A good friend recently asked me ‘what are the best exercises for back pain?’ He was a bit disappointed when I told him that my answer to that question is always…. ‘it depends’.

It depends on how long you’ve had back pain, the severity of the pain, and how easily the pain is triggered.

For example, Patient A bent down yesterday to tie their shoelaces and their back ‘went’, causing pain of 9 out of 10 whenever they move. Patient B has a 10-year history of niggly back pain that reaches 3 out of 10 when they deadlift 100kg.  Clearly these two patients have very different needs and will benefit from different exercises of a different intensity.

It depends (to some extent) on what tissues are causing the pain i.e. your diagnosis. However, it is notoriously difficult to pin down specific tissues are causing back pain, even when we use scans and x-rays.

More important than the diagnosis is your ‘functional diagnosis’. That relates to the patterns of movement and loading that cause your pain.

For example, Patient C and Patient D both experience pain with a rating of 6 out of 10 every time they do their favourite hobby. They’ve both had their pain for 3 weeks and they are both generally fit and well. However, while Patient C gets their pain while squatting and deadlifting at the gym, Patient D experiences pain when sprinting at the track. Even if all signs point towards the same tissues being involved, the pain is triggered by very different movement and loading patterns, and the patients will likely respond very differently if I give them the same set of exercises.

It depends on the underlying problems that are creating overload in your spine.

Patient E and Patient F both experience low back pain when they sit for more than an hour at their desk. Patient E has stiff hips, rounded shoulders and a severe curve in their mid-back, all of which force them to round out their back when sitting. Patient F has loose hips, and good mid-back and shoulder flexibility, but still rounds out his back at his desk. So, while Patient E is likely to benefit from hip, shoulder and mid back mobility and flexibility exercises, Patient F would be wasting their time. Patient F would be much better served performing movement control exercises and strengthening to help him maintain an improved posture at his desk.

It depends on your general health.

It depends on what you enjoy doing.

It depends on how much time you have to do exercises.

It depends what equipment you have access to.

And more…….

OK, so what TYPE of exercises should someone with back pain work on?

Surely core stability exercises would be useful?

Indeed, they have been shown to be effective in reducing pain in the short term for people with chronic back pain https://pubmed.ncbi.nlm.nih.gov/19217208/

However, other authors are less impressed, concluding: “There is strong evidence stabilisation exercises are not more effective than any other form of active exercise in the long term” https://pubmed.ncbi.nlm.nih.gov/25488399/

Perhaps movement control exercises are the golden bullet?

One randomised controlled trial compared a low-load movement control programme for patients with back pain to high-load lifting exercises. Here the low-load group outperformed the high-load group in some measures. https://pubmed.ncbi.nlm.nih.gov/25641309/ However, a follow-up at one and two years showed no statistical differences between the groups.

Perhaps stretches are the most effective exercises for back pain?

This study showed that self-stretching exercises were just as effective as motor control exercises for people with chronic back pain. https://www.sciencedirect.com/science/article/pii/S1836955323000176

The reality is that research can be selectively chosen to support nearly any claim. While research should guide us, I prioritise the client in my decision-making process. I consider all the ‘it depends’ factors noted above and try to use a healthy dolop of pragmatism when prescribing exercises.

If you want to know what to do first, this is the general approach I follow in the clinic:

  1. First, relieve pain. The human body doesn’t tend to function well in the presence of significant pain. Some muscles shut down, while others tighten, causing changes to mobility and altered movement patterns. Exercises can form part of a strategy to help reduce pain. Gentle mobility exercises and self-massage often work well at this stage.
  2. Next, restore mobility and soft tissue flexibility. It is difficult to exercise effectively if you don’t have the joint mobility or muscle flexibility to get into healthy and functional positions. These exercises include joint mobilisations and muscle stretches.
  3. Once you have the necessary range and flexibility, it is important to control and coordinate your movement patterns. At this stage, exercises are devised to control movement of specific joints or of whole-body movements. For some back pain sufferers, these exercises may be started immediately as part of their ‘pain relief’ strategy.
  4. Lastly, once you move well, you can think about adding endurance, strength, speed and power to your rehab. Be wary about following strength and conditioning plans for back pain if you haven’t first considered working on your mobility, flexibility and movement control.

I believe that effective exercise prescription is about doing the right thing, at the right time for the right person.

So, which exercises are best for you right now?

It depends!


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