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Physical exercise in the treatment of low back pain:

 

Guideline for athletes

 

by: Bill Tancred and Geoff Tancred

 

Bill Tancred (UK) MBE PhD si Professor of Sports Studies at Buckinghamshire Chiltern University College an a former world class discus thrower.

 

Geoff Tancred (UK) MCSP DipRG & RT is a consultant in health and fitness for industry.

 

    This article attempts to review the literature supporting the beneficial role of exercise in the prevention and treatment of low back pain. Provided certain considerations are applied, findings overwhelmingly advocate the use of exercises in the treatment of such afflictions.
    Various exercise considerations are also described together with their significance in planning successful treatment.
    Principles governing the design of exercise programmes are also offered with a view to making the treatment procedure as effective as possible. A distinction between health and skill-related fitness is also explained.

 

Introduction


    The many methods of diagnosis available in determining the various types of low back pain (LBP) are diverse.
    On careful analysis and consideration of the anatomy of the vertebral column, the structural intricacies of it's component parts and it's variety of functions, it is clear that the causes of backache can result from many forms of dysfunction. The causes of LBP are numerous and in part due to an ever-increasing sedentary lifestyle, less physical activity among young people and adults, the conveniences of modern living, overweight and obesity which contributes to extra stress on the spine, poor postural habits, poor body mechanics in working procedures (ergonomics), certain repetitive motions, and the un- avoidable accident or trauma-induced injury to the back (Fryomoyer and Cats-Baril,1991 ; Kottke, 1982; Cailliet,1982).
    Any or all of these factors contribute to the wear and tear of the structures of the spine that may lead to LBP or injury to the back. LBP is, therefore, a complex and multi-faceted problem. People suffering from LBP will often be affected physically, psychologically, economically, socially and recreationally. Hence, the effectiveness of treatment is an important aspect in alleviating these affects.
    The omnipresence of spinal disorders in various populations has been well documented (Anderson, 1981; Gilula, 1981; Stoddard, 1969; Torgerson and Dotler, 1976; Troup et al, 1981). Anderson (1981) indicates that 50% to 80% of all adults will suffer from back pain during their lifetime.
    It is clear that the treatment of LBP is a difficult task when taking into account the numerous techniques and applications that are now available. While appreciating the vast scope of treatment protocols in general use for LBP, the focus in this article is on exercise.
    Regular exercising can have many beneficial rewards to the individual and is perhaps an area which does not always have the same emphasis as other forms in the overall treatment strategy (Davies et al, 1979; Tollison and Kriegal, 1988). This is perhaps due to the specialization required in selecting and performing appropriate exercises leading to recovery and restoring well-being. More recently, however, Lamb and Frost (1993) criticized the standard and frequency of exercise therapy in general, while Norris (1995a) asserted that exercise therapy is a specialist clinical skill and a key tool in restoring patients' well-being.
    An important consideration for the clinician is the ability to select accurate, valid and reliable tests of functional capacity so that specific exercise needs can be identified. Based on the above factors and patients' needs, exercises must be selected and recommendations made with regard to their frequency, intensity, time (duration) and type -the FIT principle (table 1 ).

 

 

    The implementation of the FITT principle will depend on a number of factors which would include the severity and nature of a patient's LBP, age, body build, current 'fit- ness' status, personality make-up and motivation.
    On selecting appropriate exercises, monitoring measures should evaluate the effectiveness of the chosen exercises and determine whether the patient is fit to return to work, home and/or sport.

 

Prophylactic Measures


    'Prevention is better than cure' is a term commonly believed and thought important by health professionals. With greater education and public awareness, attempts have been made to decrease the severity and incidence of LBP through such organizations as the Health Education Authority in Britain with its 'Look after yourself' project (1994) and the Health and safety Executive (HSE, 1992, 1994). Nevertheless, certain people may be predisposed to LBP, therefore the identification of such individuals could be useful. Those at greater risk of LBP may exhibit one or more of the characteristics shown in table 2.

 

 

    Individuals who suffer from LBP demonstrate several forms of physical deficiency that warrant the use of exercise in such treatment (Kraus, 1972). They typically lack sufficient levels of muscular strength, flexibility and endurance in the muscles of the lumbar spine, abdominals and pelvis (La Rocca and Nachemson, 1987). Pollock and Wilmore (1990) claim that such individuals are often in poor general condition and overweight. The aim of exercise prescription in the treatment and prevention of LBP should therefore be to improve and/or correct these deficiencies.
    Posture also plays a role in the prevention or causation of LBP, particularly when lifting and transporting objects (HSE, 1992, 1994). In many instances the incidence of LBP may be lowered after training in the use of proper lifting techniques (Magora, 1970; HSE, 1992). The former also found a higher incidence in people who either sat for prolonged periods or were unable to sit at all during the working day. There is a need, therefore, for employers and employees to avoid situations of prolonged unchanged posture and to appreciate the importance of good body mechanics while standing or sitting. Anderson (1981) noted that sitting in bent-over work postures increased the risk of LBP, and stressed the importance of changing posture while working. It is evident that the severity or incidence of LBP can be eased to a large extent through preventive measures or early intervention in such conditions that may predispose to LBP as indicated in table 2. In such situations, the values and benefits of regular exercise programmes become more evident in helping to reduce the onset and severity of LBP (Davies et al, 1979; Pollock and Wilmore, 1990).


