You could be forgiven for being a bit confused about back exercises. Workplaces are often full of posters saying, “keep your back straight – bend your knees”, and yet yoga and Pilates classes encourage bending the back. We are cautioned to take care when lifting, yet we see Olympic weightlifters handling enormous poundage’s, apparently without injury. What’s going on?
Well, evolution has given us a strong, flexible spine supported by seriously powerful muscles. We can swing from bars, lift weights, run for miles across hard surfaces, and survive in temperatures ranging from cold snowy mountains to dry arid deserts. Our powerful hips and legs help us sprint, lift, bend, and reach. At least, the human body is capable of all these things but sadly our modern-day lifestyle often does not allow us to use them. The result is deconditioning – we become stiffer and weaker so when we are challenged to do something such as lifting in the garden or bending to do some DIY our body’s breakdown giving pain and injury.
This is where the 3R’s approach to back rehabilitation comes in. It provides a framework to guide users through the minefield of back exercises from the point of injury to return to full (and often very much better) function.
a framework to guide users through the minefield of back exercises
The 3R’s approach offers a clinical framework to guide patients, therapists, and exercise professionals through the rehab process. The approach divides rehabilitation into three interrelated phases which are aligned with the timing of healing tissues. When you are injured, your body repairs itself very effectively, and goes through three phases, injury, repair, and remodelling. Injury disrupts the tissue and causes internal bleeding and swelling, repair knits the tissues back together, and remodelling makes the tissue better suited to its function, so healed ligament would end up different to healed muscle for example. In the 3R’s approach we follow this healing timescale and the first phase of the 3R’s is reactive.
The reactive phase is where a patient’s tissues are often irritable or inflamed, and they are fearful partly because the injury has just happened, or it is still limiting most aspects of their life. It may be disturbing their sleep, preventing them from working fully, interrupting driving and sitting for prolonged periods, and limiting common daily activity such as bathing, housework and playing with the kids. The condition is easily stirred up and often seems to have no pattern, getting slightly better or very much worse almost by itself. At this stage the most important action is a good examination by a therapist. They will be able to rule out more serious conditions (so called ‘red flags’) or refer on to someone who can. The therapist will take time to explain what has happened and why the symptoms are there. For example, why pain may be in the back or travelling into the leg, why and how muscles may be weaker as though your leg is ‘giving way’ and why your symptoms may sometimes appear as cold, numbness, or tingling rather than just pain. They can advise on the best positions to limit your symptoms and simple home actions to take which will make you more comfortable. Many therapists will use treatments to ease pain and these can make things more comfortable and help you sleep better, getting you through the early stages of your condition. Examples include hands on treatments (manual therapy and massage), acupuncture, supports (back belts and taping), and electrical machines which can help ease pain. None of these is magical and people vary widely in their response, but if you get some short-term pain relief from treatments such as these, they are helpful to calm things down.
One very important feature of the reactive phase is learning how to relax. Often when you are ill or injured, there is the thought that you must fight it, and common language often encourages this. I ‘beat my backache’ I am ‘fighting my pain’. However, one of the factors which can make pain worse, is muscle splinting. When muscles contract and don’t relax readily they can become painful. Learning to relax by using the breath for example is often a good way to reduce pain intensity. If it helps, go for a walk and get out into the fresh air. If your pain reduces and you generally feel better, try to do this a couple of times each day. As things start to ease, you move from the reactive phase of the 3R’s approach to recovery.
You enter the recovery phase as your pain eases and your back condition becomes less irritable. How will you know? Well, your pain intensity may reduce. If a score of 10 is the worst possible pain and 0 is no pain at all, you may move from 8 out of 10 down to 5 or 6 out of 10. Also, the frequency of your pain may reduce. Rather than feeling pain 4 or 5 times a day you may only notice it once or twice. If you have been taking pain killers, you may need them less often or be able to manage on lower strength pills. Also, you might be able to do more before you get a flare up. For example, when you first noticed your condition it might have limited your sitting for a maximum of 15 minutes before pain came on, whereas now your able to sit for 30 mins.
The aim of the recovery phase is to gradually increase the capability of the spine. By using progressive (gradually more challenging) exercise we aim to build up your ‘back fitness’. To do this we use techniques traditionally used in the gym and modify them to make them more suitable for use on a spine which has been injured. One of the major guides to this phase of the 3R’s approach is the ‘S’ factors of fitness, which represents the different aspects of exercise with sports emphasising some factors more than others.
