Exercise and Low Back Pain

Low back pain affects many individuals, limiting their daily activities. The problem can be related to musculoskeletal issues or stem from pathological origin, which is a less common issue than musculoskeletal low back pain. This post will be look at why it is best to exercise to reduce and also avoid low back pain in medically cleared individuals.  

Individuals with chronic (a minimum of 3 months pain), acute (up to 6 weeks of pain), subacute (lasting 6-12 weeks), and nonspecific (pain not caused by a specific disease or spine pathology) low back pain tend to lack proper recruitment of the core muscles; whereas, specific low back pain may be caused by unique or unusual pathophysiologic mechanisms such as; disc herniation, tumor, osteoporosis, arthritis, diseases, trauma, mechanical disorders or spinal pathology (1).

Motor control training is a method used to reduce low back pain. Motor control training is a popular method that aims to restore co-ordinated and efficient use of the muscles that control and support the spine (2), however research has shown that motor control exercises may exhibit no substantial evidence in reducing any pain in individuals with chronic low back pain (2–6).More on this below.

Interestingly, exercise is proven to be an effective means for decreasing low back pain (7), however, most individuals who suffer from nonspecific, chronic or acute low back pain believe that any form of exercise will only increase the pain, luckily this is not the case. Most of these individuals who suffer with chronic low back pain tend to be sedentary, in-active individuals (1), therefore, they avoid exercise on the fear that it will only aggravate the pain. There are ways to exercise that will have only have a positive effect and reduce low back pain, but a few things need to be taking into consideration on the coach’s behalf before a training intervention begins.

What is the cause of the individuals low back pain?

This can be anything from a mobility restriction, weak core muscles, poor posture, motor recruitment etc. Seeking advice from a trained professional is recommended to determine the cause of your low back pain i.e., a physiotherapist, chiropractor, strength coach etc. Once the cause of the pain has been determined, the coach can then use a training intervention that will progressively allow the individual to adapt to a training stimulus i.e., slower progressions, less intensity and volume based on the individuals case and/or pain, resulting in improved spinal stability, flexibility, endurance and a reduction in pain.  

Exercise programs that consist of coordination, stabilisation, strength and resistance training have been scientifically proven to reduce low back pain (8). Furthermore, studies have shown that individuals who participate in a supervised, individualised exercise program have significantly greater physical benefits to those who have participated in a home based program performed alone (9,10).

The motor control issue

At the start of this I stated that motor control exercises have been shown to have no benefit in reducing pain, while this seems to be true, motor control training is an important area of the exercise program that still need to be intervened. The benefits of motor control training are to encourage appropriate muscle recruitment of the required muscles before a training session, especially when performing resistance training. If there is a lack of muscle recruitment during an exercise the body will perform the exercise using the path of least resistance which may led to increased pain or injury.

The core

When considering the muscles of the core, there are two main muscles that can be related to recurring low back pain if they are under-active or generally weak, hence, motor control training needs to be performed to activate these. The Multifidi is a deep spinal muscle, and its role is to stabilise the joints within the spine, and the Transversus abdominis which sits deep within the core and provides thoracic and pelvic stability. The Transversus abdominis is the first muscle to become active during any limb movements in healthy individuals (11). Furthermore, studies have shown that individuals with chronic low back pain tend to have delayed motor recruitment of these specific muscles (7).

Activation exercises can be performed at the start of a training session to enhance core muscular activation. The Bird dog is a stability exercise that will enhance motor recruitment of the Transversus abdominis and Multifidi muscles. The exercise should be performed with slow and controlled movements, with no rocking of the hips or extension of the low back. Bridges are another go to exercise that should also be performed at the start of a training session since this exercise will target the Multifidi and the Glutes. Place the feet flat on the floor, hip with apart and lift the hips up and hold for 2 seconds, ensure the low back does not overextend at the top before lowering down with control.

Activation strategies are only one area that should be addressed with regard to chronic low back pain, but tightness in the hip flexors can also be a cause of low back pain. There are 3 main hip flexor muscles that can become a hindrance if eccentrically orientated or generally weak. Iliacus, Psoas major and Rectus Femoris, when tight or in an eccentrically orientated position can increase pelvic rotation in either an anterior or posterior direction, depending on the orientation of the hip flexors.

Individuals who receive medical clearance to exercise are advised to start an exercise program and avoid a sedentary lifestyle. Benefits of this include increased health and wellbeing, exercise tolerance and increased functional capacity to be capable of doing everyday activities such as playing with the kids, doing the gardening and most importantly, been pain free. If the pain allows for some daily activities, it is best to start an exercise program to strengthen and activate the muscles mentioned above. This should be started with a trained professional to ensure you are performing the exercises correctly for the first 4 – 6 weeks as this time frame will allow new motor patterns to be dialled in.

References

1.         Ronai P, Sorace P. Chronic Nonspecific Low Back Pain and Exercise. Strength Cond J. 2013 Feb 1;35(1):29–32.

2.         Saragiotto BT, Maher CG, Yamato TP, Costa LO, Menezes Costa LC, Ostelo RW, et al. Motor control exercise for chronic non‐specific low‐back pain. In: The Cochrane Library [Internet]. John Wiley & Sons, Ltd; 2016 [cited 2018 Mar 24]. Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD012004/full

3.         Costa LOP, Maher CG, Latimer J, Hodges PW, Herbert RD, Refshauge KM, et al. Motor Control Exercise for Chronic Low Back Pain: A Randomized Placebo-Controlled Trial. Phys Ther. 2009 Dec;89(12):1275–86.

4.         Macedo LG, Maher CG, Latimer J, McAuley JH. Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review. Phys Ther. 2009 Jan;89(1):9–25.

5.         Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord. 2014 Dec 15;15(1):200–31.

6.         Unsgaard-Tøndel M, Fladmark AM, Salvesen Ø, Vasseljen O. Motor Control Exercises, Sling Exercises, and General Exercises for Patients With Chronic Low Back Pain: A Randomized Controlled Trial With 1-Year Follow-up. Phys Ther. 2010 Oct 1;90(10):1426–40.

7.         Lehtola V, Luomajoki H, Leinonen V, Gibbons S, Airaksinen O. Efficacy of movement control exercises versus general exercises on recurrent sub-acute nonspecific low back pain in a sub-group of patients with movement control dysfunction. Protocol of a randomized controlled trial. BMC Musculoskelet Disord. 2012 Apr 11;13:55.

8.         Peek AL, Stevens ML. Different forms of exercise for chronic low back pain (PEDro synthesis). Br J Sports Med. 2016 Feb 1;50(3):188–188.

9.         Descarreaux M, Normand MC, Laurencelle L, Dugas C. Evaluation of a specific home exercise program for low back pain. J Manipulative Physiol Ther. 2002 Oct;25(8):497–503.

10.       Maul I, Läubli T, Oliveri M, Krueger H. Long-term effects of supervised physical training in secondary prevention of low back pain. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2005 Aug;14(6):599–611.

11.       Arokoski JP, Valta T, Airaksinen O, Kankaanpää M. Back and abdominal muscle function during stabilization exercises. Arch Phys Med Rehabil. 2001 Aug;82(8):1089–98.

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