Exercises And Treatment Approaches For Low Back Pain

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Exercise In Mechanical Low Back Pain


  • Restoration of joint biomechanics
  • Prevention of chronic pain development
  • Prevention of relapses
  • This prevents loss of function and improves physical adaptation.

Restoration Of Joint Biomechanics

  • Muscle strength, endurance, flexibility
  • By increasing the range of motion of the joint
  • Provided by preventing contractures

Prevention Of Chronic Pain Development In Exercise

  • Effects Providing Primary Analgesia
    • Endorphin release: Large muscle groups
    • Door control mechanism
  • Effects Providing Secondary Analgesia
    • Increases local blood supply. Improved muscle and intervertebral disc nutrition
    • Resolution of contracture and spasm
    • Improves depression and increases the patient’s self-esteem

Relapse Prevention

  • Preservation of joint biomechanics
  • Reduction of the load (30%) on the intervertebral disc (physiological brace)

Exercise Programme

  • Exercise should be made a habit.
  • Exercising more than once a day is better than a single exhausting session.
  • Exercise should not cause pain.
  • Exercises should start with warm-up exercises and end with stretching and relaxation exercises.
  • The least challenging movements should be started. (Floor exercises)

Recommended Exercise Types In Patients With Mechanical Low Back Pain

  • McKenzie exercises
  • Dynamic stabilisation egz

McKenzie Exercise

  • One of the most effective exercises
  • The position where pain decreases the most is determined (Centralization phenomenon)
  • The first movements can increase pain
  • Repeating joint range of motion exercises are performed
  • Isometrically exercise is done to the back extensors in extension
  • In the acute period, the exercise is performed 10 times with an interval of 1-2 hours
  • If the pain is centralizing within the first 2 days, it responds well to conservative treatment
  • It gives better results in acute cases than in chronic cases

Dynamic Stabilisation Exercise

Basic Principles

  • Objective: Reduction of cumulative microtraumas
  • Method: Neutral spinal position is taught

The neutral spinal position is the position in which the spinal column best meets the mechanical load.

  • Adjusted according to individual characteristics and disease
  • Applied under supervision
What Are The Causes Of Cumulative Microtrauma?
  • Staying in the same position for a long time
    • Sitting, standing
  • Major Movements
    • Getting in and out of the car, lying down and getting up
  • Movements requiring strength
    • Push, pull, climb
For Protection From Cumulative Microtraumas
  • Muscular strength, good flexibility and endurance are not sufficient
  • Healthy muscles need to contract at the appropriate time and this should be realised in activities of daily living


CONCLUSIONS: Neutral spinal position should be maintained during activities of daily living.

Dynamic Stabilisation Exercise

Exercise Techniques

  • Muscle strength, endurance, coordination exercises
    • Abdominal muscles (abdominal bracing)
    • Lower limb muscles
  • Flexibility (stretching) exercises
    • Paraspinal muscles
    • Hip flexors and extensors
  • Aerobic exercises
  • Walking and swimming recommended
  • Increases the release of endorphins
  • Increases physical capacity

Exercise Prescription Scheme In Low Back Pain

  • Acute Low Back Pain
    • Stay active and avoid bed rest
    • Aim: modulate symptoms, reduce activity; pharmacological treatments and other therapies are applied as adjuncts to activate quickly
  • Subacute low back pain
    • Start an aerobic exercise programme as tolerated
    • Start with general lumbar exercises aimed at trunk stabilisation
    • Objective: recommended to be active; return to normal activity; improve fitness level if necessary
  • Return to normal activity/Secondary prevention
    • Continue aerobic exercise and trunk stabilisation programme as home exercise
    • Purpose: prevent repetition
  • Continue aerobic exercise and trunk stabilisation programme as home exercise
  • Purpose: prevent repetition

Treatment Approach In Patients With Acute/Subacute Low Back Pain

  • Acetaminophen: fewer side effects, efficacy is controversial
  • Nonsteroidal anti-inflammatory drugs are recommended: one is not superior to the other
  • Muscle relaxants
  • Opioids are not recommended: not superior in return to work and pain control.
  • Superficial heat applications
  • Manual therapy
  • Corset
  • Acupuncture
  • Continue activity, avoid twisting and bending
  • Patient education

