Core Program for Low Back Pain

What you are treating

Low back pain without leg pain, from worn discs, strained muscles, or tired joints, is the most common spine problem there is. Nearly everyone has it at some point, and most episodes settle within a few weeks. For some people it becomes a recurring or constant companion. The MRI usually shows "degenerative disc disease," which is a description of normal aging, not a disease, and not a reason for surgery by itself.

What changes the course of back pain is not rest, imaging, or a procedure. It is a spine that is held by strong, enduring muscles, hips that do the bending, and a body that keeps moving. This plan builds that, and it takes about twelve weeks to feel the full effect.

The rules of the road

• Keep moving. Walk every day, starting with 10 minutes and building to 30 or more. Walking is the best back medicine there is.
• Hinge, do not bend. To pick anything up, push the hips back and bend the knees with the back flat, like closing a car door with your backside. The hips are built to bend; the discs are not.
• Avoid the morning bend. Discs are swollen with fluid after sleep. Avoid bending and lifting for the first hour after getting up.
• Break up sitting every 30 minutes. Stand, walk, or do a standing back bend.
• Sleep on your side with a pillow between the knees, or on your back with a pillow under the knees.

The three exercises

These three are the best-studied exercises for a back that lasts. They build endurance in the muscles that hold the spine while keeping the spine itself still, they put less load on the discs than any sit-up or toe-touch, and in the research they help long-term back pain as much as any other active program. Do them every day. Build endurance with more repeats of short holds, not longer holds.

• Curl-up: lie on your back, one knee bent and one straight, hands under the small of the back. Lift the head and shoulders an inch off the floor, keeping the neck neutral, hold 8 seconds, lower. 5 repeats, rest, 3 repeats, rest, 1 repeat. This trains the front of the trunk without bending the spine.
• Side plank: lie on your side propped on the elbow, knees bent, and lift the hips so the body is straight from the knees to the head. Hold 8 seconds. Same 5-3-1 pattern each side. Progress to straight legs.
• Bird-dog: on hands and knees, extend one arm and the opposite leg with the back flat, hold 8 seconds, return and sweep the knee and hand under the body. Same 5-3-1 pattern each side.

Before the three, do a few cat-camel movements on hands and knees, slowly rounding and flattening the back through comfort, to warm the spine. Not stretching past comfort, and no sit-ups, toe-touches, or back extensions with weights, which load the discs. Bird-dog is the extension work in this plan: it builds the back muscles' endurance without loading the discs.

Free the hamstrings

The hamstrings run from the sitting bones at the back of the pelvis to just below the knee. When they are tight, they pull the back of the pelvis down and tuck it under (a posterior pelvic tilt). A tucked pelvis flattens the natural inward curve of the low back (the lumbar lordosis), and a flat low back has to round forward every time you bend, sit, or reach, because the hips cannot. That chain is why I ask nearly every back patient to work on hamstring flexibility:

• Looser hamstrings let the pelvis tilt forward again, which restores the low back's curve.
• With the curve restored, bending comes from the hips (the hip hinge) instead of from the spine.
• Bending from the hips rather than rounding the back lowers the pressure inside the discs and the strain on the back of the discs and the ligaments behind them. Studies that measured disc pressure directly found it rises sharply with a rounded, bent-forward back and far less with a hip hinge.
• In young athletes with spondylolysis, a stress fracture of the pars, tight hamstrings are almost the rule, and stiff hips make the spine take up the motion in both directions. Restoring hip motion is part of protecting the healing bone.

How: stretch each hamstring for 20 to 30 seconds, 3 to 5 times, once or twice a day, with the low back kept flat: lying on your back with a strap around the foot, or with one heel on a low step and a hinge forward from the hips. Rolling the back of the thigh on a foam roller before stretching helps many people. Expect more range within a few weeks. The gain comes mostly from the nervous system allowing the muscle to lengthen, so it is kept by stretching regularly, not banked. One caution: if your low back is very arched and your pelvis already tilts forward, aggressive hamstring stretching is the wrong tool; ask me or your therapist to check your pelvic position first.

Weeks 1 to 4

• Walk daily. Learn the hip hinge and use it for every lift.
• Do the three exercises daily, starting with 3-2-1 and building to 5-3-1.
• Stretch the hamstrings daily, as described above, and roll them before stretching if that helps.
• Add bridges (lying on your back, knees bent, lift the hips, hold 5 seconds) and standing hip strength at a counter.
• In a flare: keep walking, use the cat-camel and gentle movement, use heat, and take acetaminophen on a schedule, plus an anti-inflammatory for a few days if your stomach and kidneys allow. Do not stop moving for more than a day.

Weeks 5 to 12

• Progress the three to 6-4-2 and then 8-5-3, with full side planks.
• Add squats and hip hinges with a light weight held close to the body, and later a kettlebell carry at your side, keeping the trunk still.
• Add 20 to 30 minutes of aerobic exercise three times a week: walking faster, cycling, swimming, or an elliptical.
• Physical therapy if you want coaching, or if you are not improving. Ask for a therapist who builds a program, not one who mainly applies heat and ultrasound.

Beyond twelve weeks

Keep the three exercises as a lifelong daily habit, like brushing your teeth, and keep walking. Add activities you enjoy. Most people find that back pain episodes become shorter, rarer, and less frightening. Sleep, weight, smoking, and stress all affect back pain, and each is worth working on.

Medicines, injections, and procedures

• Acetaminophen and short courses of anti-inflammatories for flares. Not daily for months.
• Muscle relaxants for a few nights during a bad flare.
• Opioids do not work for long-term back pain and cause harm. I do not prescribe them for it.
• Facet joint injections, radiofrequency ablation, or endoscopic medial branch transection can help if the pain is shown to come from the facet joints. This is a minority of people.
• Surgery for back pain alone, with no leg pain and no instability, has poor results and I rarely recommend it. Disc replacement is an exception for a carefully selected patient with pain from one or two worn discs who has done everything in this plan.

Call the office promptly if you have

• Pain that travels into a leg, or leg weakness or numbness.
• Back pain with fever, unexplained weight loss, or a history of cancer.
• Back pain after a fall or injury, or in someone with osteoporosis.
• Pain that wakes you at night and does not change with position.

Learn more

OrthoInfo, Low Back Pain: orthoinfo.aaos.org (opens in a new tab)

My guides to degenerative disc disease and lumbar disc replacement.

This plan is general guidance for Dr. Wey's patients and does not replace the advice we discuss in clinic. Stop and call us if an exercise causes pain that travels into a leg, or if you notice the warning signs at the end.