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  • Writer's picturethe PT & the Patient

Lower Back Pain - What's right for you?

Updated: Mar 17, 2021

There's a lot of great information on the internet about how to recover from pain and injury on the internet. But even when the information is from a reputable source and correct, it's really critical to make sure you understand what injury the advice is meant to help with, and if it applies to you.


The right advice for one person isn't necessarily right for someone else even if the symptoms seem to be the same. I'll explain with an example from my own experience with lower back pain, but the idea of this article is to explain three things:


  1. Just because your symptoms are the same as someone else's does NOT mean it has the same cause.

  2. A different cause for the issue means a different cure is often needed.

  3. Doing something that helps someone with the same symptoms could hurt you instead. If your cause is different and your cure may often need to be different.

We'll use lower back pain as an example and show you why this is. Along the way we will also be providing you with expert advice from our Doctor of Physical Therapy, Eric Hsia to understand two potential causes of lower back pain. We'll also provide exercises appropriate for helping with these two types of lower back pain.


Remember, there are many causes for lower pack pain, so when reading the article, remember to only do these exercises if the cause applies to you. Unlike many sources of information on the internet, we're never going to dispense "generic" advice for everyone. We'll always be crystal clear on who these exercises or advice is for, and how to differentiate if it's appropriate for your situation.



 

As a sufferer of back pain, I was scrolling through social media and encountered this exercise below:


You may have seen this image or one like it floating around the internet. Numerous comments supported this as working to help reduce their lower back pain. One comment even suggested their PT instructed them to do this exercise daily. I was shocked as I was told to do the opposite by my own PTs and to avoid exactly what this image suggested. In fact, doing this exercise caused additional pain.


I spoke with Eric Hsia, Doctor of Physical Therapy to discuss why this exercise was being suggested on a lower back pain group and helped some people while I was being directed to do the exact opposite (see below). The exercise suggested on social media (above) actually caused pain and other symptoms for my back and sciatica, but the exercise assigned to me (below) helped.



Does this mean one exercise is bad and the well meaning people on the forum were wrong?


No.


Let’s dive into what’s happening here with the goal of helping you avoid causing more injury and to make sure you’re getting the right advice to help your condition. We will of course provide the information on what exercises are recommended for each condition, but even more importantly we want to help you understand how to evaluate the information you find online and whether it’s appropriate for you.


You might encounter a variety of exercises that are being promoted to help your back. Some work and some don’t or even make things worse!


What helps you or hurts you is dependent on the source of your pain.


This includes possibilities like a particular imbalance of strength in your muscles, postural problem or the injury you have. This is why it’s really important to see a PT and MD for evaluation and diagnosis so you are aware of the root causes of your pain, weakness and other symptoms and do only the exercises that are appropriate for your condition.


We discuss which interventions can help you for lower back pain (LBP) and how to tell the difference. But whether your issue is LBP or something completely different, you should keep reading to understand why you need to know what’s causing your pain before doing a random exercise off the internet.


It’s important to note that the intervention needed depends on the cause of your pain, which is found during screening by your physical therapist. While it may be tempting to try a shotgun approach to exercises found online, you’re as likely to encounter exercises that are inappropriate for your condition as appropriate. We’ll give you an example below for the two opposing exercises that are often recommended for lower back pain but can be helpful or detrimental depending on your actual condition.


 

Example of Anterior Pelvic Tilt (Archers):


JC is a woman presenting our PT with complaints of low back pain (LBP) and stiffness. She does not recall any specific mechanism of injury but notes that her pain began approximately 4 months ago when her company shifted all non-essential employees to telecommuting (working from home). She reports that she spends 7 hours per day sitting at her desk. Her pain is worse when sitting and increases throughout the day. JC suspects that her LBP may be coming from her sitting posture, and has been trying to sit up straighter when sitting at her desk. However, she has found little relief to her symptoms.



Upon postural screening, we find that JC sits with an anterior pelvic tilt (see above) which is commonly correlated with tight hip flexors, decreased core strength, and tight erector spinae (lumbar extensors) muscle group. In plain english - if you sit with what most people would consider “good” posture, but take it too far - arching your back, with shoulders and butt back, chest forward - sitting up against the edge of your seat super straight. This is a common problem often caused by excessive sitting without adequate breaks to exercises and stretch. From a patient perspective, you might find your muscles in the front of your hips and thighs to be tight. All of this might cause lower back pain, and/or hip or knee pain.


Here the intervention that I saw suggested on social media is appropriate, while her attempts to sit up even straighter are detrimental. It wasn’t appropriate for me, and would actually do more harm for me because this is not the condition I suffer. So if you try an exercise you saw suggested online, note that it may not be appropriate unless it clearly explains what condition it’s for, and you have that specific cause for your pain and other symptoms.


These are relatively easy and safe exercises Eric Hsia, DPT would recommend for this condition. There are of course other exercises that would help, but may not be appropriate for everyone with an anterior pelvic tilt:


Half-kneeling Hip Flexor Stretch



  1. Start in a half-kneeling position, with one knee up and one knee down. You should feel this stretch on the side with the knee down.

