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.

• Back exercise and physical therapy • How a physical therapist can help with exercise • What is the McKenzie Method for back pain and neck pain? • Water therapy exercise program

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. (Continued on next page.)