by Teddy Willsey, DPT, PT, CSCS, USAW
Personal Training Quarterly August 2018
Vol 5, Issue 1
A primary goal of many exercise programs is to reduce the likelihood of injury. Low back pain (LBP) is a common causes of disability. Nearly all fitness professionals are forced to address LBP to some extent, regardless of the age or population with which they work. The purpose of this article is to shed light on contemporary research surrounding LBP. It will provide an evidence-based explanation of the difficulty in determining the cause of non-specific low back pain (NSLBP). Additionally, it will discuss psychosocial aspects of pain and address the fitness professional’s role in NSLBP. Lastly, this article will explain the mobility-stability continuum of exercise selection.
Please note, any suspicion of neurological signs or symptoms including shooting pain, weakness, changes in sensation, radiating symptoms, or unrelenting pain should always be referred to a qualified healthcare professional for further evaluation. This article only applies to NSLBP, or pain without a known pathoanatomical cause.
Healthcare professionals develop an understanding of the causes of NSLBP through a product of their own education and experience. Despite the many structural theories attempting to explain NSLBP, none have proven to be explanatory in all cases. Examples include assessing trunk strength, hip range of motion, and pelvic tilt, to a name a few. Due to the inconsistent symptom presentation and often favorable treatment outcome, researching NSLBP has proven challenging (8). Diagnosing and properly labeling cause for back pain is further complicated by the lack of reliability of diagnostic imaging for spine related pathology (5,9).
All of these factors combined lead to a high degree of ambiguity surrounding NSLBP.
Contemporary research suggests that the psychosocial factors associated with the experience of pain are crucial to understanding NSLBP. Life satisfaction, happiness, education, self-confidence, as well as depression levels have all been shown to be strongly related to chronic NSLBP (3,6,10,24). Research on the biopsychosocial model of pain can help to account for cases where biology and structure alone do not make sense (11). Unfortunately, public awareness on this topic is still relatively low.
Fitness professionals can play a significant role in shaping their clients’ perceptions about back pain. When individuals experience NSLBP, they tend to search for the cause somewhere in their typical daily regimen (18). They form beliefs based on their own education and experiences. These beliefs can be both misinformed and challenging to dispel. Fitness professionals are oftentimes the first in line to answer questions regarding pain. It is the responsibility of the fitness professional to be comfortable discussing NSLBP with their clients and to provide up-to-date information.
In the case of a client who may have a history of back pain, but is safe to exercise, fitness professionals can help their client’s recovery by creating a positive atmosphere and discouraging negative self-talk and feelings of hopelessness (16). It can be helpful to remind them that well-researched methods are available to create programs, modify exercise, and alter environment and ergonomics in order to improve comfort and decrease pain. They should also remind clients that the majority of NSLBP resolves with conservative medical care (2). Fitness professionals can assist in reducing fearful and catastrophizing behavior.
The mobility-stability continuum is a common paradigm used to understand LBP and prescribe exercise (1). This structural-based thought process assumes LBP is caused by imbalance of mobility and stability; whereas, an ideal dosing of the two is said to create a healthy and functional back. For example, most fitness professionals consider hip mobility and trunk stability as key components of low back health. These qualities are assessed in many of the widely used screens and assessments for identifying low back health.
The purpose of mobility exercises, such as a hamstring stretches, is to increase joint range of motion. Two straightforward ways to assess mobility are lunges and deep squat tests. The purpose of stability exercises, such as planks, is to strengthen supporting musculature. Two typical ways to assess strength are trunk stability and trunk flexion exercises. Typically, mobility and stability exercises are used together in a program addressing NSLBP. The mobility-stability continuum is a common paradigm that is easily relatable for the general population. Most people can appreciate the dichotomy between stretching and strengthening. This provides a consistent way to prescribe and explain these exercises to clients.
There is reason to believe that mobility exercises can be beneficial in the treatment and prevention of back pain. Hip range of motion is a common consideration with back pain. Two of the typical narratives that individuals have regarding the explanation of their back pain. Although there may be a strong theoretical basis for both of these structures influencing spinal motion, their specific influence on pain is not as well understood.
When clients report feelings of perceived tightness in muscles, the role of the nervous system and muscle tone cannot be discounted. Assessing mobility is more complex than simply taking one’s word for it. During periods of pain, in both chronic and acute cases, involuntary descending neural control processes initiate muscle guarding in the form of tonic contraction. This can explain feelings of tightness as well as observed restrictions in mobility. It is thought that this is a protective mechanism of the body. Widespread reports of tight hamstrings are an example of this common complaint (14). Typically, cessation of pain will improve feelings of perceived tightness.
Individuals with back pain exhibit decreased mobility of the surrounding structures of the spine as well as the spine itself (13). In addition to hip flexor and hamstring stretches, spinal segment motion exercises are often used in the treatment and prevention of NSLBP. Exercises, such as the cat-cow and standing trunk rotations, should be performed by taking the spine through a comfortable range of motion. A thorough movement assessment can help to determine individual mobility and range of motion needs.
There is strong evidence to support the practice of strengthening and stabilizing the muscles surrounding the trunk and lumbar spine. In addition to changes in mobility, research has shown alterations in patterns of the trunk stabilizers in patients experiencing pain (2,11). It is thought that trunk strengthening and endurance exercises can help normalize firing patterns, decrease spinal motion, and improve spinal stabilization. Many of these exercises are referred to as anti-extension or anti-rotation movements, and their goal is to maintain a neutral spine position.
Injury prevention through trunk strengthening is meant to promote tissue and movement adaptation (13). The strategy has more recently been referred to as building tissue resilience. Two examples of exercises with the potential to improve lumbar spine tissue stabilization, teach core bracing, and improve overall trunk strength are the plank and bent-over barbell row. Both of these exercises can be progressed by adding time, weight, and instability.
Research has shown increased trunk muscle electromyography activity when instability is added to core stability exercises (7). The dead bug, crawling patterns, and many other common core exercises fall into the category of instability exercises. Standing on one foot, planking on one arm, or using an unstable surface are three ways to increase instability during trunk strengthening and endurance exercises.
It is important to note that addressing NSLBP does not always need to involve complex exercise prescription. Some studies have shown general exercise to be just as effective as physical therapy for treating NSLBP (19). Walking programs are shown to be effective for NSLBP as well (17). On the prevention side, recent research has even shown improvements in intervertebral disc strength in runners (4).
The fitness professional can play a significant role in helping clients with NSLBP by choosing appropriate exercises, leading informative discussions, and considering psychosocial aspects in their approach. Working with a client with back pain never changes the goal: help them move pain free and improve their strength and conditioning
This article originally appeared in Personal Training Quarterly (PTQ)—a quarterly publication for NSCA Members designed specifically for the personal trainer. Discover easy-to-read, research-based articles that take your training knowledge further with Nutrition, Programming, and Personal Business Development columns in each quarterly, electronic issue. Read more articles from PTQ »
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