Back Pain Exercises and Prevention: Practical Guide

Back pain (lower back pain) affects 80% of the population at least once in their lifetime. Prevention is based on three pillars: strengthening the deep trunk muscles, regular stretching and adopting good postures. These measures significantly reduce the risk of chronic lower back pain, disc herniation and recurrence after surgery. Dr Dimitriu recommends a personalised exercise programme for each patient.

Why Muscle Strengthening Protects the Back

The lumbar spine supports most of the body's weight and undergoes significant stress during every movement. To maintain its stability, it cannot rely solely on bone and disc structures: muscles play a crucial role in protecting the spine.

The concept of a natural muscular corset is fundamental to understanding back pain prevention. This corset consists of several muscle groups working in synergy:

• The transversus abdominis: this is the deepest muscle of the abdominal wall. It acts like a natural belt that, when contracted, increases intra-abdominal pressure and reduces stress on the intervertebral discs. Biomechanical studies show that a toned transversus can reduce the load on the lumbar spine by 30 to 40%.
• The multifidus muscles: these small muscles located along the spine ensure segmental stabilisation. They control micro-movements between each vertebra. In patients with chronic lower back pain, atrophy of these muscles is often observed, which explains the importance of strengthening them specifically.
• The pelvic floor muscles: often overlooked, they actively participate in stabilising the pelvis and lumbar spine. Their synchronised contraction with the transversus improves the efficiency of the muscular corset.
• The paraspinal muscles: spinal erectors, quadratus lumborum and other deep back muscles maintain posture and control trunk movements.

A well-developed muscular corset allows you to:

• Reduce mechanical stress on intervertebral discs, thus limiting their degeneration
• Stabilise the spine during movements and efforts
• Improve proprioception (perception of body position in space)
• Prevent sudden or poorly controlled movements that can cause injury
• Promote better load distribution across the entire spine

Essential Strengthening Exercises

Dr Dimitriu recommends a progressive programme of strengthening exercises, to be adapted according to each patient's level and any existing spinal pathologies. These exercises can be practised at home, without any special equipment.

1. Front Plank (Abdominal Plank)

This is the reference exercise for strengthening the transversus and the entire deep abdominal wall.

Correct position:

• Starting position: lying face down on a mat
• Support on forearms (elbows under shoulders) and on toes
• Body aligned from head to heels: avoid arching the back or raising the buttocks
• Gaze towards the floor to keep the neck aligned
• Active contraction of the transversus: draw the navel towards the spine
• Regular breathing during the exercise

Progression:

• Beginners: 3 sets of 15-20 seconds with 30 seconds rest
• Intermediate: 3 sets of 30-45 seconds with 20 seconds rest
• Advanced: 3 sets of 1 minute to 1 minute 30 seconds with 15 seconds rest

Modified variation: support on knees rather than toes for beginners or in case of pain.

2. Side Plank

This exercise targets the oblique muscles and quadratus lumborum, essential for lateral trunk stability.

Correct position:

• Lying on your side, supporting on forearm (elbow under shoulder)
• Feet stacked or one in front of the other for more stability
• Lift the pelvis to align the body from head to feet
• Free hand on hip or arm extended towards the ceiling
• Avoid tilting forward or backward

Duration: start with 3 sets of 20 seconds on each side, progress to 45-60 seconds.

3. Hip Bridge (Glute Bridge)

Excellent for strengthening the glutes, hamstrings and lumbar paraspinal muscles. This is a particularly important exercise as weak glutes are a common cause of lower back pain.

Correct position:

• Lying on your back, knees bent, feet flat on the floor hip-width apart
• Arms along the body
• Lift the pelvis by pushing on the heels, until aligning shoulders-hips-knees
• Contract the glutes in the top position
• Hold for 2-3 seconds
• Lower slowly without completely placing the pelvis on the floor

Progression: 3 sets of 12-15 repetitions. To increase difficulty, maintain the top position for 5-10 seconds or perform the exercise on one foot.

4. Bird-dog

This exercise improves coordination, stability and strengthens the deep back and abdominal muscles.

Correct position:

• On all fours, hands under shoulders, knees under hips
• Neutral back, gaze towards the floor
• Simultaneously extend one arm in front and the opposite leg behind
• Maintain arm-back-leg alignment
• Avoid arching the back or tilting the pelvis
• Hold for 5-10 seconds, then switch sides

Programme: 3 sets of 8-10 repetitions on each side. Start by lifting only the arm or only the leg if the complete exercise is too difficult.

5. Dead Bug

Particularly effective for strengthening the transversus and improving coordination between upper and lower limbs.

Correct position:

• Lying on your back, knees bent at 90°, shins parallel to the floor
• Arms extended towards the ceiling
• Press the lower back to the floor by contracting the transversus
• Slowly lower one arm behind the head and the opposite leg towards the floor
• Keep the back pressed to the floor throughout the movement
• Return to starting position and alternate

Programme: 3 sets of 10-12 repetitions on each side, controlling the movement well.

