How Exercise Affects Low Back Pain

Resistance and strength training, free weights, walking, running, cycling, yoga, Pilates, and directional preference.

While many exercise modalities are promoted as good for low back pain, Michael C. Geraci, Jr., MD, PT, took a closer look at current evidence to determine which exercises are best for the spine in his presentation at the North American Spine Society’s 34th Annual Meeting in Chicago, IL. The clear winners are walking and strength training using free weights.

walking is a good exercise option for most peopleWalking while swinging your arms is a good exercise option for most people. Photo Source: iStock.com.

Dr. Geraci is Clinical Associate Professor of Physical Medicine and Rehabilitation at The State University of New York (SUNY) at Buffalo and Michigan State University’s College of Osteopathic Medicine in East Landing. He is in private practice at Geraci Spine and Sports Medicine in Williamsville, NY.

Resistance Training Prevents Age-Related Muscle Loss

While effects of aerobic exercise on cardiovascular health is well known among both patients and providers, current guidelines recommending resistance training 2 days per week to help prevent or treat bone loss (eg, osteopenia, osteoporosis) and progressive loss of muscle mass/strength (ie, sarcopenia) may be less understood.1 Sarcopenia starts at age 30, with adults losing 0.5% to 1% of skeletal muscle each year until age 70, when the rate of muscle loss doubles to 2% per year, Dr. Geraci explained. Thus, from age 30 to 70, the average person will lose up to 40% of muscle mass.2

Resistance training is key to preventing sarcopenia and lowers the rate of muscle loss between the ages of 30 to 70 to only 5%, according to Dr. Geraci.2 Resistance training helps build muscle strength and mass by working your body weight against gravity. In contrast, walking, running, biking, and swimming are not as effective at preventing sarcopenia. In a study of frail institutionalized patients in their 90s, high-resistance weight training led to a nearly 175% increase in strength and improved functional mobility.3

In addition, resistance training has the added benefits of improving balance and preventing falls. In order to improve balance, “we have to get the foundation right first, and that is improving strength,” Dr. Geraci said.

general exercise guidelinesGeneral Exercise Guidelines for aerobic and resistance training. Source US Department of Health and Human Services.

Strength Training Increases Bone Density

Resistance training also can help increase bone mineral density and prevent osteopenia and osteoporosis. For example, Dr. Geraci pointed to a study showing that premenopausal women who performed 50 vertical jumps (mean height, 8.5 cm or about 3.5 inches) showed a 3% to 4% increase in bone mineral density after 5 months, which he said is at least equivalent to the effects of bisphosphonates treatment.4 In contrast, these effects were not found in postmenopausal women after 12 months of the same protocol of vertical jumps. Vertical jumping, sometimes called a Sargent jump, involves jumping upward using both arms and legs.

Choose Free Weights Over Seated Weight Machines

Patients with lower back pain also should choose free weights over seated weight machines. Free weights offer higher loads as was demonstrated in a study showing a 140% greater increase in strength with free weights versus machines.5 For example, when comparing a squat with barbell to a seated leg press, squats are linked to a 50% greater increase in testosterone and threefold increase in growth hormone, both of which are responsible for building muscle and burning body fat.5 In addition, seated leg press machines are thought by some experts to increase the risk for disc herniation, Dr. Geraci noted.

Endurance Exercises May Protect the Spine

“Endurance is a little more important than strength in the spine, however, both are important,” Dr. Geraci said. Research suggests that dysfunction exists when an average patient cannot hold a side bridge for 45 seconds or a prone plank for 55 seconds.6

example of a side bridge exerciseExample of the side bridge exercise. Photo Source: iStock.com.

A study involving 4 NHL teams (McGill, unpublished data) found that players who could hold a side bridge for 70 seconds bilaterally had no sports hernias and less low back pain or injuries to the hip, knee, and ankle. Thus, endurance is somewhat protective, Dr. Geraci said. “Many NFL teams are now using McGill’s Big Three—bird-dog, side bridge or side plank, and modified curl-up—before practices and games,” Dr. Geraci explained.7

example of bird-dog exerciseExample of the bird-dog exercise. Photo Source: iStock.com.

Walking Is one of the Best Exercises for Low Back Pain

“Walking is still one of the best exercises,” Dr. Geraci said. He emphasized that patients should be instructed to move their arms from their shoulders using a reciprocal gait when walking as the annular fibers [tough outer wall of a disc] in vertebral discs stabilize when the arms and legs move in different directions. In addition, walking is best done briskly, which puts a lower load on the spine, he noted.