Treatment Approach In The Patient With Chronic Low Back Pain

Function-orientated approach

  • Education: focussed on overcoming the patient’s fear of movement
  • Exercise motor control exercises, aerobic exercises, core stabilisation exercises, strengthening exercises, flexibility exercises, stretching exercises, balance exercises, pilates, yoga, thai chi
  • Cognitive behavioural approaches and stress management
  • Multidisciplinary rehabilitation
  • Acupuncture
  • Massage
  • Manipulation

Pain-orientated approach

  • NSAID short course
  • Opioids: As effective as NSAIDs, but many patients discontinue treatment
  • Muscle relaxants:?
  • Duloxetine, antidepressants
  • Corticosteroids: no different from placebo
  • Epidural corticosteroid injections
  • Use pharmacological and nonpharmacological treatments together, start treatment primarily with nonpharmacological treatment, if it is not sufficient or if you cannot apply it, use pharmacological treatment
  • Physiotherapy applications
  • Dry needling, prolotherapy
  • Kinesiological taping

Surgical Treatment

  • Indications for definitive surgical treatment of low back pain
    • Development of cauda equina syndrome
    • Progressive motor deficit
    • Unresponsiveness to conservative treatment

Red Flags In Low Back Pain

  • Age > 50, especially women and men with osteoporosis or compression fracture
  • Age > 70
  • Unexplained fever, urinary or other infection history
  • Unexplained weight loss
  • Trauma, cumulative trauma
  • Night pain
  • Cauda equina syndrome (saddle anesthesia, urinary or fecal incontinence)
  • History of osteoporosis
  • History of cancer/strong suspicion of cancer
  • Long-term use of corticosteroids
  • Intravenous drug use
  • Immunosuppression or diabetes mellitus
  • Progressive or focal neurological deficit accompanied by symptoms of disability
  • Back pain lasting longer than 6 weeks
  • History of previous surgery

Yellow Flags In Low Back Pain

  • Psychosocial factors that may be effective in low back pain
  • Psychosocial barriers to recovery that can increase the risk of long-term disability and work loss
  • Yellow flags should be identified and treated early to prevent chronicity in low back pain
    • The belief that pain is harmful and can lead to serious disability
    • Avoidance of activities due to fear of pain
    • Belief in passive treatment rather than active treatment
    • Low or negative mood
    • Job dissatisfaction
    • Overprotective family or lack of family support
  • Many things can happen on an MRI.
  • Many people have problems with their MRI
  • If the patient’s complaints and clinic are not compatible with the problem detected on MRI, it is incorrect to say that it is caused by this.
  • If you do not think of additional serious problems, treatment is planned and followed up.


  • Modification of daily living activities
    • Choose the right shoes
    • Lift heavy objects with your legs, not your back, and keep them close to your body
    • When bending forward to work, bend without excessive bending or twisting of the back, avoid positions that increase inter-vertebral pressure, and bend at the knees or hips
    • When carrying heavy objects, carry them close to the body and balance the center line without bending to the side
    • Use your arm, core, and hip muscles when lifting weight, not your back
    • Keep your spine straight when standing
    • Move while maintaining the erect position of the spine while bathing
    • Dress in a pain-free position when dressing, and if pain occurs when dressing while standing, dress while lying down
    • Sit upright in a chair, lean slightly back to support your back, and sit with your legs apart
    • Stand up and move around from time to time when sitting, and change positions
    • Avoid sudden movements. When getting out of bed, turn sideways, dangle your legs, and get up with support from your arms. When sitting in a chair, sit with your back straight, then pull your body back, and when getting out of a chair, come forward first, then support yourself with the arms of the chair and get up with your back straight.
    • Get in the car sideways first and then take your body inside
    • When driving, sit with your back straight and support your back with a slightly reclined back
    • Sleeping on a firm and orthopedic mattress, bending your legs slightly during sleep and placing a pillow under your calves in supine position, placing a small pillow between the two legs in side position, and placing a thin pillow under your stomach and lower leg in prone position to relieve pain.
    • When brushing your teeth, washing your hands and face, do not bend over the sink, keep your back as straight as possible and do your work.
  • Exercise
    • Flexibility
    • Strengthening
    • Conditioning
  • Elimination of other risk factors
    • Do not smoke
    • Pay attention to your weight, eat a balanced diet
    • Psychological factors

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