What are the Best Physiotherapy Exercises for Lower Back Pain?
Hey everyone,
There has been some debate on what would be the best exercise for lower back pain. My answer is… it’s case by case! Depending on what your problem is there is no catch all exercise that will fix everything. Every back injury is different because each person has their own unique anatomy and activities.
Common exercises
There is a series of exercises that come up quite commonly when people come into my clinic with back pain. Many of my clients have reported that their back pain improves when they do these exercises. I’ve picked the top 3 most common back stretches people share with me during their initial assessment at Break Free Physiotherapy.
Cat cow
Cat (Bottom) and Cow (Top) Positions
This is a very common exercise you’ll find on social media. It’s a great exercise to help warm up, as it introduces a general range of motion in both flexion and extension. Flexion and extension describe what direction your spine moves in. In the case of flexion your spine curls forward, versus extension, which curls your spine backwards.
The only downside to cat/cow is that it doesn’t expose your spine to end range loading. End range loading is when you take a joint to the very end of its available range of motion. End range loading is often extremely important when it comes to relieving stubborn back injuries and maintaining healthy joint mobility.
Windshield wipers
‘Windshield Wipers’
This exercise adds a rotational component to the lower spine and provides a similar effect to cat/cow. People will often mention this exercise relieves their lower back stiffness in the morning. Most patients will lie on their back, place their feet on the bed, and rock their knees side to side to roughly 45 degrees. For more stubborn injuries, end range loading may be necessary in only one direction to relieve pain.
Child’s pose
Child’s Pose
A timeless classic. A lot of my clients love this exercise because they feel this nice stretch in the lower back. A lot of my clients report that they feel something is happening, because they feel a natural pull in the area where they feel tight or painful. In a healthy spine, this exercise is helpful in stretching a variety of muscles, mainly the erector spinae, which are a grouping of muscles that attach close to the middle of the spine. For many people this exercise is perfectly fine, but for others who have pain when they bend forward or sit for long periods, it may actually increase their pain.
How do I know if these exercises are appropriate for me?
It all depends on what pain patterns develop as you repeat a movement. If you complete a stretch and it worsens your symptoms as you hold or repeat it more, it may be wise to stop. However, if you repeat a stretch and your pain improves with more repetition, the stretch may be helpful.
Another sign is a loss of range of motion or stiffness after a stretch or exercise. However, if you repeat a movement and your range of motion improves and stiffness is relieved, it’s more likely a good movement for your lower back.
Some other key signs include the location of pain and where it travels. For example, if your pain starts to travel down your leg, this is a sign that things may be getting worse. New sensations like tingling and numbness are also suggestive of a worsening condition.
The best thing to do when you are unsure is to stop all exercise and seek help from a physiotherapist before continuing. If you can pinpoint what exercise or movement is making your pain worse, note this down and share this with your health care practitioner. This information will be helpful in finding the source of your injury.
Is bending forward bad for my spine?
This comes down to your presentation. Bending forward, sitting for long periods, and child’s pose put your spine into what physiotherapists classify as flexion. Flexion is the most common mechanism of injury for lower back pain but it doesn’t mean that flexion is bad. In fact, our spines are made to flex forward. However, what often happens is we favour one position, and over time we develop problems. Here are some other examples of flexion if you are not sure:
Parents picking their baby out of the crib
A runner bending over while standing to tie their shoe
Factory workers picking up a box without using their legs to squat down
Truck drivers and office workers sitting for a long time
Dentists repeatedly looking at the teeth of their clients
Doctors who perform surgery bent over the operating table
Teachers who work with younger children and have to sit on the ground, bend forward or sit in smaller chairs
At Break Free Physiotherapy, we identify patterns to help you find pain relief and the source of your injury. If the above sounds like you, we call this flexion intolerance. If you are flexion intolerant, you will also find that:
Sitting over time will be uncomfortable – your back pain worsens and you lose range of motion in your lower back. You may or may not have leg symptoms like pain, tingling and numbness .
When you get up from sitting for a long period of time, you feel stiff – my clients describe difficulty getting up from a chair. They put their hands on their legs to help support themselves as they stand. They walk their hands up their thighs to help them get up to a standing position.
You will have some good days where your pain is not there and other times when the pain is constant; The frustrating part is that your back pain will limit you from doing what you enjoy.
Being stooped forward, kneeling/crouching, or bending over something for long periods/repeatedly will worsen your symptoms. The intensity of back pain increases, or the surface area of where it hurts will become larger.
Walking, standing, and short bouts of movement seem to provide temporary relief. In some, but not all cases, you may notice a worsening of symptoms as you walk further or stand longer.
Does this sound like you? If so, you would benefit from physiotherapy!
What are some common positions that are helpful for someone who is flexion intolerant?
