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Low Back Exercise Risk vs. Reward

Helping patients prevent low back pain through exercise programming
The economic impact of low back pain (LBP) is greater than $100 billion per year and causes more disability globally than any other condition. (1,2) It is the most common cause of activity limitation in adults aged 45 and younger and only second to arthritis in people aged 45 to 65. (3) Of these people who suffer an episode of LBP approximately 50% will experience a recurrence by year one, 60% by year two and 70% by year 5. (4) Given this economic and societal burden, a considerable amount of effort has gone into understanding the cause, treatment and prevention of this global problem.

Lumbar Disc HerniationThere are multiple risk factors that can cause LBP ranging from trauma such as sports injuries to weakened core muscles to simply prolonged periods of sitting to name a few. The most common cause of low back pain is from the intervertebral disc as the outer one third is highly innervated with nerves (5,6,7,8). Therefore, any damage to this outer layer whether it be micro due to repetitive injury or macro due to a trauma causing a disc herniation, the surrounding musculature is affected. This article discuss how this affects the muscles that stabilize the spine and will provide suggestions to prevent an initial onset or minimize the likelihood of a reoccurrence through evidence based exercise programming.

In order to develop appropriate low back stabilization programs, we must first understand some of the reasons why people experience back pain. To being with, altered motor control and deconditioning of the deep spine stabilizer muscles are some theories suggested in the literature today. The recurrence rate of low back pain is most significant in individuals who have suffered at least one episode of low back pain. MacDonald et al demonstrated a delayed onset of the deep spine multifidus muscle activation with subjects who had a history of LBP (9). This means that the deep spine muscles should activate prior to the actual movement in order to stabilize spine. Therefore, individuals with a history of low back pain experience this delay in motor control leaving them vulnerable to injury with activities of daily living.

In another study Nijis and colleagues showed that pain alters motor control and normal movement resulting in compensation strategies even after the subjects had recovered from their episodic LBP (10). The long term sequel of these compensation patterns are pathological changes of the multifidus muscle including atrophy, fatty infiltration and weakness in as many as 80% of people with LPB (11).

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Considerations for exercise programming to prevent low back pain
This study provides support for Exercise programming should focus on stabilizing and strengthening the deep spine and major muscles of and around the low back. One of the larger muscles that is integral to the stability of the spine is the quadratus lumborum as noted by McGill and colleagues. They found this muscle was “best suited to be the major stabilizer of the lumbar spine.” They further stated the “side support” or “side bridge” exercise was identified to optimally challenge the quadratus lumborum and the muscles of the abdominal wall while minimizing lumbar spinal loads. (12)

Therefore, based on McGill’s findings, performing an endurance side bridge or side plank is an ideal way to not only improve spine stability but it can also be used to establish a strength baseline with patients. The full side plank position is performed with the top foot placed on top or in front of the lower foot for support. Instruct your patients to lift their hips off the floor to maintain a straight line over their full body length, and support themselves on one elbow and their feet. The uninvolved arm was held across the chest with hand placed on the opposite shoulder. The test ends when the hips returned to the floor. This exercise and test can also be regressed and performed with the knees bent and contacting the floor when working with deconditioned patients.

Full Side Plank Position

Normal endurance times in the full plank position for health men and women with a mean age of 23 years are 90 seconds and 70 seconds respectively. (12) Given the relatively young age of the participants in this particular study shorter endurance time may need to be considered when working with patients with a history of low back pain. If your patient experiences pain when performing this maneuver at any point, the test should be stopped immediately.

Now that a strength baseline is established, appropriate exercises can be selected. When working with a population of patients with a history of low back pain, one must consider the type of exercise and its effects on the low back or the “Risk vs Reward” of an exercise. The chart below adapted from the work of Wilke and colleagues demonstrates the intradiscal pressure with common exercises and activities. (13) Note that standing represents 100% of intradiscal pressure while performing a sit up is more than double.

Intradiscal Pressure

Although the below “Superman” exercise can be beneficial to improve erector spine strength, it results in 180% of normal intradiscal pressure compared to standing. Therefore, the “Risk vs Reward” should be considered when recommending exercises for patients with a history of LBP.

Helping clients prevent low back pain through exercise programming

The Bird Dog and Curl Up is a great exercise for increasing core muscle activity minimal joint loading as well as the ‘Stir the Pot’ (low risk, high reward) versus a sit up on a ball (high risk, high reward). When developing generic protocols to prevent low back pain it is safer to focus on integrating exercises that are below the ‘injury risk line’ and are focused on high exercise volume.

The Bird Dog and Curl Up is a great exercise for increasing core muscle activity minimal joint loading as well as the ‘Stir the Pot’ (low risk, high reward) versus a sit up on a ball (high risk, high reward). When developing generic protocols to prevent low back pain it is safer to focus on integrating exercises that are below the ‘injury risk line’ and are focused on high exercise volume.

Bird Dog – Activate core muscles. Raise one arm to shoulder level as opposite leg simultaneously lifts off floor, extending to hip height. Pause momentarily. Return to start position and alternate sides. Maintain a straight spine position, not allowing your hips to twist or rotate. Do not hyper-extend low back when extending leg.

