Before you start an exercise program it is important to understand the nature of your back pain. It is important to assess whether your pain is acute (less than 4 weeks), subacute (4-12 weeks), or chronic (over 12 weeks). All exercise programs must be designed to each patient specifically considering age, physical capacity, and other existing medical conditions.

Initiation of an Exercise Program
It is best for people who have subacute and chronic low back pain to start an exercise program, especially when the patient is experiencing a decrease in the strength, endurance, fatigue, or if their muscles are atrophied. Studies have shown that patients who have chronic low back pain who regularly participate in moderate leisure time activities usually have better motor function and experience less pain compared to patients who are less physically active.

Proposed Mechanism of Benefit of Exercise
There is no single mechanism that is best for all patients with low back pain. There are many mechanisms that may cause a person’s lower back pain that include musculoskeletal, neurological, and/or psychological contributors to the pain. Tissue injury is a very complicated process with involvement of peripheral and central nervous system. At the same time, inflammatory processes are happening at the site of the pain. It is important to understand that exercises reduce the inflammatory process that is often involved in pain. Programs can indirectly reduce the pro-inflammatory cytokines and the oxidative stress involved in chronic low back pain. Physiologically exercise can have positive effects on human muscle, joint, and intra-vertebral disc metabolism, which is seen in disc herniations. The intervertebral disc does not have active blood supply and mostly receives its nutrients by the process of passive diffusion which is often optimized by motion and impact. In other words, exercise and motion allows important nutrients to enter into the disc. In addition, exercise provides great psychological benefit which helps reduce the stress, anxiety and depressive symptoms that the patient often experiences with their chronic low back pain. There is no doubt that some patients are anxious about reinjuring the back and exhibit fear of movement when they are often asked to initiate an exercise program. Exercise will also help these patients become more independent, allow them to participate at home, do regular duties, and transition them to a fulfilling life at home and work.

Physician Counseling & Evaluation Prior to Starting Exercise
It is important the physician sets expectations before an exercise program is started. The physician and the patient both need to discuss the fears of starting a program. The physician also needs to consider the fitness level of the patient and the availability of resources that are necessary to formulate an appropriate exercise plan. It is important that the physician does motivational interviewing and provides the adequate motivation that would allow the patient to start exercising and stay compliant. Some of these patients with chronic low back pain have multiple barriers in the motivation factors to performing these exercises. Some of the deep motivation factors include lack of interest in accessibility, time, high cost, self-conscious, embarrassment, anxiety, frustration, and anger. It is sometimes simpler to set goals that are achievable and that the patient will enjoy. It is also important the patient feels good and overall feels optimistic about the whole process. Using technology like step counters and fitness trackers can help patients remain optimistic about and engaged in their goals.

Patient’s Fear with Exercise
Many patients have preconceived notion of their back pain and have seen other providers who have mentioned key phrases that relate to the structural back abnormalities as the main cause of the back pain. However anatomical variations or radiographic findings that does not necessarily correlated to the cause of their pain. Patients can be repelled when words like bone-on-bone, degenerating, bulging, or herniated discs, which are often not the main cause of the patient’s pain, are used in their treatment plan. Exercise programs largely will benefit patients, and it is best for patients to openly communicate with their healthcare providers about their concerns regarding initiating an exercise plan.

Increased Pain Initially with Exercise
Many patients will experience a temporary exacerbation of the pain symptoms once the exercise program is started it is important that the physician discusses this with the patient and reminded him that this is a normal process. Discussing different exercise options with the patient had multiple exercise options to help them with their low back pain based on their age exercise tolerance and the nature of their pain. It is true that some patients have never been active regularly prior to the injury or of had many years with a have not participated in any exercise. In such patients it is best to start an exercise program from a supervised graded program which should provide more moral support and coaching. In these situations, its best for patients to seek consultation through physical therapy.

Risk of Exercise
Patient will often ask what other possible risks of starting an exercise program and is there a risk of reinjuring the area. There is a hypothetical chance that patients with serious cardiopulmonary disease processes like arrhythmia, congestive heart failure can have severe cardiac effects when the start exercising. But even these patients can benefit from a graded exercise program both in respect to the cardiac function and the low back pain. Elderly patients may be at greater risk of injury due to impaired proprioception and balance. In these cases a physical therapist can be very useful to mitigate the risk of injury and having the proper support system.