We sometimes need to take a break from spinal flexion to allow time for your lower back to heal. For example, if you spend a lot of time sitting, try standing more often. When you lie on your back with your legs straight, does your back and leg pain get better? When you sit in a soft deep-seated couch, does your pain worsen? Try using a stiffer chair such as an ergonomic office chair or dining room chair to see if pain decreases.
Noticing patterns in different positions can help you gather more information so your physiotherapist can pinpoint the source of your back and leg pain.
What if I have leg symptoms? What does this mean?
If you have tingling, numbness, or pain down one or both legs, it is important to share this with your physiotherapist. We call this phenomenon peripheralization. Peripheralization is when symptoms that are from your back travel down your leg towards your toes. This indicates that your back injury may be worsening.
Centralization is the opposite of this pattern. Centralization occurs when symptoms that are further down your leg start to move up towards your spine.
These images depict peripheralization when moving left to right, or centralization if going right to left.
For example, let’s say sitting starts to cause your leg and foot to hurt. When you lay on your back, you notice that your pain is no longer in your foot but just in your leg. As you spend more time in this position the pain will then move to your lower back. This is centralization.
Our goal is to centralize pain. Research has shown that patients who centralize, will have improved functional outcomes and better quality of life. (Sufka et al, 1998)
Once we’ve achieved centralization, we want to maintain this! That means continuing to avoid actions that worsen symptoms like bending forward, sitting, tying your shoe, cleaning the toilet, loading the dishwasher, etc. We need to give your spine a break from bending forward (this does not mean you get to stop doing chores forever!).
I will often use the analogy of the cut knuckle. When you have a cut on your knuckle and you keep bending that knuckle, the cut will never heal. When you keep your finger straight, the cut will heal and then you can begin bending your finger again. The same goes for bending forward. We avoid flexion of the spine temporarily to allow the injury to heal. Once the injury heals, we can return to bending forward, and even modify how we bend forward to decrease our chances of re-injury. At Break Free Physiotherapy, we are looking for the long-term solution for your back pain by providing you the tools to prevent the same injury in the future.
Some common examples of exercises that cause injury to flexion intolerant people
When recovering from an injury, flexion intolerant people want to avoid these exercises. This does not mean these exercises are bad, just that they may not be appropriate for a short period if you have pain with flexion. This list is compiled from 9 years of experience in my practice.
Crunches – These can really aggravate people with lower back pain as you are forcefully putting your spine into flexion.
Cycling or upright stationary bikes – If you are bent forward on a bike for a long period, this can aggravate your lower back if flexion is not your best friend.
Deadlifts – This is a common exercise that causes back pain. Without proper form, coaching and strength training of your trunk, you may run into problems avoiding spinal flexion.
Loaded Squats – Similar to deadlifts, proper mobility of your spine, hip, and ankles joints are required for this to be safe when adding higher weight. Bracing and breathing technique is also very important.
Standing toe touches/hamstring stretches – If you have tight hamstrings, this will likely put strain on your lower back. When your hamstrings are tight, this will cause more of a posterior pelvic tilt thus putting your spine in more flexion.
Pigeon stretch – A very common hip stretch popularized by social media for gym enthusiasts before a squat. In most cases, this will promote hip flexion, but for those with a flexion intolerance, this may cause more problems before the lift.
Remember this does not mean you need to avoid these exercises forever, or be fearful of them. By being aware of what activities and positions aggravate your back, a physiotherapist can offer guidance on how to modify those activities to decrease strain. Taking a temporary break from an aggravating activity and providing a stretch to relieve pain will help you return to activity more smoothly and safely.
Your physiotherapist at Break Free will complete a repeated movement analysis to find pain patterns if you’re stuck on what makes back pain better or worse. Once the source is pinpointed and your pain has decreased, your physiotherapist will provide exercises to strengthen muscle imbalances designed to help you get back to activity and maintain it long term.
Final Thoughts
Do not let fear stop you from returning to something you love doing. We sometimes accept things as inevitable and chalk it up to old age. However, with new research emerging and a better understanding of the human body, we now have tools provided by physiotherapists to live a more purposeful and healthier lifestyle that does not need to be filled with pain and limitation. If you are interested in getting an assessment with one of our skilled physiotherapists, click here! We would be honoured to work with you!
References
Sufka A, Hauger B, Trenary M, Bishop B, Hagen A, Lozon R, Martens B. Centralization of low back pain and perceived functional outcome. J Orthop Sports Phys Ther. 1998 Mar;27(3):205-12. doi: 10.2519/jospt.1998.27.3.205. PMID: 9513866.
Corey Kim
Co-Owner and Physiotherapist
Hey, my name is Corey, and I’m a co-owner of Break Free Physiotherapy and Wellness. I was born in Seoul, South Korea but grew up in London, Ontario. I finished both my Bachelor of Arts in Kinesiology and Master of Physical Therapy degrees at Western University. I’m passionate about helping people find pain relief through movement and believe in self-empowerment by sharing knowledge of the human body and its ability to heal. [full bio]
