Lower Back Pain & exercise/movement

Preven&onofLowBackPain

“Thecurrentevidencesuggeststhatexercise

aloneorincombina6onwitheduca6onis

effec6veforpreven6ngLBP.Other

interven6ons,includingeduca6onalone,back

belts,andshoeinsoles,donotappearto

preventLBP”

ASystema&cReviewandMeta-analysis-SteffensetalJAMA2016

Bardin,etal2017

"I'vebeenstudyingbackpainforthepast

50yrs,andifanyonesaystheyknowwhere

backpaincomesfrom,they'refullofshit.”

ANachemson

•  Stress

•  Sleep

•  Beliefs

•  Previous experiences

•  Emotions

•  Social and work factors

•  Predicted expectation of recovery

Whathavewelearnedfromtenyearsoftrajectoryresearchinlow

backpain?

KongstedBMC2016

•  Non-specificlowbackpain(LBP)isoFencategorisedasacute,

subacuteorchronicbyfocusingontheduraKonofthecurrent

episode.

•  limitaKonofthatconceptisthatitdoesnotdifferenKatebetweena

recentonsetepisodeexperiencedforthefirstKmeandarecent

flare-upofrecurrentLBP

•  InvesKgaKonsoftrajectoriesunderpinthenoKonthatdifferenKaKon

betweenacuteandchronicLBPisoverlysimplisKc,andwebelieveit

isKmetoshiFfromthisparadigmtoonethatfocusesontrajectories

overKme

•  Lookatlongtermtrajectory

•  BytreaKngpeopleacutelywithLBPdowekeepthem

chronic?

Beliefsaroundexerciseandmovement.

PracKKonerandperson!

Beliefs about the back pain Ben Darlow. 2016

•  69% of people believe they should take it easy

•  59% believe if an activity causes pain it should be avoided in the future

•  55% believe exercise risk outweighs the benefit

•  35% believe bed rest is mainstay of therapy

This is a PROBLEM for an active approach to back pain!

PeopleareWEAK!

•  Theresultsof26prospecKvecohortstudies

•  InvesKgateifthereisevidencethatlowmusclestrength,low

muscleendurance,orreducedspinalmobilityarepredictorsof

futurelowbackorneck/shoulderpain

•  InconclusiveevidenceforarelaKonshipbetweenphysical

capacitymeasuresandtheriskofneck/shoulderpain

Asystema&creviewoftherela&onbetweenphysicalcapacityandfuturelowback

andneck/shoulderpain

HamburgvanReenen–Pain2007

SomethingneedstochangetogetbeOer

•  ThefindingsdonotsupportthenoKonthatthetreatmenteffectsof

exercisetherapyincLBParedirectlyaVributabletochangesinthe

musculoskeletalsystem.

•  FutureresearchaimedatincreasingtheeffecKvenessofexercise

therapyincLBPshouldexplorethecoincidentalfactorsinfluencing

symptomimprovement.

Isaposi&veclinicaloutcomeaQerexercisetherapyforchronicnon-specificlowbackpain

con&ngentuponacorrespondingimprovementinthetargetedaspect(s)ofperformance?A

systema&creview

EuropeanSpineJournalApril2012

Thatthereisamagicexercise

•  Despiteitbeingthemostcommonlyusedformofphysiotherapytreatment

withintheUKthereisalackofposiKveevidencetosupportitsuse.

•  29studieswereincluded

•  ThereisstrongevidencestabilisaKonexercisesarenotmoreeffecKvethanany

otherformofacKveexerciseinthelongterm.

•  Thelowlevelsofheterogeneityandlargenumberofhighmethodologicalquality

ofavailablestudies,atlongtermfollow-up,strengthenourcurrentfindings,and

furtherresearchisunlikelytoconsiderablyalterthisconclusion.

Smithetal.Anupdateofstabilisa&onexercisesforlowbackpain:asystema&c

reviewwithmeta-analysisBMCMusculoskeletalDisorders2014

Itssomephysicalfactor!

•  Sizeofthelumbarlordosis

•  PelvicKlt

•  Leglengthdiscrepancy

•  Lengthofabdominal,hamstring,andiliopsoasmuscles

•  Enduranceofthebackextensormuscleshadthehighest

associaKonwithLBP

•  MuscleenduranceandweaknessareassociatedwithLBP

RelaKonshipbetweenmechanicalfactorsandincidenceoflowbackpain

Nourbakhshetal.JOSPT–2002

Bendingisbad

•  198Danishblue-collarworkers

•  ≥30°,≥60°and≥90°

•  ResultsofmulK-adjustedlogisKcregressionsindicatednosignificant

posiKveassociaKonsbetweenforwardbendingandLBPintensity.

•  Onthecontrary,higherduraKonofforwardbendingof≥30°was

associatedwithlowerLBPintensityduringallday

Areforwardbendingofthetrunk

andlowbackpainassociatedamong

Danishblue-collarworkers?

