clock (where the hands of the clock would rotate around) is a marble. Tilt the clock (pelvis) so that marble moves toward 6 o’clock. Then return to the start (marble back to the center). Do not tilt the clock the opposite way, which would cause the back to arch. Remember to use the abs to perform this exercise and not the legs.
10. Kneeling hip flexor stretch
30 sec hold for 2 reps each side
Assume a position with one knee on the ground and the opposite foot forward with both knees bent at approximately 90 degrees. Hold onto a chair or stick for balance if needed.
Tuck the tailbone and slowly draw the hips forward as if someone is pulling from the front pocket until a stretch is felt in the front of the leg. The range of motion won’t be very great. Do not lunge too deep and exceed the point of stretch. Hold the stretch for 60 to 90 seconds, alternate sides, and repeat on the opposite side.
11. Doorway hamstring stretch or strap hamstring stretch
60 sec hold for 2 reps each side
Doorway hamstring stretch: Starting position
Lie in a doorframe and place one leg up against the door jamb.
Keep the leg straight so that the stretch is felt in the back of the leg, preferably in the hamstrings, although some may feel it more strongly in the calf muscles. If there isn’t much pull, get further into the doorway. If it is too intense or you can’t straighten out the leg, back up a little. Try to relax into the stretch. Hold this stretch for 60 to 90 seconds, alternate sides, and repeat using the other leg.
Strap hamstring stretch: Starting position
Lie on the back with a strap under the foot, holding the ends of the strap in each hand.
Lift the leg up by pulling the strap with the hands until a stretch is felt in the hamstrings. Keep the knee straight for this stretch; it is much more effective this way. At the beginning, the leg that stays on the ground can remain bent. As you progress, straighten it out to increase the intensity of the stretch. Hold for 60 to 90 seconds, alternate sides, and repeat.
12. Knee-to-chest stretch
30 sec hold for 2 reps each side
Lie on the back with the knees bent at 90 degrees and with the feet flat on the floor.
Bring one knee into the chest and hug it by wrapping the hands or the arms around the thigh and hold. Hold for 30 to 60 seconds then repeat on the other side, alternating sides each time.
13. Seated side bend
2 sec hold for 12 reps each side
Sit tall in a chair with the hands at the sides and the fingers reaching toward the floor.
Gently side bend while reaching the fingers of one hand toward the ground. Return to the starting position and repeat on the other side, alternating each time. Begin with a small range of motion and slowly increase as the movement becomes comfortable.
Above we have included the exercises for month one of Brian Richey’s six month recommended plan. The full plan can be accessed in Back Exercise.
By the end of the six month plan, you should be able to manage your low back pain with the exercises given. You should then be able to take part in activities such as yoga and pilates, but it is advisable to start slow.
Low back pain may come and go, but as you strengthen your muscles you may find that your low back pain is less frequent and spouts of pain are much shorter.
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