Hinge Health Question and Answer session: Lower Back Pain

Welcome to the Hinge Health Q&A session on lower back pain. I am Karl Rosenberg, a registered physical therapist in London, UK. I have been helping people in my clinic for the past 26 years, and I work with Hinge Health to digitize best practice care for those suffering from chronic pain. 

Thank you to everyone who sent in questions over the past week—I hope that my answers will give you the tools you need to manage your back pain long into the future!

All the best,
Karl Rosenberg, B.App. Science (Physio), MCSP, HCPC PGDip CST

P.S. It’s important to note that if your doctor’s advice goes against any of my recommendations, you should check with your doctor before following my notes. They’ll have had the benefit of examining you in-person, which I don’t! Please see the full disclaimer at the end.

How often should I do my back exercises?

With constant back pain is it better to do some specific back exercises every day, or 3 or 4 times a week?

KR: Both! Little and often is good advice to maintain normal flexibility and function, and not get into the yo-yo cycle of too much activity one day followed by under-activity that is needed to recover the next. Pacing your exercise so that you don’t overdo it on good days or skip a session when you feel a bit too painful or not bothered on a bad day, is key to sustained exercise and improvement.

Recent research into back pain is showing that old-fashioned barbell strengthening exercises in a gym, like squats and dead lifts, can reduce the disability and weakness that often goes with low back pain.

This type of strength exercises NEEDS a days' rest at least, to recover if you are to get the most from them, however this is not a starting point for most people with back pain, but it can be a goal. This sort of training absolutely needs to be coached and monitored to prevent injury, and I would strongly recommend that this is taught on a one-to-one basis.

How to sleep on my back with lower back pain?

I struggle to sleep on my back as I have lower back pain after about 5 minutes, so I have to sleep on my side. It’s as though the back muscles relax and then won't move when I try to—like my back is frozen. It is then really painful to change positions. Any ideas you can suggest to improve this?

KR: Sleep with pillows under your knees, so that you are not lying so straight, this can unload the spine in bed at night. Also make sure your mattress is not due to be renewed and it is the correct firmness for you. You may try a gentle flexibility program before going to bed at night.

How to prevent waking up from back pain?

I get quite severe back pain which can wake me from sleep sometimes. Is there anything I can do?

KR: Pain at night can be an important indication of other problems, so first thing is make sure that you have consulted directly with a health professional—which can easily be done over the phone—to discuss your symptoms and to screen out any serious pathologies.

Next consider your sleeping position, as some are harder on your back than others. For example, lying face down can force your back into extension which can be eased by a pillow under your chest or hips, and sleeping on your side can cause you to twist, so try propping pillows under your top knee and keep it elevated. If you sleep on your back a pillow under your knees can help to unload a tight lumbar spine. 

You may consider the suitability of your mattress, is it too firm causing you to move around a lot at night to relieve pressure on shoulders and hips, or too soft and not supportive? Do you get a better sleep in different beds? Spending a few minutes at the end of an evening loosening up before bed also helps, to balance time spent in soft sofas in front of TV.

What to do if anterior tilt in the hip is causing my back pain?

My hip is rotated forward and I have a hollow lower back, which I think partly underlies my back pain. What can I do to tilt my hip back and straighten my lower back a bit? Ideally a solution would fix it for the long run so I don't have to constantly remind myself to tilt my hips back. Thanks!

KR: Hip (and leg) alignment is largely determined by the orientation of the hip acetabulum (or socket) of the hip joint on the pelvis. This orientation is how you are made up and not liable to be changed too much whatever exercise you do—however an anterior rotated pelvis and deep lumbar lordosis (the anatomical description of your alignment) can be due to a muscle balance problem known as the lower crossed syndrome, which can certainly be a factor in back pain.
In this syndrome, the hip flexors are too tight, and pull the lumbar spine forward and the pelvis with it, whilst the gluteal muscle are too weak to pull your pelvis back.

Hip flexor stretches and hip extensor strength are my prescription, with enough time and repetitions to make them work.
Also when standing try pushing your weight back and down through your heels, rather than have the weight on the balls of your feet: this helps to get the weight going back and down through the hips rather than out in front. Simple awareness of how your feet are loaded avoids the need to constantly remind yourself to do something with the hips. And another good cue to remind you to hold the posture can be a few strips of sporting tape applied to your lower back when you are in the ‘correct’ position. As you start to come out of that position the tape pulling on your skin can gently remind you to straighten up!

HH: A good example of a hip flexor stretch is the 'Butterfly stretch' and to strengthen those hip extensors 'Bridging' in the Hinge Health app can really help!

The best swimming stroke for back pain?

What swimming stroke is best for back pain? Are there any that I shouldn’t do?

KR: Swimming is widely regarded as good exercise for back pain, but I have treated patients who found that learning to swim can be a bit of struggle when you have pain. So I am assuming that you already can swim.