VillumsenErgonomics2014

Peoplejustneedmoremovement/load

•  BeingphysicallyacKveisoFensuggestedtobeimportantinthe

prevenKonandmanagementoflowbackpain.Thissimpleview

doesnottakeintoaccountthattherelaKonbetweenthelevel

ofacKvityandbackpainmaybeaU-shapedcurve-i.e.both

inacKvityandexcessiveacKviKespresentanincreasedrisk

•  AmoderateincreasedriskforCLBPwasfoundforboth

parKcipantswithasedentarylifestyleandforthosebeing

involvedinphysicalstrenuousacKviKes

Physicalac&vityandlowbackpain:aU-shapedrela&on?

Heneweeretal-Pain2009

•  Alongitudinalcohortstudyoveroneyearincluding124paKents

withsub-acuteLBP.

•  ResultsshowedthatonlyinasubgroupofpaKentsadecrease

hadoccurredaFertheonsetofpain,whereasnosignsofphysical

decondiKoningwerefound.

•  assumpKonthatpaKentswithCLBPsufferfromdisuseand

physicaldecondiKoningempiricalevidenceissKlllacking.

DisuseandphysicaldecondiKoninginthefirstyearaFertheonsetofbackpain

Bousema2007

FearofmovementisnotassociatedwithobjecKveandsubjecKvephysicalacKvitylevelsin

chronicnon-specificlowbackpain

Carvalho2016APMR

Thatwecanusegeneralisedphysical

interven&onsforspecificproblems

•  NoneoftheobjecKvemeasuresofphysicalacKvitywere

associatedwithfearofmovement–InacKvitynotassociated.

•  Fearofmovementwasassociatedwithdisability(Roland-

Morris)

•  SuggeststhatpeopleDOusetheirbodiesAPARTfromspecific

movements

•  Generaliseduseofthebodymaynothaveanfurthereffect

Dopeoplewithlowerbackpainhavedifferent

movementhabits?

Tsang-BMC2017

•  MuchlowerlevelsofvariabilitywithLBP

•  Theabilitytoregulatethelumbo-pelvicmovementpaVernduringthe

bendingtaskthatexecutedatvariousspeedlevelswasshownonlyin

pain-freeindividualsbutnotinthosewithlowbackpain(over3

months)

•  Individualswithlowbackpainmovedwithastereotypedstrategyat

theirlumbarspineandhipjoints

•  Contributetomaintenanceandchronicity

Theeffectsofbendingspeedon

thelumbo-pelvickinema&csand

movementpaOernduringforward

bendinginpeoplewithand

withoutlowbackpain

Tsang-BMC2017

Theeffectsofbendingspeed

onthelumbo-pelvic

kinema&csandmovement

paOernduringforward

bendinginpeoplewithand

withoutlowbackpain

Differencesinlumbarspineandlower

extremitykinemaKcsduringastep

downfuncKonaltaskinpeoplewith

andpeoplewithoutlowbackpain

Hernandez2017

•  Subjectswithlowbackpaindisplayedlesslumbar

spinemovementthancontrolsacrossallthreeplanes

ofmovement

•  AredistribuKonofacKvityto

differentregionsofthe

lumbarerectorspinaewas

observedwhenpain-free

individualsperformeda

repeKKveliFingtask.

•  PeoplewithLBPperformed

therepeKKvetaskby

increasingtheacKvaKonof

thesameregionsofthe

muscleovertheduraKonof

thetask,thatis,without

variabilityinmuscleacKvity”

Reducedtask-inducedvariaKonsinthedistribuKonof

acKvityacrossbackmuscleregionsinindividualswithlow

backpain– Falla.Pain2014

Comparinglumbo-pelvickinema&csinpeoplewithand

withoutbackpain:asystema&creviewandmeta-analysis

LairdBMC2014

•  43studies

•  Onaverage,peoplewithLBPhavereducedlumbarROM

andpropriocepKon,andmovemoreslowlycomparedto

peoplewithoutLBP.

•  WhetherthesedeficitsexistpriortoLBPonsetis

unknown

Changesinthemechanicalproper&esofthe

trunkinlowbackpainmaybeassociatedwith

recurrence

Hodges2009JofBiomechanics

•  N=14(RecurringLBP)N=17(healthy)

•  LBPgrouptrunksKffnesswasincreased

•  AugmentedtrunkmuscleacKvityandchangesin

reflexcontroloftrunkmuscles

•  Consequencesforpainandrecurrence

Lowbackpainstatusaffectspelvis-trunkcoordina&onand

variabilityduringwalkingandrunningSeayetalClinBiomech2011

•  CollecteddataduringwalkingandrunningofcoordinaKonofthoraxandpelvisin3

planes.

