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by Dr. David Borenstein M.D. updated 10/2021

Aerobic exercises that improve endurance can help back pain as discomfort starts to decrease. How will you know that you are improving? You will notice that you will feel more comfortable for increasing amounts of time out of bed. You will be able to walk longer distances around your house and outside. As you get better, you will be able to sit for longer periods of time without feeling tired.

Choose an exercise program that you will continue over an extended period of time and something that is easily accessible. You may love to swim, but if there’s no pool nearby, this program is not realistic. Exercises most helpful for low back pain are walking, swimming, or riding a stationary bicycle. Before your back pain began, you may have been running instead of walking, or swimming timed laps instead of paddling in the pool, or riding a regular bicycle. I am frequently asked, “How much exercise can I do?” The question is best answered with an explanation of the “Comfort Zone.”

Exercise makes these muscles more efficient and the clue to successful training is to use muscles without damaging muscle cells. With damage, the muscles must heal for longer periods of time. This is counterproductive. Finding the fine line between stressing your muscles and causing damage can be difficult. I try to guide my patients to find a happy medium with the concept of the “Comfort Zone.”

If you have been exercising and have developed low back pain, cut back your exercise to one tenth of what you were doing before the pain started. For example, if you were walking 10 blocks, you would cut back your exercise to one block. You might say that is no exercise at all, but that amount of exercise would be in the “Comfort Zone.” You would do the exercise and would feel no additional soreness the next day. That means you are able to do the exercise safely without causing any damage to the stressed muscles.

Then, every other day increase your exercise another block or another minute. As you increase your effort you will gradually move toward the “Margin Zone.” In this zone, the muscles stay sore for a longer period of time measured in hours, but less than a single day. At this point, cut back your exercise slightly to the previous level that did not cause increased soreness. Continue training at the lower level of effort until no soreness remains at the end of the exercise. At that point, the “Comfort Zone” of exercise has been expanded. Increases in times or repetitions are slowed at this point so that your training is between the “Comfort Zone” and the “Margin Zone.” Over time you will expand your “Comfort Zone” to increasing levels of exercise.

The goal of this slow progression is to get the benefits of exercise without falling into the “Discomfort Zone.” This is where discomfort may last for extended periods of time measured in days. Exercises are discontinued entirely until muscle pain from the exercise has resolved. The trouble with being in this zone is determining the amount of exercise that is safe. It may have been at one block or ten blocks. You cannot tell. That is why starting out in the “Comfort Zone” is so important.

This basic concept can work for any form of exercise—the treadmill, the stair climber, or strength machines. Start out with an amount of exercise that is safe. Once you know that you can complete the exercise without increasing your pain, you can quickly increase your exercise without causing a relapse. I have seen many patients improve with this guidance for their exercise. Try these concepts. I know that you will gain the benefits of exercise with much less risk for reinjury.

The Elusive Last 10 Percent of Recovery

After a while, you will have achieved a significant improvement in your condition with a combination of therapies. Your level of improvement may allow your return to work and most of your recreational activities. However, let’s say you have a specific activity that you enjoy. This may be hiking five miles, playing three sets of tennis, or running twenty miles per week. Your activity improvement may be 85 or 90 percent of your original state before back pain occurred. This level of improvement may mean that you are able to hike, but only four miles. Your tennis games may be shorter and less frequent. Your running may be 16 miles on the track at the high school. Your function is not as good as it was prior to your episode of back pain—but it is in the “Comfort Zone.” Some people who have had this improvement are not satisfied with their function. They search for the final 10 percent of function. They want to be exactly as they were prior to their back episode.

The difficulty is that this final 10 percent can be difficult to achieve. The search for this 10 percent is as successful as the quest for the Holy Grail. I have seen many patients search for that one elusive therapy that will restore them to their original state. They concentrate on what is lost versus what they have regained. They end up disappointed. Their pessimistic attitude makes it more difficult to reach their goal. People who accept their improvement and work from that point have a better chance to reach their goal. Think about it.

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Maintain a Positive Attitude

You may not believe it, but just learning about the causes of back pain and the fact that it gets better on its own has a great therapeutic effect. The positive feelings that come from knowing that your problem will be solved heal low back pain. Understanding the cause of your back pain goes a long way in relieving your anxiety concerning the potential threat to your health. The relief of stress plays an important role in the resolution of back pain, whether acute or chronic. Such knowledge is as powerful as manipulation by a chiropractor or exercises supervised by a physical therapist.

In a study conducted in the state of Washington, researchers assigned 321 people who had back pain for seven days or less to an exercise program supervised by physical therapists, to manipulation treatments given by chiropractors, or to an educational booklet about low back pain. In the first month of the study, the people in the exercise and manipulation programs had less pain. However, at one year, no differences could be found concerning days lost from work or the frequency of additional attacks of low back pain among the groups. The cost of the educational booklet was one third of the expense of the exercise and manipulation therapies. Knowledge is an affordable way to treat low back pain. The people informed about their back pain with the educational booklet needed to go to the doctor less frequently than those who received no information.

You can learn about back pain from this book and others, from videotapes and audiotapes on back exercises, and from the Internet. But be careful on the Internet. There’s a great deal of wrong information there, so know the reputation of the group presenting the information. I have listed a number of Internet sites from well-regarded professional groups in appendix C. These web sites are updated on a regular basis to offer current information.

One of my patients has taught me the power of a positive attitude. She is ill with a multitude of medical problems, any one of which could devastate a negative person. She returns to my office on a regular basis. She is always nicely dressed and has a smile on her face despite chronic pain and disability. I asked her what her secret was. How in the face of all these difficulties, the chronic nature of her illness, the multiple medicines she needs to take to function, does she continue with such a positive attitude? She told me her secret was very simple. Long ago when her problems started to mount up, she made a choice. She said, “I can be better or bitter. I decided to concentrate on the e and not the i.” She is a testimonial to the therapeutic powers of a positive attitude. Be positive and you can be better even in the face of adversity.