Choice of Exercise
All programs are beneficial and there is no data to prove that one single exercise technique is superior than others with patients with chronic low back pain. It is most important the patient does exercises that he enjoys the most, therefore compliance and satisfaction will be high. Talk to your doctor about what type of exercise is best for you.

Walking
Walking is the simplest and is most readily available form of exercise which is very effective in decreasing symptoms from chronic musculoskeletal pain like low back pain. It can be easily done, even amidst the COVID-19 pandemic. Walking is also very beneficial for patients who are suffering from fibromyalgia.

Other Aerobic Exercises
Aerobic exercises are most critical in improving physical functioning in patients with chronic low back pain. In such cases it is important the patient does not experience chest pain at the time of exercise. Younger patients can usually tolerate the heart rate up to 180 BPM. Patients who have coronary artery disease should consult with her cardiologist before starting a regular exercise regimen.

Stretching Exercises
Stretching is a very simple exercise that can be done at home and it is done without any supervision It can be done multiple times and takes a short period of time. Patients can often go to physical therapy centers and learn the stretching exercises and do them at home.

Pilates
Pilates is a type of exercise that is involved in controlling movements of the whole body to start with the core and then flows outwards work the limb. The most important health benefit of Pilates is body alignment, improved breathing strength, coordination, and balance. It is best to start Pilates with an athletic trainer who can evaluate you for your level of fitness and slowly start you on an exercise program.

Yoga
Yoga is a mind-body practice with multiple components including physical poses, controlled breathing, and meditation. Yoga can also be adapted for different age groups and different fitness levels. Yoga will improve pain and stretch the muscles of the back which is often a secondary cause of with patients with low back pain.

Tai Chi
Tai Chi is a mind-body exercise very similar to yoga which focuses on balance, mental acuity, breathing, and can also be used and management of low back pain. It is a very good exercise program to for people to start when they reach their 60s, 70s, and 80s.

Core Exercises & Spine Stabilization
Core exercises and spine stabilization exercises are recommended to be done to activate control and coordinate the deep muscles of the sub-spine abdomen and pelvis. Initiate his exercises performed at rest followed by addressed in different positions. Ultimately these exercises are done with activity and more functional task.

Graded Activities & Functional Restoration
This is an approach which is often used to slowly increase the exercise and simultaneously increasing the stretching of the muscles. Sometimes these exercises involve using resisted equipment in a progressive fashion. They can cause pain flare-ups, but the ultimate goal is to increase the stretching of the muscles which ultimately reduces the spasms in the muscles. This also the sensitizes the pain producing process. It is important the patient is received proper support and praise for the successful participation.

Multidisciplinary Approach to Rehabilitation
Does exercise prevent low back pain? Overall, the consensus is that participation of exercise may prevent incidental episodes of low back pain as well as recurrence of low back pain. Multiple studies have been done and it has shown the patient to regularly exercise are less likely to develop new low back pain. Other studies have also shown that patients who have a history of chronic back pain are less likely to have low back pain. It is very important even for patients who have multiple recurrent low back pain episodes start an exercise program and continue it. This will prevent further recurrence or escalation of the pain. What is a role of exercise and acute low back pain? Most experts believe that acute low back patient’s which have had this pain develop within the first four weeks. These patients should not start an exercise regimen at this point. However, it is best for them to avoid bed rest and stay active as possible. These patients are the only subcategory of patients where initiation of an exercise regimen is not recommended.

Exercise has multiple benefits to patients who are suffering from subacute chronic low back pain. Exercise therapy improves their pain and function but there is no one clear explanation by which exercise will reduced her symptoms. Often the mechanisms involved are neurological, biochemical, and psychological. It is important the patient is received proper counseling prior to initiation of an exercise program. Overall, the risk of exercises causing rare serious medical condition are slim. No simple exercise technique is superior over others for patients with subacute and chronic low back pain. It is important the patient does not exercise program that they enjoy the most and have experience doing it. The best exercise sometimes is walking and stretching. Patient who have done Tai Chi, yoga, or Pilates would prefer to do those exercises because it has a component of meditation and relaxation. The only subgroup of patients with exercise program is not recommended to be initiated or patients with developed acute low back pain. In these patients it is best to have them evaluated by their physician before any exercises started. But in these patients, it is best to avoid complete bed rest and remain as active as possible. Overall exercise has multiple benefits in patients with subacute and chronic low back pain and it is useful in preventing recurrent back pain or escalation of the pain. Ask your doctor what their recommendation for your exercise plan is and get back to living your life.