Essential Stretches

Stretches complement the strengthening programme by improving flexibility and reducing muscle tension. They should be performed gently, without jerking, holding each position for at least 30 seconds.

1. Piriformis Muscle Stretch

The piriformis is a small deep muscle of the pelvis that can compress the sciatic nerve when too tight, causing sciatica-type pain.

Technique:

• Lying on your back, cross right ankle over left knee
• Grasp left thigh with both hands
• Gently pull the thigh towards the chest
• Feel the stretch in the right buttock
• Hold for 30-60 seconds, repeat 2-3 times on each side

2. Psoas-iliacus Stretch

The psoas-iliacus is often shortened in people who spend a lot of time sitting. Its excessive tension can create excessive lumbar lordosis and pain.

Technique:

• In a forward lunge, back knee on the floor
• Push the pelvis forward keeping the torso upright
• Feel the stretch at the front of the hip of the back leg
• To intensify: raise the arm on the same side towards the ceiling and lean slightly to the opposite side
• Hold for 30-45 seconds, repeat twice on each side

3. Hamstring Stretch

Hamstrings that are too tight increase stress on the lumbar spine during trunk flexion.

Technique:

• Lying on your back, leg extended towards the ceiling
• Wrap a towel or strap under the foot
• Gently pull the leg towards you keeping the knee straight
• The other leg remains extended on the floor or knees bent if needed
• Hold for 30-60 seconds, repeat 2-3 times on each side

4. Quadriceps Stretch

Important for muscular balance of the thigh and pelvic mobility.

Technique:

• Standing, supporting on one foot (hold onto a support if needed)
• Grasp the ankle of the opposite foot and pull the heel towards the buttock
• Keep knees close together, do not arch the back
• Push the pelvis slightly forward
• Hold for 30-45 seconds on each side

5. Cat-Cow Stretch

This dynamic stretch improves mobility of the entire spine and relaxes the paraspinal muscles.

Technique:

• On all fours, hands under shoulders, knees under hips
• "Cow" phase: inhale while arching the back, gaze upwards
• "Cat" phase: exhale while rounding the back, chin towards chest
• Perform the movement slowly, in synchronisation with breathing
• Repeat 10-15 cycles

Daily Ergonomics

Exercises and stretches are only effective if complemented by good daily ergonomics. Dr Dimitriu emphasises the importance of postures and movements in back pain prevention.

Sitting Position at Work

Prolonged sitting is one of the main causes of lower back pain in modern societies. A biomechanical study shows that pressure on lumbar discs is 40% higher when sitting than when standing.

Optimal position:

• Seat angle: the backrest should form an angle of 100-110° with the seat (slightly reclined), not 90° as often recommended
• Lumbar support: a cushion or the chair's integrated support should match the natural curve of the lower back
• Foot position: feet flat on the floor or on a footrest, knees at 90° or slightly higher than the hips
• Arm position: elbows at 90°, forearms resting on armrests or desk
• Screen position: top of the screen should be at eye level, approximately 50-70 cm away
• Keyboard and mouse: close to the body to avoid arm extension

Active breaks: it is essential to stand up every 45 minutes to walk for a few minutes, do light stretches or simply change position. The saying "the best position is the next one" summarises well the importance of mobility.

Lifting Loads

Lifting loads is a common cause of acute lower back pain, often due to lack of knowledge of proper techniques.

Correct technique:

• Get as close as possible to the load
• Bend the knees, not the back (use leg strength)
• Keep the back straight during lifting
• Hold the load against the body
• Avoid trunk rotations while carrying a load: pivot with the feet
• If the load is heavy: divide it into several times or ask for help
• Use a trolley or cart for significant loads

Pressure on the L5-S1 disc can reach 10 times body weight during lifting in poor position, compared to 3-4 times with correct technique.

Sleeping Position

We spend about a third of our lives sleeping: sleeping position therefore has a significant impact on the spine.

Recommended position:

• On the side: this is generally the best position. Place a pillow between the knees to maintain alignment of the pelvis and spine
• On the back: acceptable if you place a pillow under the knees to reduce lumbar lordosis
• On the stomach: to be avoided as this position increases lumbar lordosis and forces cervical rotation

Mattress choice:

• Neither too soft (lack of support) nor too hard (pressure points)
• A medium-firm mattress is generally optimal
• Replace the mattress every 8-10 years

Pillow choice:

• Should maintain head-neck-back alignment
• Height adapted to shoulder width (higher for sleeping on the side)

Post-Surgery Reconditioning Programme

After spine surgery, whether for a disc herniation, spinal stenosis or other pathology, physical reconditioning is essential to optimise results and prevent recurrence.

Dr Dimitriu proposes a four-phase programme, to be adapted according to the type of surgery and each patient's progress. This programme must always be validated by the surgeon and initially supervised by a physiotherapist.