For example, if you are a bodybuilder you will emphasise ‘strength’ and if you practice yoga you will focus more on ‘stretch’ with each ‘S’ factor encompassing several sub-components. When a fitness component (or several) is chosen, the FITT mnemonic is applied, to describe how much effort is put into the action. Let’s take a simple spine twisting exercise as an example. Sit upright on a firm chair and loosely fold your arms at chest height (to prevent you from slouching which can sometimes stir back pain up). Turn to the right, pause and then turn to the left. As you get to the end of the movement on each turn, use your arms to pull you slightly further (pulling your hand on the elbow of your folded arm). It is common firstly for one side to be more flexible than the other (you can go around further in one direction), and for your back to be slightly painful. Perform 5-8 reps to each side and you should note the pain and stiffness in you back easing.
In terms of ‘S’ factors and FITT, this exercise works ‘stretch’ (lengthening the tight spinal muscles) ‘strength’ (using you trunk muscles to pull you around) and ‘spirit’ (gaining confidence as you move). You should practice the exercise two or three times a day (frequency) and pull gently rather than hard (intensity). There is a brief hold at the end of each movement (time) and the exercise is performed without any resistance such as a weight or band so is free moving (type).
During rehabilitation it is often better to practice the exercises supervised and your therapist is usually the best person to do this as they understand what is wrong with your back (pathology). They will construct an individualised rehab programme which is appropriate to both your needs (lifestyle, job, home for example) and to your back condition (muscle pain, disc injury, nerve entrapment for example). The aim is to gradually allow your back to move freely, and to re-strengthen the trunk (back and front) muscles to give you confidence to take part in all the actions you would want to. This is important because often people feel afraid of re-hurting their back after injury and this thought limits them – it even has an official medical name, it is called Kinesiophobia – literally fear of movement. It is very common to hear someone say, ‘I can’t do that because of my back’ or ‘my back is too weak to lift heavy weights nowadays’. This limitation is normally as much psychological (mind) as physical (body). The resilience phase of the 3R’s approach aims to tackle this head on.
In the resilience phase we increase the variety of movements, build up resistance to target strength, and use actions which are more functional, meaning that they are similar to movements you may be required to do in your job or leisure activities such as lifting, stooping, pushing and pulling, moving quickly and dealing with unexpected challenges involving your back. By building things up gradually we improve both your physical capacity to do things and your confidence that you are able to do them, avoiding self limiting beliefs. Resilience is a word which encompasses both mind and body. It’s really about being able to ‘get back up when you are knocked down’. Mental or emotional resilience includes things like a positive attitude, and the ability to see failure as helpful feedback. Physical resilience is the body’s capacity to adapt to challenges and to recovery effectively. It relies all the ‘S’ factors of fitness mentioned above, but also involves broader lifestyle factors such as support from family and friends, having a good diet, and taking time to relax and recover.
Resilience is a word which encompasses both mind and body
Moving through the 3R’s approach
The 3R’s approach may either be used as a progression through the whole pathway, or individuals may start at a specific phase reflecting their stage of healing or recovery and move on from there.
Take lifting as an example. Lifting involves taking an object from a low height and moving it upwards. Functionally this may be moving a box from the floor to a shelf, but early on the action must be split up to include actions at the hips, knees, and spine. We might deliberately put a limit on bending in the early phases of an injury when things are painful and easily stirred up (irritable). As things calm down movement of the legs and bending the spine is gradually re-introduced building both strength and confidence. It is important to do this gradually to allow the body tissues to change. Weak muscles strengthen, stiff joints move, and we build up our confidence that we will be able to do things without getting injured again – but this takes time. Taking time in this way allows gradual physical and mental changes (adaptation), and so the challenges (both physical and mental) are graded – gentle first, harder later. Whilst once we were cautious and controlled in our simple lifts, we are now more varied, less controlled and lift heavier and more awkward loads.
For some, their tissues may have recovered but the limit is more mental (confidence and kinesiophobia described above). The aim for these individuals is to move into the resilience phase more quickly and to build confidence – but again in a gradual way (graded exposure). You might fear lifting something heavy from the floor and so avoid it. Well, lets begin lifting something very light from a stool and gradually work down to a chair, low box, and then the floor. We can also build up the weight, alter the size and shape of the object, and change the complexity of the lift (lift and turn, lift, turn, and reach). In this way the 3R’s approach gives you the opportunity to get the most out of your back and your life!
If you want to find out more about the 3R’s approach to back rehabilitaiton read Dr Chris Norris’ article in this professional science journal HERE. For therapists and exercise professionals, he runs a two-day course teaching these techniques. Find out more HERE.