Three exercises that provide sufficient spine stability with minimal loading are known as the “Big 3” which are the modified curl-up, side plank and quadruped bird dog. Spine stability requires muscles to be co-contracted for durations with relatively low levels of contractions. These exercises are designed for endurance and motor control and not for strength. (14)

Helping patients prevent low back pain through exercise programming

McGill Curl up – Lift shoulders off floor, trying to maintain a neutral spine position without rounding low back. Do not allow head to move forward of shoulders during movement. Elbows can remain in contact with floor during movement. Pause momentarily. Return to start position.

When performing these and other exercises to improve core stability, abdominal bracing or activation of the abdominal wall musculature is also recommended. These exercises should be performed in a neutral spine position when possible avoiding pelvis tilting and excessive low back rounding or arching. After the patients have demonstrated sufficient strength and motor control, they may be progressed to exercises that involve flexion and extension in order to further strengthen the abdominal and erector spinae musculature. (15)

Low Back Exercise Risk vs Reward

Stir the Pot – Begin kneeling in front of stability ball. Rest elbows on ball. Straighten legs into a plank position. Keeping spine straight, roll elbows in a circular motion on the ball. Perform this movement in 10 second intervals resting 3 seconds in between reps.

Here are some general guidelines for working with patients with previous or existing low back conditions (16):

• Never exercise through pain.
• Groove appropriate and perfect motion and motor patterns before adding load or other challenges.
• Start by taking gravity out of the equation: start supine or prone, quadruped, kneeling then standing.
• Increase intensity or time, but not both.
• Intensity can be increased by either changing resistance or changing stability.

If the patient is ready to be progressed, the following guidelines will help you do this safe and effectively (17):
• If the patient is still making progress, continue with the current work load.
• If the patient is at plateau, progress at a 2-10% increase.
• If the patient experiences flare-ups, decrease volume.

Some other suggestions to consider when working with patients with a history of LBP are:
• Avoid unsupported forward flexion exercises at first
• Avoid lifting both legs in a supine or prone position
• Avoid rapid movements especially twisting at the waist
• Extend warm-up and cool down periods
• Focus on good form, training the movement and not the muscles

As with all exercise programs, long-term adherence and exercise execution on a regular basis are important to achieve satisfying results. After the patients have mastered the movements and are able to maintain good form, they can be tasked with short at-home protocols in forms of print outs or videos that will help them doing the exercises on their own. It is typically recommended to give patients protocols for 2 – 4 weeks. Ideally they should come back to the office after the completion of this to recheck their form and to learn the appropriate exercise progressions. Regular check-ins and exercise progressions will also increase program adherence and long-term results.

References
(1) Hoy, D., et al. 2014 The global burden of low back pain: estimates from the Global Burden of Disease 2010 study
(2) Crow, W., Willis, D. 2009. Estimating cost of care for patients with acute low back pain: a retrospective review of patient records. J Am Osteopath Assoc. 2009 Apr;109(4):229-33.
(3) Loney, P., Stratford, P. 1999.The Prevalence of Low Back Pain in Adults: A Methodological. Review of the Literature. Physical Therapy. Vol 79(4):384-396.
(4) Hoy, D., et al. 2010. The Epidemiology of low back pain. Best Practice and Research Clinical Rheumatology. 24:769-781.
(5) Zhang, Y., et al. 2009. Clinical diagnosis for discogenic low back pain. Int. J. Biol. Sci. 5(7):647-658
(6) Bogduk, N., et al. 2013. Lumbar Discogenic Pain: State-of-the-Art Review. Pain Medicine. 14: 813–836.
(7) Delitto, A., et al. 2012. Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association
. J Orthop Sports Phys Ther. 42(4).
(8) Hancock, M., et al. 2007. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 16:1539–1550.
(9) MacDonald, D., et al. 2009. Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain. PAIN 142, 183–188.
(10) Nijis, J., et al. 2012. Nociception Affects Motor Output, A Review on Sensory-motor Interaction With Focus on Clinical Implications. Clin J Pain Volume 28, Number 2.
(11) Danneels, L., et al. 2001. Effects of three different training modalities on the cross sectional area of the lumbar multifidus muscle in patients with chronic low back pain. Br J Sports Med 35:186–191.
(12) McGill, S., et al. 1999. Endurance Times for Low Back Stabilization Exercises: Clinical Targets for Testing and Training From a Normal Database
. Arch Phys Med Rehabil Vol 80.
(13) Wilke, H., el al. 1999 New In Vivo Measurements of Pressures in the Intervertebral Disc in Daily Life. Spine. Vol24, Number 8, pp 755–762.
(14) McGill, S. 2010. Core Training: Evidence Translating to Better Performance and Injury Prevention. Strength and Conditioning Journal. Vol 32(3).
(15) Akuthota, V., et al. 2008. Core Stability Exercise Principles. Curr. Sports Med. Rep., Vol. 7(1) 39-44.
(16) Adapted from Blog by Ed LeCara, PhD, DC, MBA, ATC, CSCS
(17) Med Sci Sports Exerc. 2009 Mar;41(3):687-708

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