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For many of the millions of Americans who suffer with back pain, trying to maintain a healthy sex life can be frustrating. But back pain doesn’t have to mean no sex, though it may mean taking a different approach to lovemaking. And that can be a good thing. As the saying goes, “Where there’s a will, there’s a way.” The first step is to get a sound diagnosis from a doctor or therapist. Remember that sexuality is an integral part of normal, healthy relationships. So be sure to ask how a specific back condition might affect it, and follow the advice received. Ideally, both partners should be present so both hear the same advice.

Emotional and psychological issues
Understandably, the limitations brought about by back pain may produce stress that can damage a relationship. The person who doesn’t have the pain often finds it difficult to understand what his or her partner is experiencing. The negative effects that pain has been causing in a couple’s sex life can sometimes spill over into other aspects of the relationship.
Good communication is critical. Otherwise, one partner may mistakenly interpret a reluctance to engage in sexual activity as an excuse for not wanting to be close, which can lead to feelings of rejection and resentment.

To reduce the tension, try to create an atmosphere in which neither partner will feel rushed. Be patient with each other. Many therapists suggest setting the stage with a gentle massage, a hot bath or shower, or the application of a pain cream – any of which can relax the muscles and ease pain. Even under the best of circumstances, back pain may occur during sex. Knowing this, couples should plan how they’ll respond ahead of time, so they can avoid becoming angry or frustrated.

Positions and approaches
For people with lower back pain there may be a preference either for bending forward, or standing straight / bending backwards.

Bending backwards/standing straight. For some people with degenerative disc disease or a disc herniation, standing up straight or bending backwards tends to feel better, and bending forward tends to make the pain worse. These people are usually most comfortable when the spine is straightened or bent backward slightly (basically stand more upright, not slouched). Bending backwards is called “extension”.

Bending forwards. For some people with spinal stenosis, they feel better when they bend forward, and worse when they stand more upright. People with spinal stenosis may resist standing upright and may slouch or tip their shoulders forward to feel more comfortable. Bending forward is called “flexion”.

These differences must be taken into account when deciding which sexual positions might work best.

When standing up straight and/or bending backwards (extension) feels better
For example, if a man with lower back pain prefers “extension” then he can use the missionary position, with the woman bending her knees toward her chest. For this to work, the man has to support himself on his hands so his back is extended or bent backwards more. Or she can straddle him (facing away or towards him) while he lies on his back with a pillow under his lower back or he may sit in a sturdy armless chair.

A woman with this type of lower back pain may want to lie on her stomach with a pillow under her chest, allowing her partner to enter her from behind. Or she can straddle him – facing toward him or away – as he sits in a chair, which lets her control both the position of her lower back and her movement. She can also use the missionary position, supporting her lower back with a rolled up towel or flat pillow and being careful not to bend her legs up too far, or perhaps bend one leg towards her shoulder and to the side slightly. Do not pull too much for this may flatten the low back and cause more flexion.

When bending forward (flexion) feels better
A man with lower back pain who prefers flexion may be more comfortable entering his partner from behind as they both kneel on the bed. Or, the woman can kneel on the edge of the bed, facing in, while he enters from behind, allowing him to bend forward as he stands. Also, they can lay in a side-lying position with him entering from behind (sometimes called the fetal position or spooning).

A woman with this kind of lower back pain may want to try the missionary position, keeping her knees bent and pulled towards her armpits. The more she brings her knees upward, the more the spine will bend. If she opts to straddle the man, she should bend forward and put her chest against his.

Anyone who suffers from severe back pain should lie on his or her back on a relatively firm surface with pillows supporting the knees and head, with a small rolled up towel placed under the lower back. A position where both partners are on their sides may also work.
For some people, positions that allow genital intercourse may simply be too painful. In this case, partners can try other options that are less taxing on the back, such as massage, gentle touching or oral sex.

As a rule, the partner with lower back pain should take a passive role in lovemaking, with the other partner introducing stimulation in a very relaxed manner. Just remember to take it slow. And identify as specifically as possible which movements are comfortable and which ones hurt and should be avoided.

