Low back pain
Low back pain affects many individuals and it can limit their daily activates. The problem can be related to musculoskeletal issues or 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), 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 (Ronai & Sorace, 2013).
Motor control training has been and is still 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 (Saragiotto et al., 2016), however, research has shown that motor control exercises exhibited no substantial evidence in reducing any pain in individuals with chronic low back pain (Costa et al., 2009; Macedo, Maher, Latimer, & McAuley, 2009; Saragiotto et al., 2016; Smith, Littlewood, & May, 2014; Unsgaard-Tøndel, Fladmark, Salvesen, & Vasseljen, 2010). More on this below
Interestingly, exercise has been proven to be an effective means for decreasing low back pain (Lehtola, Luomajoki, Leinonen, Gibbons, & Airaksinen, 2012), however, most individuals who suffer from nonspecific, chronic or acute low back pain believe that any form of exercise will only increase the pain, fortunately, this is not the case. Most of these individuals who suffer with chronic low back pain tend to be sedentary, in-active individuals (Ronai & Sorace, 2013), therefore, they avoid exercise on the fear that it will only aggravate the pain. However, 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, therefore, improving 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 (Peek & Stevens, 2016). 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 alone (Descarreaux, Normand, Laurencelle, & Dugas, 2002; Maul, Läubli, Oliveri, & Krueger, 2005).
At the start of this, it was stated that motor control exercises have been shown to have no benefit in reducing pain, while this is true, motor control training is an important area of the exercise program that still need to be addressed. The benefits of motor control training are to have proper 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 find a way to perform the exercise and this may have led to more pain or injury.
When it comes to the muscles of the core, there are two main muscles that can be the cause of recurring low back pain if they are not activated or 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 (Arokoski, Valta, Airaksinen, & Kankaanpää, 2001). Furthermore, studies have shown that individuals with chronic low back pain have a delayed motor recruitment of these muscles.
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. Bridges are another go to exercise that should also be performed at the start of a training session. These 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, then lower down with control.
Activation strategies are only one area that can be looked at with regard to chronic low back pain, tightness in the hip flexors can also be a cause of low back pain. There are 3 main hip flexor muscles that, when weak or tight, can become a hindrance. Iliacus, Psoas major and Rectus Femoris, when tight can increase pelvic rotation in either an anterior or posterior direction, depending on which of the hip flexors are tight.
Individuals who receive medical clearance to exercise are advised to start an exercise program and avoid a sedentary lifestyle. Benefits to this are: increased health and wellbeing, exercise tolerance, 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.
Arokoski, J. P., Valta, T., Airaksinen, O., & Kankaanpää, M. (2001). Back and abdominal muscle function during stabilization exercises. Archives of Physical Medicine and Rehabilitation, 82(8), 1089–1098.
Costa, L. O. P., Maher, C. G., Latimer, J., Hodges, P. W., Herbert, R. D., Refshauge, K. M., … Jennings, M. D. (2009). Motor Control Exercise for Chronic Low Back Pain: A Randomized Placebo-Controlled Trial. Physical Therapy, 89(12), 1275–1286.
Descarreaux, M., Normand, M. C., Laurencelle, L., & Dugas, C. (2002). Evaluation of a specific home exercise program for low back pain. Journal of Manipulative and Physiological Therapeutics, 25(8), 497–503.
Lehtola, V., Luomajoki, H., Leinonen, V., Gibbons, S., & Airaksinen, O. (2012). 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 Musculoskeletal Disorders, 13, 55. https://doi.org/10.1186/1471-2474-13-55
Macedo, L. G., Maher, C. G., Latimer, J., & McAuley, J. H. (2009). Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review. Physical Therapy, 89(1), 9–25.
Maul, I., Läubli, T., Oliveri, M., & Krueger, H. (2005). Long-term effects of supervised physical training in secondary prevention of low back pain. European Spine Journal: Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 14(6), 599–611. https://doi.org/10.1007/s00586-004-0873-3
Peek, A. L., & Stevens, M. L. (2016). Different forms of exercise for chronic low back pain (PEDro synthesis). Br J Sports Med, 50(3), 188–188. https://doi.org/10.1136/bjsports-2015-095745
Ronai, P., & Sorace, P. (2013). Chronic Nonspecific Low Back Pain and Exercise. Strength and Conditioning Journal, 35(1), 29–32. https://doi.org/10.1519/SSC.0b013e3182822bb1
Saragiotto, B. T., Maher, C. G., Yamato, T. P., Costa, L. O., Menezes Costa, L. C., Ostelo, R. W., & Macedo, L. G. (2016). Motor control exercise for chronic non‐specific low‐back pain. In The Cochrane Library. John Wiley & Sons, Ltd. https://doi.org/10.1002/14651858.CD012004
Smith, B. E., Littlewood, C., & May, S. (2014). An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskeletal Disorders, 15(1), 200–231. https://doi.org/10.1186/1471-2474-15-416
Unsgaard-Tøndel, M., Fladmark, A. M., Salvesen, Ø., & Vasseljen, O. (2010). Motor Control Exercises, Sling Exercises, and General Exercises for Patients With Chronic Low Back Pain: A Randomized Controlled Trial With 1-Year Follow-up. Physical Therapy, 90(10), 1426–1440. https://doi.org/10.2522/ptj.20090421