For acute lower back pain, Dr. Geraci suggested walking 5 days a week using the following schedule: 30 minutes in the morning, 20 minutes at lunch, and 30 minutes at the evening time.

Is Running Bad for the Spine?

“There is no greater incidence of back pain or wear and tear on the lumbar discs in runners,” Dr. Geraci said. However, running is not recommended in patients with acute disc herniation as running increases the stress on low back discs by twofold compared with walking. Jumping, such as in basketball or other sports, puts 5 times the stress on the lumbar discs compared with walking.

Swimming has no known benefit for low back pain. Male swimmers have the lowest bone density of all male athletes. In addition, the second most common injury in swimmers, after shoulder problems, is low back pain. In contrast, walking in water carrying kettlebells and dumbbells can be beneficial.

  • Remember: Before beginning any exercise or stretching program, talk to your doctor first.

Cycling May Increase Disc Pressure

While cycling is a great aerobic exercise, Dr. Geraci noted cycling may lower bone density in the spine, but not at the hip. Additionally, the seated leaning forward position in cycling increases disc pressure in the lumbar spine.

Yoga and Pilates: Pros and Cons for Lower Back Pain

Yoga has many benefits in terms of improved core strength, flexibility in peripheral (eg, knees) joints, breathing, mindfulness, and balance. Both yoga and Pilates include some exercises that may be beneficial to the spine such as prone planks (including leg lift or rocking variations), side bridges/planks with variations, bird-dog, and cat-cow, Dr. Geraci noted.

example prone plank exerciseExample of the prone plank exercise. Photo Source: iStock.com.

However, some postures with excessive flexion (forward and/or backward bending) or rotation (twisting movement) of the spine may increase the risk of low back pain (see Table below). There is no clear evidence that yoga is beneficial for the spine, except in some cases of nonspecific low back pain and chronic low back pain, he said.

Table: Yoga and Pilates Positions That May Aggravate Low Back PainTable: Yoga and Pilates Positions That May Aggravate Low Back Pain. Source: Geraci MC. Popular exercise methods deconstructed. Presented at North American Spine Society 34th Annual Meeting, Chicago, IL. September 25, 2019.

While general stretching is important for the hips, knees, ankles, and subtalar (feet) first metatarsophalangeal (big toe) joints, no studies show that flexibility of the lumbar spine is beneficial in protecting against low back pain, Dr. Geraci said.

Balance and Brain Health

In a study of postural instability involving 1,400 adults (average age, 67 years), participants were given two tries to stand on one leg for up to 60 seconds.8 All patients also underwent brain MRI. Analysis showed that participants who could not stand on one leg for 20 seconds were at higher risk for cerebral small-vessel disease (cSVD), which is associated with stroke, dementia, and Parkinson’s disease, Dr. Geraci said. In fact, a linear or straight-line relationship was found between the frequency of postural instability and the severity of cSVD.

Directional Preference Exercises Improve Outcomes

Directional preference (DP) exercises move or centralize low back pain and symptoms using mechanical loading strategies (MLS) to reduce pain and improve movement. MLS includes repeating specific movements and/or holding a certain posture.9

According to Dr. Geraci, DP exercises are beneficial for both acute and chronic as well as radicular (eg, leg pain) and axial low back pain. Axial lower back pain may be referred to as mechanical back pain that may be caused by muscular stress related to poor posture. In particular, hyperextension [straightening or stretching the back beyond normal limit] may help rehydrate lumbar vertebral discs and may be best when combined with standing up from seated positions every 30 minutes, Dr. Geraci noted.10

“Many patients show recovery in just 2 weeks,” Dr. Geraci said. “Directional preference exercises improve outcomes by seven-fold and may reduce the need for surgical repair of disc herniation by up to 50%,” Dr. Geraci said.

Conclusion

Dr. Geraci concluded that the best exercises for reduction of disability and prevention of low back pain include walking, bridges, planks, bird-dog, and modified curl-up, which allow for high activation of muscle and low load on the spine. Strength training with free weights also is essential and patients should include a squat, lunge, lift, push, pull, and carry in their routine.

  • Remember: Before beginning any exercise or stretching program, talk to your doctor first.

Disclosure
Dr. Geraci has no relevant financial disclosures.

Updated on: 12/10/19
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