Brave new world
Trying new positions can be a rewarding journey of exploration that leads to a new intimacy between partners. Just because back pain may limit one’s physical abilities, it doesn’t have to limit sensuality. Never underestimate the power of candlelight and soft music. And as an added benefit, restoring healthy sexual relations will lower stress, and lower stress often leads to less pain.

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When done in a controlled, gradual, and progressive manner, active exercise distributes nutrients into the disc space and soft tissues in the back to keep the discs, muscles, ligaments and joints healthy. Consequently, a regular exercise routine helps patients avoid stiffness and weakness, minimize recurrences of low back pain, and reduce the severity and duration of possible future episodes of low back pain.

Depending upon the patient’s specific diagnosis and level of pain, the back pain exercise and rehabilitation program will be very different, so it is important for patients to see a spine specialist trained to develop an individualized back exercise program and to provide instruction on using the correct form and technique.

For most back conditions, active exercise and stretching – not rest – is typically necessary to help reduce pain and encourage healing.

To be effective, a patient’s back pain exercise program should be comprehensive, working the whole body even if it targets the back. A balanced workout should include a combination of stretching, strengthening, and low impact aerobic conditioning.
Stretching as part of a back pain exercise routine

Almost everyone can benefit from stretching the soft tissues – the muscles, ligaments and tendons – in the back and around the spine. The spinal column and its contiguous muscles, ligaments and tendons are all designed to move, and reduced motion can accentuate back pain. Stretching different muscles and ligaments is essential for gaining and maintaining mobility and flexibility. Patients with chronic back pain may find it takes weeks or months of stretching to mobilize the spine and soft tissues, but will find that meaningful and sustained relief of low back pain typically follows the increase in motion.

The most important muscles to target are:
Hamstrings, in the back of the leg, to aid correct posture while sitting and standing, and support the gluteus muscles in the buttocks and the hip flexors and minimize stress on the low back.

Piriformis, which run from the back of the femur (thigh bone) to the sacrum (the base of the spine). When tight, this muscle can cause sciatica-like pain, and has been linked to sacroiliac joint dysfunction.

Psoas Major which is attached to the front portion of the lower spine and can greatly limit low back mobility if tight, making it hard to stand for extended periods or kneel on both knees.

Gluteus muscles of the buttocks which support hip flexibility as well as the pelvis
Stretching should be done daily, perhaps several times a day, to ensure flexibility. See also Stretching for back pain relief.

Developing strong core muscles in the abdomen, lower back and gluteus is critical to decreasing the stress placed upon the lower back. Many different exercises can contribute to overall strengthening of these core muscles, and two types of exercise programs are often recommended for back pain patients are:

Dynamic lumbar stabilization. This back exercise is designed to help patients find their “neutral” spine, which is the position that allows the patient to feel the least discomfort. The back muscles are then exercised to teach the spine how to stay in this position and help the patient be aware of the position.

McKenzie extension exercises. These back exercises focus on extending the spine to reduce the pressure on, and the pain generated from, a herniated or degenerating disc. Pain relief can be felt in both the back and the leg, and when the pain is very acute the exercises may be done several times a day.

Both of these types of exercises are best learned working with a chiropractor, although with practice patients can do the exercises by themselves. See also Strengthening and back pain exercises.

Engaging in a low-impact cardio exercise program will aid rehabilitation and maintain everyday functionality. While some back pain patients can engage in running and other types of cardio exercise, for many with serious back pain it is more realistic and comfortable to engage in low impact cardio conditioning that is easy on the joints and gentle on the back.
There are several types of aerobic exercise that are gentle on the back and, when done on a regular basis, highly effective in providing conditioning:

Walking. In general, walking is very gentle on the back, and walking two to three miles three times per week is very helpful for patients.

Biking or cross-training. Bicycling or using an elliptical cross-trainer are also effective ways to exercise without putting stress on the back.

Water therapy. Exercising in the water provides weightless conditioning, which minimizes stress on the back and joints throughout the body.

Most physicians recommend at least 20 to 30 minutes of cardio exercise every other day to keep in shape. Patients could alternate days of cardio and strength conditioning to get a daily dose of exercise and allow muscle groups time to rest.

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