Spinal exercise is an important part of any spinal rehabilitation program. The timing of the prescription of spinal exercises is very important, so as not to cause more trouble for the injured patient.
Recommendations on Exercise
The use of active methods of care, such as exercise, have been discussed in some detail in published articles and books on the subject.1,2,3 Guidelines have been established that suggest that, in the first week of an acute episode of spinal pain, active strengthening exercises should be avoided, because they tend to aggravate acute conditions.
After a brief period of rest (usually three days or less), reactivation to usual activities of daily living is to be encouraged. Within the first week of an acute injury, endurance exercise programs that minimally stress the spine, such as walking or swimming, are found to be beneficial.2,3
Typically, we have our acutely injured patients begin a walking regimen in the first week of care, consisting of walking 10-15 minutes per hour throughout their waking hours. A protocol for spinal rehabilitation authored by Troyanovich, et al.,4 also suggests the use of applications of deep cooling procedures in the acute phase of treatment to control pain and inflammation. The application of ice packs in thirty-minute intervals, in combination with the initial walking regimen of 10-15 minutes per hour, is an adequate first step in patient management.
The next types of exercises that are advocated are range of motion exercises in the non-painful directions. We typically employ extension, lateral bending, and axial rotation movements, as long as they can be performed without pain.
A word of caution is necessary here. Spinal exercises should not provoke a patient’s acute pain. The patients should always be warned that the movements should not cause any acute increase of their pain and should not cause any radiation of pain into their extremities. If such an occurrence of pain is provoked, the patient can still be instructed to perform the range of motion exercises; however, the patient is instructed to perform the movements at a slower pace, through a smaller range of motion that is not painful, or to discontinue the exercise and simply continue with their walking regimen.
Christiansen5 has described a specific protocol for using isometric and isotonic exercises. He recommends that such exercise programs begin with isometric exercise, since they are best suited for use early in rehabilitation programs because, ideally, no active movement occurs during the performance of isometric exercise. What this means, in a practical sense, is that, since no movement of the joints occurs, the likelihood of further injuring the articular tissues is very low. Consequently, for patients ready to move to the next step in their rehabilitation programs, submaximal isometric exercises are an ideal procedure to follow their initial walking regimen and range of motion exercises.
For simplicity of discussion, we advocate isometric exercises in the same planes of motion as described above, including extension, lateral bending and axial rotation. For greatest benefit, Christiansen5 recommends using the “rule of 10’s”. That is to say, the patient is instructed to perform 10 repetitions per set and up to 10 sets per day (i.e., up to 100 reps per day). The total of 100 repetitions per day is considered a long-term goal and the patient is cautioned to begin with three to five sets of 10 reps per day and gradually add one additional set of 10 reps per day, until the full number can be accomplished without aggravation of symptoms and without causing radiation of symptoms into the extremities.
After completing approximately one to two weeks of isometric exercise, most patients are ready to begin isotonic (resistance) exercises. Recent guidelines, based upon reviews of the scientific literature on resistance exercise, suggest that acute patients should avoid beginning resistance exercise programs until two weeks have passed since the onset of symptoms.2,3 Sub acute and chronic patients may begin resistance exercise programs as early as the first week of treatment.2,3
Low-cost resistance exercise can be accomplished in the practitioner’s office with the use of a small number of simple devices. Several companies produce differing gauges of surgical tubing that can be used to provide resistance while performing spinal exercises. The advantage to these devices is that they are relatively inexpensive and require little or no special hardware to mount in the home or office setting. In addition, there is no scientific evidence that suggests that expensive resistance exercise equipment is any more effective in spinal rehabilitation than these simple devices.2
Heyward6 has described protocols for isotonic exercise designed to increase strength, endurance, and for toning of muscles. Based upon her data, endurance training of trunk muscles requires a protocol of three sets of 15-20 repetitions per set, performed at least three times per week for six weeks or more. This is the frequency and duration we advocate.
Additionally, the speed of the muscular contraction is important. The patient should take approximately one to two seconds to move into concentric position against the resistance of the exerciser (contraction phase) and another one to two seconds as they move back to the neutral position (eccentric contraction phase).
Patients are started on isotonic exercise at approximately the beginning of the second or third week of their rehabilitation programs (after completing one to two weeks of isometric exercise). The rubber tubing type exercisers are used initially, performing three sets of 15-20 repetitions. Between each set of exercises, the patient is asked to rest for one to two minutes before proceeding to the next set. After one to two weeks of using relatively low resistance tubing, the patient then advances to higher resistance tubing.
At first, isotonic exercises are performed under the supervision of the doctor or an assistant. When the patients can perform the exercises competently, they are allowed to exercise independently in the office. This practice allows patients to enter the office and begin their exercises without having to wait for the doctor or assistant and facilitates a shorter duration of time in the office for each patient visit.
The isotonic resistance exercises are performed for the duration of the patient’s in-office rehab program. Patients can, then, be sent home with the device to continue spinal strengthening programs upon their discharge from care.
Note: This information in not intended as healthcare advice. The determination of the risk and usability of information rests entirely with the attending doctor of chiropractic.
Dr. Roger R. Coleman is a 1974 graduate of Palmer College of Chiropractic, practicing in Othello, WA. He is a member of the Adjunct Research Faculty at Life Chiropractic College West, and on the postgraduate faculty of National University of Health Sciences.
Dr. Stephan J. Troyanovich is a 1987 graduate of Palmer College of Chiropractic, practicing in Normal, IL, and a member of the Adjunct Research Faculty, Dept. of Research, at Life Chiropractic College West. He may be reached at 309-454-5556.
1. Spitzer O, et al. Scientific monograph of the Quebec task force on whiplash-associated disorders: redefining “whiplash” and its management. Spine 1995;20(8S):2-73.
2. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical practice guideline no. 14. AHCPR Publication No. 95-0624. Rockville, MD: Agency for Health Policy and research, Public Health Service, U.S. Department of Health and Human Services. December 1994.
3. Abenhaim L, Rossignol M, Valat JP, et al. The role of activity in the therapeutic management of back pain. Spine 2000;25:1S-33S.
4. Troyanovich SJ, Harrison DE, Harrison DD. Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther 1998;21:37-50.
5. Christiansen K. Chiropractic rehabilitation volume I: protocols. Ridgefield, WA: Chiropractic Rehabilitation Association 1991.
6. Heyward V. Advanced fitness assessment & exercise prescription. Champaign, IL. Human Kinetics 1998.