Exercise Programmes

 

    Gowers (1904) is often credited as being the first to recognize the importance and value of physical activity in the treatment and prevention of LBP: He suggested that lumbago and muscular rheumatism in general could be cut short at its onset by active exercises. He indicated that the treatment then available for LBP was counter-irritation of the lumbar extensor muscles and hypodermic injections of cocaine, repeated daily for between two and three weeks. Because this range of treatment was so limited, the suggestion of exercises was welcomed. Subsequently, exercises have played a crucial role in the treatment of LBP as well as other clinical ailments.
   Therapeutic exercise essentially is the prescription of bodily movements or muscle contractions to correct an impairment, improve muscoskeletal function or maintain a state of well-being (Kottke, 1982). Designing therapeutic exercise prescription programmes for the treatment of LBP (Liemohn et al, 1988) requires careful consideration of numerous factors. A sound knowledge of the various causes of LBP is necessary, as is an understanding of the specific role exercises have in treating such afflictions. Exercises and activities should be useful as therapeutic modalities if they are defined, analysed and classified according to Cynkin (1979).

    Farfan (1975) and Floyd and Silver (1955) have stressed the importance and value of spinal muscular strength in providing sup- port and stability to the lumbar spine. More recently, Graves at al (1989) and Pollock et al (1989) focused much attention on the use of exercise in the development and maintenance of strength in the lumbar extensor muscles. There is a great variety of clinically used exercises that are advocated in the treatment of LBP. However, some have serious drawbacks that may limit their effectiveness (Pollock et al 1989) when treating LBP patients (contra-indicated exercises). Likewise, Lamb and Frost (1993) are critical of exercise therapy in general. Therefore, the selection and manner in which specific exercises are performed must be given serious consideration, along with careful assessment and observations at all times.


All-round Fitness


    Many agree that risk injury and LBP is reduced to some extent if the level of fitness is increased. Such a claim is supported by Cady and Bischoff (1979), whose study involved the relationship between prior levels of physical conditioning and the frequency of subsequent back injuries involving 1,652 firefighters. Five measures of physical fitness and conditioning (three for cardiovascular fitness and one each for strength and flexibility) were used to categorize subjects into three groups according to their fitness level. Their findings revealed that the frequency of back injury was ten times greater for the least fit group than for the most fit group. Cady and Bischoff (1979) concluded that increased fitness protects against LBP to a significant degree.
    Cady and Bischoff (1979) firmly established the need for exercise and general fitness in combating injury and LBP. Jackson and Brown (1983b) and Tollison and Kriegal (1988) also recommended exercise to achieve a greater level of fitness in patients with LBP. In view of such support for exercise in the treatment of LBP, the relative importance overall fitness in relation to the treatment and prevention of LBP should be reviewed in a proper context. Treatment foremost neuromuscular and muscoskeletal injuries generally involves exercise to increase the strength and flexibility of muscles and other soft tissues involved in joined function. The treatment of LBP should be no exception. The purpose, therefore, of achieving greater levels of general fitness should be viewed as secondary to the aim of restoring and maintaining adequate function of the lumbar spine.
    The various 's' factors of stamina, strength, suppleness, specificity, speed, skill and psychology, along with co-ordination, should form the basis of a rehabilitation exercise program. This will allow for a balanced and varied program to be devised. These 's' factors are described more fully by Norris (1995a) who also cites the possible consequences of imbalance when focus is placed only on isolated 's' factors to the exclusion of others.

 


    The concept of fitness is sometimes subdivided into related fitness (HRF) and skill related fitness (SRF) as depicted in the figure. The factors indicated in these two components should also be considered when devising an exercise program to suit a patient together with the 's' factors.  The various 's' factors and HRF and SRF components are too numerous to review in detail, but nevertheless should be viewed in their entirety when devising an exercise program for the prevention and treatment of LBP. However, the concept of flexibility (suppleness) will be described in its importance to LBP to provide an example of how the other aspects of fitness/health may be approached.


Flexibility

    Flexibility is joint specific and is the ability to move through a range of motion (ROM). The extent of ROM depends on several specific variables, including distensibility of the joint capsule, muscle viscosity, muscle weakness, adhesions of scar tissues and flexibility of ligaments. Any of these can affect the spine. The assessment of flexibility has been extensively reviewed by Corbin (1984). The ROM can serve several purposes (table 3).

