Alex Simotas, MD

Hospital for Special Surgery
Board Certified Physiatrist
Specializing In Spine & Sports Medicine

Home > Wellness & Exercise > Exercise Facts > Making Exercise Work For You

Making Exercise Work For You

What to Know Before You Begin

The road to recovery is not without bumps and challenges. Depending on your original condition, expect a process of rebuilding with phases, adversities, and setbacks. You will need fortitude, focus, and commitment.

Perhaps you’ve had pain for months or years (chronic or episodic pain). Recovery cannot happen overnight. Truly reversing this condition will take time. Improving physical capacity, strength, and endurance may take time. Temporary setbacks with spikes in pain may continue to occur. Don’t despair! Instead, remember these key messages:

  • Your spine is healthy.
  • Pain does not equal harm or injury.
  • Exercise is safe.

The recovery process is like a investing in a bank account. Exercise, with gradual increases, is like money you invest. The interest builds slowly and it is often hard to see immediate benefits. With time, however, your investment accrues value. Consistent small investments start to add up to real wealth.

Similarly by exercise and engaging and slow increases in daily activities, you are investing in your health and well-being. The results build slowly, investing in your health through consistent exercise, starts to add up to real physical changes you can see.

Planning and Goal Setting

Organization and commitment are key elements for success. Set up a weekly plan, and stop using pain as a gauge for activity. There is no need to stop your activities as soon as you experience pain. Plan in advance how much you will do.

Activities can be categorized into:

  • Exercise
  • Work related activities
  • Activities of daily living (ADL’s)
  • Hobbies

In the beginning, there may be particular activities you cannot perform. However, by taking baby steps any reasonable goal can be achieved. Use the 10% rule. Never do 10% more of a specific activity from one day to the next. Keep track of your progress with a tally log showing your activity on a consistent basis.

Rehabilitation Strategies: Graded Exposure

Two rehabilitation strategies have some degree of proven effectiveness. Both the concept of graded(or gradual) activity. One strategy is graded exercise and the other is graded activity exposure.

  • Both require you set specific goals which track the amount of activity you perform.
  • Gradually increase these goals.
  • This strategy will replace pain directed exercise.
  • Pain directed exercise means you perform as much as you tolerate or until pain occurs.
  • In graded exercise: Create a daily exercise plan.
  • In graded activity: Plan a to take on specific activities (i.e. sitting continuously) you avoided or found particularly difficult with back pain.
  • You can do both at the same time.

You may want to develop a small list or chart of difficult activities similar to the one below:


Shaving Sitting at computer Running Sitting through movies Playing with kids
Vacuuming Driving Tennis Gardening Sex

Developing an Exercise Plan

There are many ways to develop an exercise plan.

  1. If you’re an exercise novice, start slowly and keep it simple.
  2. Consistency is often more important than the the type of exercise.
  3. Intensive exercise at least twice a week (Once a week is not good enough).
  4. Cross train: Try to combine a variety of types of exercise.
  5. Make targets or goals for each activity.
    • For strength, this means 10-12 reps for each exercise.
    • For aerobic, set a target heart rate and maintain it for a set period of time.

For most patients I usually recommend:

  • Daily stretches and strength home exercises (at least 20 minutes).
  • Intense exercise sessions 3 to 4 times per week: Half devoted to strength, half aerobic (i.e. walking, run, stairs, elliptical, swim or bike).

Here are some simple things to keep in mind:

  • Increase everything gradually.
  • Really think of predetermined goals based on slow, steady increases.
  • Adopt a positive self-image. Strong, self-reliant, capable and motivated.
  • Avoid changing activities based on pain one day to the next.
  • Don’t expect immediate changes in pain, more or less.
  • Don’t anticipate pain based on your past experiences: i.e. “always get pain after I do this”.
  • Focus on what you can do right now and not what you can’t.
  • Compliment yourself for achieving each goal.

The Activity Chart

The graph below shows graded or gradual activity (green = wellness activity). Pain is not a guide to activity. The reason is simple. In chronic pain, the pain intensity often varies from day to day, often for unclear reasons. The red line shows the daily pain level.

The reaction activity line (pink) is the amount of daily activity or exercise that you would take on using pain as a guide to your activity. On bad pain days, you do less exercise, and on good days, you are likely to do more. You are, in effect, the mirror image of your pain.

By contrast, the wellness activity line (green) shows gradual increases in activity irrespective of pain intensity. Of course this means that initially, you will be challenged to continue with the planned exercise even if you may feel worse, even though this may feel unnatural.


Reaction activity or “pain based activity” will encourage an avoidance response and sensitize you to having greater and more uncontrolled automatic responses to pain. This is a common pattern in patients who complain that exercise only makes their pain worse or that physical therapy hurts them.

In contrast, a graded exercise and activity schedule will gradually desensitize your pain. Make you stronger and more active. It takes time, but sure enough, you will gain strength, endurance, and the capacity to do the things you enjoy.

Finally remember the three key messages mentioned initially—that your spine is healthy, pain does not equal harm or injury, exercise is safe—you will have the right strategy to focus your efforts.