  • Backstroke and front crawl, with goggles and face and head supported in the water, would be my recommendation, with attention to a steady kick and good alignment, gentle pace no racing.
  • Breaststroke can force your back into an over-ached position, especially if you are swimming and keeping your head up out of water to keep your hair dry! But I would not rule it out as long as you don’t swim all your laps with it.
  • Butterfly is not one that I would suggest at the outset, but the dolphin kick on back or front can be a great way of training the core muscles.

The advice of "it hurts then don’t do it" applies in this case!

Lumbar stenosis treatment without surgery?

I have a message for Karl. My diagnosis from the NHS scan and confirmed by a doctor is that I have lumbar stenosis, which I understand to be a degenerative condition and is directly causing my sciatica. I have been advised that the only effective long-term treatment for this is surgery. I'd be keen to know if Karl has experienced success in treating stenosis without surgery. I have seen an improvement in pain from Hinge, but the sciatica never goes away unless I sit down.

KR: The degree of stenosis , that is how much narrowing is present in your spine, really determines the success of non-surgical management. This means if you have a large structural problem then surgery may be your only option. But before committing to surgery I always advise giving conservative management a thorough try. This may include steroid injections as well. Also, some pain relief for sciatic symptoms (whatever the cause) can be achieved with 'neural flossing' or 'sciatic  gliding' types of exercise, as well as making sure that there is not too much tension or over-activity of the gluteal muscles, especially the piriformis. Maintaining a good balance of abdominal bracing and gluteal control to help maintain a posterior pelvic tilt can improve the loading of the lumbo-pelvic region which may help your pain.

HH: To perform a 'neural flossing' exercise, please follow the steps below:

  • Sit in a chair with the feet flat on the floor.
  • Straighten the leg that is suffering from sciatica and tuck the chin into the chest.
  • Only straighten the leg as far as you can without it hurting too much, though it is okay to feel a bit of sensation.
  • Lower the leg and look up towards the ceiling.
  • Do this fifteen to twenty times.

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How to prevent back pain during pregnancy?

Karl, what are some good exercises to do for the back during pregnancy? I'm not expecting (!) but this back pain started during my first pregnancy and I'd like to be proactive next time!

KR: Pregnancy-related lower-back pain can be due the increasing load on the spine as your baby grows, and the softening of the pelvic and lumbar ligaments that occurs naturally from the end of the first trimester, to allow easier passage of the baby through the birth canal. 

To help control alignment from the Sacroiliac joints, getting good at exercises such as buttocks squeezes, hip bridging (one and two leg options), and hip extension exercises can reinforce that area of the spine to help cope with the loosening ligaments as pregnancy progresses. It would be better to get proficient at these now so that you are better placed to support joints in future. Good luck!

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Hanging to stretch out the back?

Should I try hanging so that gravity is stretching my back out? Maybe putting ankle weights on to help the stretch? Thank you

KR: Whilst hanging will definitely reduce the gravitational load on a spine, which may help to decompress painful discs or joints, this will only work if the supporting muscles can fully relax.

Hanging via your hands will need fairly intense activation of the muscles of the arm, shoulders, upper back, lower back and hips and pelvis, with even more work to support extra ankle weights, which may not be all that relaxing and pain reducing. It could be considered a conditioning type of exercise and as such may help with spine health, but not one I would suggest for someone already having back pain.

For a more gentle anti-gravity effect, an inversion table with tilt-back supports you via your legs, and you can adjust the angle with which you tilt. This controls the amount of stretch on the spine and would be an easier approach.

I think my facet and sacroiliac joint are causing my pain, what should I do?

I believe my back pain is coming from the facet joints on both sides—but mainly left. Are there any specific exercises you could recommend I do daily to ease the pain? I was originally told it was the sacroiliac joint causing the issue but now after having an injection to the sacroiliac joint which didn't do anything, my consultant thinks its the facet joints.

KR: Pain, especially low back pain, can rarely be ascribed to just one structure. If you have pain coming from a facet joint, you may well have an amount of protective muscle tightness or cramping in the area, your disc may be compressed, your nervous system ‘wound up’ and sending your brain an over supply of pain messages. Stress and poor sleep are also known to increase a person’s sensitivity to pain, fear avoidance and catastrophizing about pain also can have a negative influence on pain experience. Finally not all pain is equal to damage,  but can simply be a sign that your body is unhappy with the current situation and is telling you to change something.

I have found that patients with long term low back pain (whatever the structures involved ) benefit from a long term approach of loosening of the hip flexors (iliopsaos mainly) and strengthening the posterior chain (glutes, hamstrings and erector spinea muscles), and I would direct any patient with mechanical low back pain in this direction.

Specifically for facet joints, unloading with spinal twist stretches to the side away from the pain tends to open up and unload the joint, and gently passive lumbar extension can restore better joint function, like the cobra pose in yoga.

HH: To loosen those hip flexors again the 'Butterfly stretch' help, and the strengthening exercises you do in exercise therapy (such as the 'Side Plank' and 'Bridging') can help work that posterior chain as Karl mentioned.

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