 


    All exercises, regardless of their nature and purpose, should be performed with quality of movement (i.e. skill) so that control and safety remain paramount. In relation to LBP this is supported by Waddell (1987) who claims that controlled exercises help in restoring function. reducing distress. and promoting an earlier return to work. Further support for motor and muscle control in LBP is provided by Jull and Janda (1987).

    The need for adequate levels of flexibility in the various muscles of the trunk and pelvis are important considerations. Farfan (1975) claims that the flexibility of the lumbar spine provides a mechanical advantage for function and efficacy. Shortened muscle structures due to poor ROM may adversely affect spinal mechanisms, thus resulting in possibly increased loads on the spine.
    Bach et al (1985) consider pelvic mobility to be essential in lifting and bending activities. They also report that tightness in the hip flexor muscles could limit pelvic movements so much that it could cause excessive strain on the lumbar spine. Likewise, according to Bach et al (1985), tightness in the hip extensor muscles could eventually result in a reduction of the lumbar lordotic curve, making the spine less resilient to axial loadings.
    Individuals with LBP generally show a significant limitation in ROM during various movements of the trunk and pelvis, usually accompanied by tight hamstrings (Farfan, 1978). Compared to healthy individuals, people with LBP demonstrate decreased levels of ROM in trunk flexion and extension according to Smidt et al (1983) and Lagrana et al (1984). Smith (1977) found those afflicted by LBP had decreased levels of ROM in hip flexion and extension.
    From the above findings, it can be deduced that exercise to increase or maintain flexibility of the trunk and pelvis regions is essential in the treatment and prevention of LBP. However, Jackson and Brown (1983a), Kirkaldy-Willis (1990) and Panjabi (1992) offer caution in that too much mobility may excessively load the spine, overstrain or compress pain sensitive structures, or cause inflammation, potentially exacerbating the development of low back disorders. Care must therefore be taken against overtraining for this component of fitness.
    Generally, joints should only be worked through their pain-free ROM, according to Kottke (1982). Weak muscles should not be overstretched when exercised, otherwise they will function less effectively (Kraus, 1972). Excess fatigue of muscles should also be avoided (De Vries, 1968). These principles also apply generally to other muscle groups and joints of the body.
    A question also arises over hypermobility and stability/instability of the lumbar spine when discussing flexibility. This aspect is adequately explained by Norris (1995a) who also offers a comprehensive discussion on lumbar stabilization through an exercise program (Norris, 1995b).


Exercise Prescription


    An exercise program is a personalized regimen of recommended physical activity, specifically and systematically designed. The program should indicate clearly the mode, frequency, intensity, time (duration) and type (FITT principle -table 1) of exercise/activity and the progression should be monitored closely. This approach can be applied regardless of age or functional ability, following careful consideration of the individual's health history, risk factors, behavioral characteristics, motivation and personal goals. Other factors also need to be considered when activities and exercises are selected for therapeutic purposes (Hopkins, 1978) and are shown in table 4.

 


    The specific purposes of an exercise program will vary among individuals, depending upon their interests, needs, backgrounds and current health status, and whether the purpose is to enhance or maintain general health, prevention or treatment, rehabilitation or relief of pain. The application of the SMART principle will help when devising an exercise program to the needs and support of the patient (table 5).

 

  
    All these purposes should carry equal weight for any exercise program, whether for a healthy or injured individual. The major aims of an exercise program for LBP patients are essentially twofold: to counteract any detrimental effects following bed rest and/or previous sedentary lifestyle patterns, and to maximize the patients functional capacity within the physiological and anatomical limitations of their affliction.
    An exercise sequence may have to be modified or evaluated entirely if expectations of its effect and impact are not fulfilled or complications arise early in the program. These are shown in table 6.

 


    These considerations make it difficult to recommend a specific active exercise prescription schedule because so many variables need to be observed. There might be extensive assessment and the current health status of the individual must be known before exercises can be beneficially prescribed. A well-designed exercise program with appropriate content will help to foster an improvement in lumbar strength and flexibility, reduce LBP, and motivate the patient.

 

Conclusion


    The potential severity and extent of LBP has been explained. Provision of specific exercise programs for the prevention and treatment of LBP has also been discussed. Various methods of application of exercises and their effectiveness have been cited from a range of documented research with the general consensus being that exercise helps in the treatment and prevention of LBP.
    The literature reviewed advocates the use of personalized exercise programmes for the restoration and maintenance of adequate lumbar function. These would include flexibility, stamina, strength, skill, speed and specificity.
    Various guidelines have been offered for designing personal exercise programmes with a view to restoring health to and pre- venting further complications for LBP sufferers. However the various considerations cited can also apply to other therapeutic exercise programs for other clinical conditions. Careful consideration of these guidelines should help to make the treatment aims of LBP more effective. .

 

FROM: NEW STUDIES IN ATHLETICS/IAAF  1.00

 

 

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