Phase 1: Weeks 1-3 Post-operative

Objective: promote healing, reduce inflammation, maintain basic mobility.

Authorised activities:

• Progressive daily walking: start with 5-10 minutes, increase by 5 minutes each day up to 30-45 minutes
• Diaphragmatic breathing exercises
• Gentle ankle and foot mobilisation
• No strengthening exercises

Prohibitions:

• Trunk flexion beyond 45°
• Carrying loads > 2-3 kg
• Trunk twists
• Prolonged sitting (max 20-30 minutes)

Phase 2: Weeks 3-6 Post-operative

Objective: recovery of mobility, beginning of gentle muscle strengthening.

Authorised activities:

• Walking: 30-60 minutes per day
• Gentle swimming (after complete healing): backstroke, light crawl
• Gentle stretching exercises: piriformis, hamstrings
• Beginning of strengthening: isometric contractions of transversus, unloaded hip bridges
• Exercise bike at low resistance

Progressions:

• Progressive increase in sitting time (in 10-minute increments)
• Carrying loads up to 5 kg if correct technique

Phase 3: Weeks 6-12 Post-operative

Objective: progressive muscle strengthening, functional recovery.

Strengthening programme:

• Front plank: 3 sets of 15-30 seconds
• Side plank: 3 sets of 15-20 seconds on each side
• Hip bridges: 3 sets of 10-15 repetitions
• Bird-dog: 3 sets of 8-10 repetitions on each side
• Weekly progression of durations and repetitions

Complementary activities:

• Swimming: all styles (except butterfly)
• Exercise bike or road cycling on flat terrain
• Elliptical trainer
• Gentle yoga (avoid extreme flexions)

Carrying loads: progressive increase up to 10-15 kg with correct technique.

Phase 4: 3-6 Months Post-operative

Objective: return to normal activities, progressive sports resumption.

Advanced strengthening:

• Core bracing: holding 45-60 seconds
• Exercises with light weights
• Exercises on unstable surface (Swiss ball, proprioceptive platform)
• Adapted weight training programme (under supervision)

Sports resumption:

• Low-impact sports: swimming, cycling, Nordic walking, golf (with precautions)
• Moderate-impact sports (after 4-6 months): progressive running, tennis, skiing
• High-impact sports (after 6 months and medical validation): contact sports, pivot sports

Long-term objective: maintaining regular physical activity (3-5 times per week) combining strengthening, stretching and cardiovascular activity.

Mistakes to Avoid

Certain misconceptions or bad practices can delay healing or worsen lower back pain.

1. Strict Prolonged Bed Rest

Contrary to an old belief, prolonged bed rest is counterproductive for lower back pain. Current recommendations from health authorities advocate limiting strict rest to a maximum of 48 hours in case of acute lower back pain. Beyond that, prolonged rest leads to:

• Rapid muscle wasting (1% per day of bed rest)
• Joint stiffness
• Risk of pain becoming chronic
• General complications (phlebitis, constipation, cardiovascular deconditioning)

On the contrary, adapted physical activity should be maintained as soon as possible.

2. Sudden Return to Activity

Conversely, resuming physical activities too quickly or too intensely exposes to recurrence. Resumption must be:

• Progressive: increase intensity and duration in steps of 10% per week maximum
• Adapted: start with low-impact activities
• Regular: four short sessions per week are better than one intensive session

3. Ignoring Pain

Pain is an alarm signal that should not be neglected. If an exercise causes pain:

• Immediate stop if the pain is acute or radiating
• Exercise adaptation if the pain is moderate
• Medical consultation if the pain persists or worsens

Note: it is important to distinguish pain from muscular discomfort. A feeling of tension or light muscular burning is normal during strengthening. However, spinal pain or pain radiating to the lower limb should be of concern.

4. Lifting Heavy Loads Too Early

After lower back pain or spine surgery, resuming load carrying must be very progressive:

• Initial phases: maximum 2-5 kg
• After 6 weeks: progressive increase according to tolerance
• Always prioritise correct technique over performance
• Use mechanical aids (trolley, cart) when possible

5. Neglecting Warm-up

Before any physical activity or strengthening exercise, a 5-10 minute warm-up is recommended:

• Active walking
• Gentle joint mobilisations
• Light dynamic stretches

6. Doing Only Classic Sit-ups

Crunches (torso raises) and sit-ups increase intra-disc pressure and can worsen certain pathologies. It is preferable to prioritise core bracing exercises that strengthen deep muscles without excessive stress on the discs.

Frequently asked questions

Sources: NICE (National Institute for Health and Care Excellence, 2020), American College of Physicians (2017), European Guidelines for Prevention in Low Back Pain, North American Spine Society (2020), McGill S. Low Back Disorders: Evidence-Based Prevention and Rehabilitation. 3rd edition. 2015.