Active rehabilitation

Active rehabilitation gives you the opportunity to escape the chronic effects of a lower back injury. Frequent relapses is the rule unless you are prepared to go through the discipline of a daily exercise program.

This page was last updated by Dr Barrie Lewis on 15th June, 2019.

The fundamental problem is that the pain decreases much faster than you heal. Simply because the sharp stabs have halved does not mean that the tissues have been restored by fifty percent.

In fact this principle holds whether you have broken a bone, torn ligaments or slipped a disc; some form of rehabilitation is vital if you want to regain your status before the injury.

When one has a serious illness, such as pneumonia, a sense of malaise and weakness is the norm. You know that, despite the fact that breathing has returned to normal, the effect of the disease has not yet passed. One has no difficulty with the idea that a period of recuperation is important.

But with severe lower back pain, one does not actually feel sick. And once the symptoms have reduced significantly, the temptation to return to the fast lane too soon is very great. Then there is a relapse, often worse than the first episode, with sciatica radiating down the leg.

It applies equally to a shoulder injury, or a sprained ankle. The soft tissues, and especially discs, ligaments and tendons have a poor blood supply and take longer to heal than bone, for example. Plus, unless you gently exercise the damaged part, a fibrotic scar forms, likely to rupture again.

Ask any doctor of any ilk and he or she will confirm that a great many of their patients suffer from chronic and recurring pain after an injury. Mostly this is really not necessary, brought on by being overly busy and thinking that only happens to other people.

Active rehabilitation

Active rehabilitation of an antalgic posture like this is paramount; otherwise the pain is highly likely to start radiating down the leg.

An example of antalgic posture.


Antalgia (ant + algia = away from the pain) is a reflex stance the body takes on to escape the pain and protect the nerve root; it's beyond your conscious control. Active rehabilitation is vital to prevent relapse.

Usually the antalgic posture is away from the pain, but in the case of the postero medial disc herniation, then it's actually towards the agonising side.

Antalgic posture from behind.

Slipped disc

Slipped disc does not always produce an antalgic list like this; it's a very serious sign, and active rehabilitation is vital whether you go into this twisted posture or not.

The leaning tower of Pisa.

Let's consider this case. Five months ago this lady consulted us with acute lower back pain after heavy lifting. There was no pain in the leg, and it was her first incident.

All the indications were of an acute disc injury at the L4 L5 joint. As you can see, she looks like the leaning tower of Pisa. This is what's known as a functional scoliosis, or antalgic posture. That means this is a temporary twist in the spine, and she will come upright once the bulge has been reduced.

It usually takes about 3 days to a week, depending on numerous factors, and can certainly take longer if our slipped disc rules aren't rigidly adhered to.

Some of them are controversial. In general, it has been clearly shown that prolonged bed rest hinders rather than helps lower back pain.

However, patients with acute pain, and who are in an antalgic posture as she is, find they cannot stand for long, and with sitting the pressure in the ruptured disc increases dramatically; the bulging nucleus pulposis simply leaks back into the tear in the annulus fibrosis.

The only feasible option is our modified bed rest with massage. You lie down, first on your back, and then on your side, doing the slipped disc exercises regularly, and getting up every hour.

She responded extremely well to the chiropractic adjustment, taking the injury seriously. Within a week she was upright, and after two more pain free.

She even quit the weed when I told her that the disc was unlikely to heal due to the lack of oxygen. Doctors report that smoking is the largest risk factor in so called failed back surgery, and it's a serious problem with chiropractic care too.

However, there were four factors in the active rehabilitation of her back. Initially she took three of them very seriously which is why she recovered so quickly.

  1. She stopped smoking.
  2. She did the exercises faithfully.
  3. She wore a lift in her right shoe for her anatomically short leg.
  4. It's virtually impossible to lose weight and stop smoking simultaneously. She correctly chose the worse of the two evils.

However, there was a problem with her rehabilitation program once the pain had abated.

  • She developed a bad dose of the flu a few weeks later, cancelled her next appointment, and never resumed it.
  • Within a month she stopped doing the exercises, and in fact never got on to the more advanced program, destined to be started once the condition has nearly healed. 
  • It was summertime, and the orthotic in her shoe didn't fit comfortably in her sandals.
  • Thankfully she didn't start smoking again. In fact, her husband also quit, and on the basis of the savings they could afford a very nice new car.

Five months after the first incident, she relapsed whilst doing a routine small job at her office. The above photos were taken just recently at the second episode.

Is this a case of failed back chiropractic care? And how many cases of failed back surgery occur because the patient never took the active rehabilitation seriously?

Despite the reduction of the disc with chiropractic manipulation it's almost certain that some of the nucleus is for ever lost. Repeated episodes mean loss of disc space and eventually the foramen where the nerve emerges becomes severely compromised.

Take your active chiropractic rehabilitation seriously or you may find in the future you are suffering from lumbar spinal stenosis. It's not fun.

A patient with an antalgic posture after chiropractic treatment.

Three days later she is up straight, but now comes six weeks of active rehabilitation, most of which she has to do; otherwise in a few months, this will happen again, each time small amounts of disc material are lost.

She still has a deep ache but the sharp pain has stopped and the Slump test is negative once more.


Chiropractic emphasises the need for active rehabilitation; repeated episodes leading to an antalgic posture inevitably lead to a complex prolapse of the disc, and nerve entrapment.

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I have left alone. After seven treatments his pain and stiffness is 50 percent better, and he is happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti-inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He is doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost pain-free. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he is well pleased; sixty-five percent better after three treatments.

5. Mr T is a wise man; he has taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily stroll has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift; he has a short leg.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. X-rays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65-year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88-year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done. 

10. Mr X is a 71-year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a few months ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It is a non-complicated upper cervical facet syndrome, and she is doing well.

12. Mr D is a 38-year old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he could not sleep on that shoulder.

13. Mr D, a 71-year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors should not be treating the elderly most medical sites state but that is so much bunkum.

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