Low back pain and the Reconditioning Phase, Step 3: Strengthening

By Geoffrey Mackay, Clinical Director and Co-Founder of getback

Before we introduce Step 3 of the Reconditioning Phase (Strengthening), it might be worthwhile reviewing what we have learned so far. 

Firstly, it’s important to recognise there are four distinct steps of the Reconditioning Phase and patients must complete each step. Steps must be completed in the same sequence, but the completion time for each step will be individual to the patient and determined by factors that are specific to each patient. 

These factors include but are not limited to: age, gender, type and progression of the pathology, how long a patient has experienced back pain, and factors relating to a patient’s inflammatory response. Frequency of training and the patient’s ability to remain compliant to their program also play a role in their ability to progress from one step to the next. 

In Step 1 (Co-ordination) the patient relearns how to contract the multifidus (deep spinal muscles), then to co-ordinate the muscle contraction as it moves from lengthening to control a load, to pausing and then shortening as it returns a load to normal position. 

Once a patient has restored all the normal neuromuscular control over contraction the Therapist can test this by subtly adding more load, and then gradually increasing the range of movement during Step 2 (Adaptation). As this range is increased, the multifidus muscle starts to act over increasing segments of the spine. 


The spine is like a series of building blocks stacked on each other and these blocks sequentially move on each other as we bend or twist further. Once this movement approaches the 40 per cent range, we would normally expect the next layers of muscle –  the intermediate and superficial muscles – to play an increasing role in controlling the movement. 

At this point the therapist commences Step 3 of Reconditioning – Strengthening.

The aim of this step is to continually increase the pain-free range of movement and build strength. Importantly, the ratio of strength between each group of muscles is different and the Therapist will start to balance a patient’s program by bringing these strength ratios into line. 

getback Reconditioning is not just about strengthening each muscle group as much as possible, but strengthening each muscle group to bring them into balance with their opposite muscle group.

For example, for correct balance our back extensors should be 62 per cent stronger than our flexors (abdominals). In recent times there has been such an emphasis on abdominal core stabilising work that we often find patients presenting with chronic back pain with stronger abdominal muscles than back muscles. 

In fact the balance should be the other way around: the back extensor muscles should be 62 per cent stronger than the abdominal muscles. 

Back treatment results graph

A similar pattern of strength imbalance is also commonly observed in the neck. In the neck, the strength of the muscles holding the head up should be 54 per cent stronger than the strength of the muscles that bend the neck forwards. 

At getback we have identified similar ratios for all movements and a well-balanced program trains each movement to achieve its ideal strength. 

This level of preciseness in strength training is only possible on the getback devices because of their scientific capabilities. getback exercise prescription is so precise because science infers the measurements are reliable, repeatable and relevant. Similarly, if you are prescribed medicine for a condition you are not just given a jar of pills and told to take them until you feel better – you are instructed to take x amount of medication, x times a day at a particular time and for specific duration. 

At getback, exercise prescription is based purely on scientific evidence and as we gather more evidence we make small adjustments to our programs where necessary to achieve better patient outcomes.

getback patients typically experience a strength increase of 55 to 60 per cent from the start of their program to completion.

In comparison, range of motion typically increases about 10 per cent. The range of motion for both the lower back and neck have similar ratios, but these ratios are lower and the overall change in range of motion is comparably smaller.

As range of movement increases, the balance of activation between the deep multifidus muscle and the intermediate and superficial muscles is also improved. 

Patients who have weakened deep spinal muscles are often over-reactive in the superficial muscles. These superficial muscles will try to work harder to compensate for weakened deeper muscles. The common reaction we see is muscle spasm. The knot or tension commonly felt in the Upper Trapezius or spasm in the Erector Spinae are suggestive of weakness in the deeper multifidus in these regions. 

As normal strength is restored and balanced, the spasm and tension in the more superficial muscles eases. Patients are then ready to commence Step 4 of the Reconditioning Phase (Normalising), where the deep and superficial muscles coordinate their activity and a patient’s program focuses on restoration of everyday functional activities.

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