Generally, a patient’s exercise program (for active physical therapy) should encompass a combination of the following:

Stretching

Most patients who have suffered from low back pain should stretch their hamstring muscles (in the back of the thigh) once or twice daily. Patients who have low back pain tend to have tight hamstrings, and patients with tight hamstrings tend to have low back pain. It is not known which comes first, but 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. Therefore, it follows that stretching the hamstring muscles typically helps decrease the intensity of a patient’s back pain and the frequency of recurrences.

Simple hamstring stretching does not take much time, although it can be difficult to remember, especially if there is little or no pain. Therefore, hamstring stretching is best done at the same time every day so it becomes part of a person’s daily routine. A hamstring stretching routine should include applying pressure to lengthen the hamstring muscle for 30-45 seconds at a time twice daily. The pressure on the muscle should be applied evenly and bouncing should be avoided, since a bouncing motion will trigger a spasm response in the muscle being stretched.

Strengthening/pain relief exercises

There are two primary forms of exercise for strengthening and/or pain relief that tend to be used for specific conditions: McKenzie exercises and dynamic lumbar stabilization exercises. When appropriate, these two forms of physical therapy may be combined.

McKenzie exercises are named after a physical therapist in New Zealand who noted that extending the spine could reduce pain generated from the disc space. With the McKenzie approach, physical therapy to extend the spine can help “centralize” the patient’s pain by moving it away from the extremities (leg or arm) to the back. Back pain is usually better tolerated than leg pain or arm pain, and the theory of the approach is that centralizing the pain allows the source of the pain to be treated rather than the symptoms.

For the dynamic lumbar stabilization exercises, the physical therapist first tries to find 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. This technique relies on proprioception, or the awareness of where one’s joints are positioned. Performed on an ongoing basis, these exercises can help keep the back strong and well positioned.

Low-impact aerobic conditioning

Reconditioning through low-impact aerobic exercise is very useful for both rehabilitation and maintenance of the lower back. The following types of aerobic exercise are gentle on the back and, when done on a regular basis, highly effective in providing conditioning:

• Walking. In general, walking is very gentle on the back, and walking two to three miles three times per week is very helpful for patients.
• Stationary bicycling. If walking is painful, stationary bicycling is also effective.
• Water therapy. Exercise in the water provides effective conditioning while minimizing stress on the back.

Even patients with a very busy schedule should be able to maintain a moderate exercise regimen that encompasses stretching, strengthening, and aerobic conditioning.

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For lower back pain that has lasted between two and six weeks, or frequently recurs, physical therapy may be considered. Some specialists begin physi- cal therapy sooner, especially if the pain is severe. Physical therapy can help decrease back pain and increase the patient’s ability to function, and pro- vides a routine that can help prevent recurrence of the problem.

Physical therapy can be passive (something is done to the patient) or active (the patient engages in an exercise program).

Initially, therapists may need to focus on reducing the pain, which is often done with the following passive modalities:

Heat/ice packs

Heat and ice are very commonly used to help reduce muscle spasm and inflammation, as well as reduce the amount of pain experienced, and also assist in healing. The therapist may apply this treatment, but if a non-professional is going to do it a medical care provider should be consulted before beginning to be sure it will be done correctly. Importantly, care should be taken with both ice and heat so as not to burn the skin.

Some patients experience better pain relief by using heat and others have better results with ice. Many find that the best approach is to alternate the two. Treatments should last ten to twenty minutes once every two hours, and are most useful in the first few days of a flare-up of pain.

Iontophoresis

Iontophoresis is a way to deliver steroids through the skin. The steroid is applied to the skin, and an electrical current is then applied that causes the steroid to migrate under the skin. The steroids then produce an anti- inflammatory effect in the area of the pain. This is especially effective in relieving acute pain.

TENS Units

A transcutaneous electrical nerve stimulator (TENS) unit emits electrical stimulation into the area of the lower back pain. This stimulation overrides the pain signals that are sent to the brain, and can be effective in relieving pain. Usually a therapist will do a trial with this therapy on a patient, and if substantial pain relief is experienced the unit may be sent home with the patient to be used as needed for long-term pain relief.

Ultrasound

Ultrasound is a form of deep heating in which sound waves are applied to the skin and penetrate into the soft tissues. This modality is especially useful in relieving acute episodes of pain and may also enhance tissue healing.

Once the pain is lessened through passive therapies, active physical therapy (exercise) is needed to rehabilitate the spine. Therapists will work with patients to develop a proper exercise routine that will help patients avoid recurrences of low back pain, and help reduce the severity and duration of potential future episodes of low back pain.

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For a full range of information and illustrations on the back and spine, see www.spine-health.com.