  2. Engage your core by drawing in your belly button

  3. Squeeze your glute (posterior muscle) on the side with knee down

  4. Holding the core and glute contraction, slowly lunge forward until stretch is felt

  5. Make sure you do not hyperextend at the lumbar spine by keeping your torso upright (not leaning backward, because that would negate the hip rotation)

  6. Hold for 30 seconds. Alternate sides, hold the same position with the other knee forward.

  • Perform 3 sets daily.


Hooklying Supine Posterior Pelvic Tilt Exercise



  1. Lie on your back with your knees bent.

  2. Activate your core, drawing in your belly button.

  3. Squeeze your glutes (muscles in your posterior).

  4. Performing this on your back is beneficial because you can feel your lower back contact the floor, which lets you know you’ve gone far enough. There’s no need to continue curling so that you push your lower back off the ground - once it touches, you performing the exercise correctly.

  5. Flatten your lower back against the floor

  6. Ensure the movement is coming from drawing in your core and your pelvis rotation, not from pushing off the floor using your feet.

  7. Hold for 10 seconds.

  • Repeat 10 times per set; Perform sets twice daily.

Seated Posterior Pelvic Tilt Reinforcement



Here we see the reinforcement exercise I found recommended by social media. Great if you have an anterior pelvic tilt issue, but actually detrimental if you have a posterior pelvic tilt and posterior herniation like mine.

  1. Begin in a seated position without your back touching the back of the chair, with feet firmly planted on the ground.

  2. Activate your core, drawing in your belly button

  3. Squeeze your glutes (muscles in your posterior)

  4. Tuck in your tailbone but be sure not to overly round your back. Our goal is to achieve a neutral spine.

  5. Hold this position for 10 seconds.

  • Repeat 10 times per set; Perform sets three times a day (in the morning afternoon and evening).


We should note if you have a larger posterior there may be a higher chance for you to have this postural issue. (In plain English - if you have booty like Beyonce you might be more likely to have this problem!) The cause of this condition can stem from other causes as well for example if you suffer from a less common anterior herniation, this may also cause pain and other symptoms regardless of your normal seated position (or the size of your butt!).


 

Example: Posterior Pelvic Tilt (Slouchers):


What if JC presented with a posterior pelvic tilt (see below) instead? In plain English - what if you usually sit with a slump like you see below:



Posterior pelvic tilt is commonly correlated with: tight hamstrings, weak lumbar extensors, decreased thoracic spine mobility.


Here the interventions recommended by Eric Hsia, DPT that are again, relatively easy and safe for anyone with a posterior pelvic tilt. There are additional exercises that could be recommended but are not necessarily appropriate for all patients. As a patient, I've also personally performed all of these exercises and can attest they have helped me with my condition (posterior pelvic tilt and posterior herniation at the L5/S1):


Seated Hamstring Stretch



  1. Sit at the edge of your chair with one leg straight out and one leg bent normally with foot firmly planted on the ground. The leg that is straight should feel the stretch.

  2. With your outstretched foot’s heel on the ground, actively pull your outstretched foot’s toes toward you.

  3. Keep your back straight and hinge at your waist, reaching toward your toes. Try not to round through your back.

  4. Once you feel the stretch, hold for 30 seconds.

  5. Switch sides and repeat.

  • Perform 3 sets on each side daily.


Thoracic Extensions Over Back of Chair



  1. Tightly roll up a bath towel and place it between your back and your chair. It should sit just under your shoulder blades.

  2. Put your hands behind your head and lean back over the towel, opening up your chest and looking toward the ceiling.

  3. Hold for 5 seconds.

  • Repeat 10 times daily.


Anterior Pelvic Tilt Exercise



This exercise is the one I was recommended by my PT previously, which was the exact opposite of what I saw in social media and prompted this article.


  1. Begin in a seated position without your back touching the back of the chair, with feet firmly planted on the ground.

  2. Shift your weight forward, engaging your lumbar extensors (your lower back muscles) while bringing your chest forward and upward. You may feel like your back is arched.

  3. Hold for 10 seconds.

  • Repeat 10 times.


 

Conclusion:


Chronic LBP caused by prolonged sitting can be attributed to multiple factors, and there is no “one size fits all” treatment plan. Even more important, LBP can be caused by other nerve or musculoskeletal issues we did not cover in this article. Be careful when following advice you find online as it may be counterproductive to treating the root cause of your pain.


If you find advice or exercises on the internet that simply tell you what to do but don’t talk about the cause of the pain it’s trying to solve - don’t do it. Good advice should always clearly state the cause of the pain they are trying to help with and explain that a particular exercise or set of exercises is only useful if that’s the cause of your pain. If the exercise is simply generic for anyone with pain in the region, it may not be appropriate for you.


Speak to a doctor and physical therapist before beginning any exercise regimen to treat pain or injury.


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