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Understanding Rehabilitation for Chronic Back Pain

In chronic low back pain, spinal surgery may not be possible, or may only be considered after all other forms of treatment have been undertaken e.g. spinal injections and/or a spinal rehabilitation program.

After a thorough medical assessment to rule out serious or operable pathology, spinal rehabilitation may be recommended.

Spinal rehabilitation consists of:

  • Core stability exercises
  • General exercises
  • Weight loss
  • Education on position and lifting
  • Psychological treatment
  • Smoking cessation

Why core stability exercises?

Chronic low back pain leads to secondary weakness in the deep muscle supporting the spinal column. Specific core stability exercises aim to improve core strength, which will lead to better posture, less muscle fatigue, and improved spinal strength and flexibility. A core stability exercise program is usually prescribed and monitored by specialised physiotherapists (and some exercise physiologists). A long period of bed rest only exacerbates the stiffness and core muscle weakness, and so is best avoided.

In chronic low back pain, there is little role for long term pain relieving treatments such as heat, ice, massage, spinal mobilisation/manipulation or electrical machine therapy.

Why general exercises?

There is good medical evidence that physical exercise reduces low back pain. Both aerobic and strength exercises are effective, but will need to be individually prescribed and modified, taking into account exercise preference, availability of facilities and other medical problems (e.g. sciatica, osteoarthritis, or obesity). By alternating exercise (e.g. aerobic one day, strength the next) motivation is maintained and injuries are reduced.

A carefully prescribed exercise program will generally not aggravate the back symptoms, and can result in lower levels of low back pain.

Can I do other rehabilitation exercises?

Generally, other forms of exercise (e.g. Yoga, Pilates or Hydrotherapy) are safe as part of your overall rehabilitation program. This should be discussed with your referring practitioner who has a thorough understanding of your medical condition.

Why weight loss?

Obesity increases the mechanical loading on the lower back. Weight loss is advised for those with a BMI (body mass index) of over 30. Weight loss strategies include calorie restriction, specific diets, medications and exercise. In order to lose weight, your individually prescribed lumbar rehabilitation exercises program should incorporate greater emphasis on more intense aerobic exercise (e.g. cycling, swimming, or fast walking, for 40 minutes, at least 5 times per week). Your general practitioner or nutritionist/dietitian may be able to give you further weight loss advice regarding your diet.

Why smoking cessation?

Medical studies have shown that low back pain is significantly increased in smokers. It is thought that this is because smoking can cause: repeated coughing leading to disc microtrauma, poor blood flow, and decreased bone mineral density. Therefore, reducing - or preferably ceasing - smoking is recommended to all sufferers of chronic low back pain.

Why education on posture and lifting?

The level of low back pain is often increased in situations of prolonged sitting (especially with inappropriate seating), weak core muscles and poor lifting techniques. In order to reduce pain levels, frequent positional changes, ergonomic review of seating (and workplace if appropriate), instruction on good lifting techniques, and strengthening exercises will help.

Why psychological evaluation?

Chronic low back pain can lead to psychological problems (e.g. depression); and high levels of anxiety or work dissatisfaction can also increase back pain. This leads to an increased fear and avoidance of safe levels of work and exercise. Therefore, psychological assessment, and (if appropriate) anti-depressant medication may be recommended.

What if the pain increases?

Individually prescribed exercise rehabilitation should not cause deterioration of your underlying condition. However, short term aggravation of low back pain may occur.

If the aggravation is mild, then it is generally safe to continue the exercise. If the pain is moderate or severe, or not improving, with short periods of exercise avoidance, pain killers and anti-inflammatory medications, then further evaluation may be required.

If there is a dramatic increase in the level of low back pain, or if new features develop – especially if they are likely to be nerve-related (e.g. areas of numbness, weakness or pain in the arms or legs, pins and needles, bowel or urinary difficulties) then prompt medical evaluation should be sought.