3groups

•  ChronicLBP

•  Singleboutofbackpainresolved

•  Nobackpain

•  TheywereabletoidenKfyeachgroupbylevelofvariabilitythatdecreasedwith

chronicity

•  CliniciansneedtolookbeyondtheresoluKonofpainwhenprescribing

rehabilitaKonforlowbackpain

Pelvis-thoraxcoordina&oninthetransverse

planeduringwalkinginpersonswith

nonspecificlowbackpain–Lamoth2002Spine

•  IncomparisonwithhealthyparKcipants,the

gaitofpaKentswithlowbackpainwas

characterizedbyamorerigid,lessflexible

pelvis-thoraxcoordinaKon

Mechanicalcouplingbetweentransverse

planepelvisandthoraxrota&onsduringgaitis

higherinpeoplewithlowbackpain–VandenHoorn2012

•  Theseresultssupporttheargumentthat

peoplewithLBPadoptaprotecKve

movementstrategy,possiblybyincreased

trunksKffness.

Takehomes

•  Peoplewithchronicbackpainappeartomovedifferently

•  ThisischaracterisedbylessvariaKon&lessmovement

•  Morelikelytobeaneffectratherthanacause

•  Couldthismaintaintheproblem?CondiKonedbehaviorsandcoupledpain?

•  Especiallyasstrength/condiKoning/acKvitymaynotbetheproblemformany

people

Sowhatdowedowiththisinfo?

•  Encouragerelaxed,free,flowingmovement&variedmovementtasks?

•  Lookatpremovementbehaviorssuchasbracing

•  Don’ttryandmeasureorworryaboutchanging–ItmaynotmaVer!

Whichexerciseworksbestforlowerback

pain?

Cri&cisms

•  Test2exerciseswithnocontrol–Regressiontothe

mean

•  Externalvalidity–Takesawayadherenceissues

•  Singlefactorthinking

•  Canbesedentarygroups

•  Todetermine,foradultswithchroniclowbackpain,which

exerciseintervenKonsarethemosteffecKveatreducingpain

comparedtoothertreatments.

•  Combinedmeta-analysisrevealedsignificantlylowerchroniclow

backpainwithintervenKongroupsusingexercisecomparedtoa

controlgrouporothertreatmentgroup

•  Ourresultsfoundabeneficialeffectforstrength/resistanceand

coordinaKon/stabilisaKonexerciseprogramsoverother

intervenKonsinthetreatmentofchroniclowbackpain

Exerciseinterven&onsforthetreatmentofchroniclowbackpain:a

systema&creviewandmeta-analysisofrandomisedcontrolled

trials–Clinicalrehabilita&on2015

•  IndividuallyaddressedtheparKcipant’sthoughtsandbeliefsabouttheirLBPin

relaKontomovement.

•  BothintervenKonsreducedpainintensityandincreaseperformanceintestsofliF

strengthandsometestsoftrunkmuscleendurance,overKmewithnodifference.

•  Trainingwithahigh-loadliFingexercise,thedeadliF,seemsbeneficialmainlyto

paKentswithaniniKallylowerpainintensityandhigherperformance.

DeadliFtrainingforpaKentswithmechanicallow

backpain

Acomparisonoftheeffectsofahigh-loadliFing

exerciseandindividualizedlow-loadmotorcontrol

Exercises.

LarsBerglund2015

•  Comparedtogeneralexercise,corestabilityexerciseis

moreeffecKveindecreasingpainandmayimprove

physicalfuncKoninpaKentswithchronicLBPinthe

shortterm.

•  However,nosignificantlong-termdifferencesinpain

severitywereobservedbetweenpaKentswhoengaged

incorestabilityexerciseversusthosewhoengagedin

generalexercise.

•  Whynotlongterm?

•  ExpectaKonofaclinicallymeaningfultreatment?

WangXetal.Ameta-analysisofcorestabilityexerciseversusgeneralexercisefor

chroniclowbackpain.PLoSOne.2012

• 

Anaerobicwalkingprogrammeversusmusclestrengthening

programmeforchroniclowbackpain:arandomizedcontrolledtrial

Shaynaderman–2013

•  FiFy-twosedentarypaKents,aged18-65yearswithchroniclowbackpain.

•  Moderateintensetreadmillwalking;control'exercise'group:specificlowback

exercise;both,twiceaweekforsixweeks.

•  Six-minutewalkingtest,Fear-AvoidanceBeliefQuesKonnaire,backand

abdomenmuscleendurancetests,OswestryDisabilityQuesKonnaire,LowBack

PainFuncKonalScale(LBPFS)

•  Significantimprovementswerenotedinalloutcomemeasuresinbothgroups

withnon-significantdifferencebetweengroups.

•  Asix-weekwalktrainingprogrammewasaseffecKveassixweeksofspecific

strengtheningexercisesprogrammeforthelowback

NoCLEARsuperiority

• WhatacKviKesdopeopleENJOY?

•  Howeasyisitforthemtodo?

•  HowrelevantisittotheirfuncKonal

outcomemeasures?

•  Aretheyeasilyabletoaccessthenecessary

equipmentorneedspecialistinstrucKon?

w y ?

Keystoagreatrehab

program

Fitsinwithworkandfamilylife

Asfewexercisesaspossible

Minimal/easily

availableequipment

InsKllsconfidenceandsenseofselfefficacy

Takesintoaccount

preferencesUKlisesbestavailableevidence

Caneasilyberegressedorprogressed

Ismeaningfulandrelevant

CanbeperformedinanylocaKon