Exercise For Low Back Pain

Fit girl lift weights at fitness gym center. Deadlift workout.

Any article about exercise for pain needs to cover one important fact before it goes on:

The body will tend towards self-correction/health/resolution, if, and that’s a big if, the right conditions are present.

The biggest challenge facing an osteopath, or any other therapist, is finding, or more likely, stumbling upon, the right conditions for the individual seeking help.

Whilst there are general guidelines to abide by, every one of us has a unique set of experiences, thus different stories, explanations, treatment techniques and movements are required to facilitate a recovery; not to mention all the environmental factors that come into play.

This article intends to discuss the general principles that should underpin your actions when exercising for/with low back pain.

Where Most Back Pain Exercise Programs “Go Wrong”

Most back pain exercises or exercise programs are based on the notion that pain is the result of specific factors, and that these factors can be specifically identified and then specifically addressed.

There are a variety of factors that can contribute to low back pain, but aside from a history of previous episodes of low back pain, nothing drastically stands out as being identifiable. (1)

As an aside, this perhaps points the finger at us, therapists and rehab professionals, who are not doing a good enough job in the first place (on a population, not individual level).

It is also highly important for sufferers of low back pain to understand, as many people decide to cease treatment/rehab as soon as their pain is gone, rather than concluding the full course of treatment and restoring “lost” function.

Unfortunately, it is very difficult to specifically assess and as a result, address them with targeted exercises.

So knowing that specific factors may be hard to identify and treat, it seems more important to build resilience with a complete mobility, strength and conditioning program.

Take home point number 1: exercise programs for low back pain should not attempt to be specific, but rather improve all physical qualities.

There Are No ‘Good’ And ‘Bad’ Exercises

Another misconception surrounding exercise for low back pain is the concept of ‘good’ and ‘bad’ exercises.

Generally, if you are reading a fitness article, the concept of “neutral spine” is mentioned quite a lot. Lifting should always take place with a neutral spine, regardless.

If you are reading a rehab article, limits might be imposed on external loading, as in, any lifting above 10 kg is bad, and must be avoided.

Or you might read a medical article which mentions you should simply avoid things that hurt.

All of these comments have a place, and are neither right or wrong without any context to define them.

A ‘good’ exercise is one that you can do safely, is suitable for your current ability, is able to be gradually progressed and fits in with your needs and wants (aka your goals).

Take home point number 2: blanket statements and absolutes do more harm than good. There are times when a moderate approach doesn’t work and more extreme action needs to be taken, but it is rarely either or. Exercise selection is based on your needs and wants, not an arbitrary definition of good and bad.

Self-Limiting Movements

This is a concept that was popularised by American physical therapist Gray Cook, in his book Movement.

Self limiting movements/exercises are those that have an inbuilt “coaching mechanism”, meaning doing them forces you to increase your awareness with movement, and often times with these type of movements you can only perform them correctly, or not at all.

Utilising self limiting movements as part of an exercise program for low back pain allows you to safely challenge your body and brain, leading to improvements, without the risk of overdoing it.

There are many different examples of self-limiting exercises. The specifics are not as important as being able to move with increased awareness and a low risk. This is a big focus of our exercise programming for low back pain, especially in the early stages.

Take home point number 3: a good exercise program will provide both a challenge and the option to “fail safely” – thus reducing the fear associated with facing more demanding movement challenges.

Our Approach To Programming

There is no one way to program exercise for low back pain. As long as the programming is underpinned by sound principles, and not “technique based”, then it should be sufficient.

We strive for more than sufficient, we strive for optimal.

As such, over the years our approach to exercise programming for low back pain has been refined to what it currently is. Chances are, in another 5 years it will be further refined, but the vast majority will be consistent, as it is all principle based.

First, we consider the body as a whole. We don’t only do “low back” or “core” exercises, but rather we devise a total body program. This is the underpinning principle of osteopathy, and is also applicable to exercise programming.

Second, we ensure that of physical qualities are developed in the right sequence.

If we start with osteopathic manual treatment in the consultation room, we then progress to mobility and flexibility exercises.

These will usually start on the ground, as this provides the most stable environment, thus is the least threatening.

Considering pain occurs when there is a perception of threat by the brain (if you haven’t already, have a read of Pain Basics), this is one of the best ways to regain movement and avoid inefficient compensation patterns taking over.

From there you are looking to build “motor control” – this is simply the ability to control movement well.

We can call this stability, but that implies static positions and discounts the movement component. This is actually achieved simultaneously with improving movement/mobility/flexibility.

We can consider mobility as “end range strength”, and we are simply progressively challenging you so that both qualities improve.

Once you have achieved adequate movement and control (adequate is based on your individual needs), if you want and/or need, we would add load. This might be in the form of external resistance, increased leverage challenge or even changing the tempo.

Only when you are moving competently under load do we add a conditioning component – that is, more volume of work. This is the challenge of fatigue to your new found movement abilities, and if done correctly, is the difference between breaking down when the going gets tough and being able to withstand (almost) anything.

Take home point number 4: whole body, principle based programming that utilises appropriate methods of progression yield the best long term outcomes (based on clinical experience and research) (2) for sufferers of low back pain.

Conclusions

There is a well worn quote:

Methods are many, principles are few. Methods always change but principles never do.

This served as inspiration for this post – there is no point showing you how to do an exercise with no context as to whether it is appropriate for you or not.

Rather, it is important to have an understanding of why you are doing something – even if you only care about the “what”.

This understanding means you will not chop and change based on the latest article in your newsfeed.

It means you will take the time to get things right, knowing that making progress is all the matters, even if it is “slow”.

It also means that you have a better chance at a good outcome and are less likely to become a statistic of low back pain recurrence.

Reducing the article to four sentences, we would end up with something like this:

  1. Do something you enjoy doing, that has intrinsic reward – there are no “good” or “bad” exercises.
  2. Ensure you take a “whole body” approach to exercise. Don’t simply focus on “low back exercises”.
  3. Start slowly, progress gradually.
  4. Vary the stimulus over time, but not too much or too often (or you won’t elicit adaptations).

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



 

References

(1) Incidence and risk factors for low back pain: http://www.ncbi.nlm.nih.gov/pubmed/24462537

(2) Resistance training and low back pain in active males: http://www.ncbi.nlm.nih.gov/pubmed/20093971

Rethink Pain: Moving Beyond Muscles and Bones

Classical Anatomy

This is the first post in what will be a series about “re-thinking pain”, or rather, re-conceptualising it.

The aim of the series is to help you move from a tissue based understanding of pain to one based in neuroscience, which is more accurate and more correct (although a better term would probably be “less wrong”, as there is still so much to learn).

Why is this necessary?

  • The language we use around pain shapes the way we think about, and experience pain. Using tissue based descriptors of pain reinforces the idea of a “bottoms up” model of pain, which is wrong, and can often make things worse in the long term. Moving towards a neuroscience approach helps move away from this model.
  • Chronic pain is a massive problem in Australia (and around the world), affecting millions, costing billions and growing worse every year. Chronic pain often starts as poorly managed acute pain. One of the most important management strategies of any painful condition is education.

The Problem

To begin to understand how we have ended up with such a problem regarding pain requires tracing back through the centuries of medical and philosophical history.

In short, we used to describe pain as “coming from the tissues” up to our brains, where we felt it.

What is now understood, is that pain is a brain output, with many different “filters”, that are unique to each and every one of us, being applied before we are consciously aware of it.

Despite having this knowledge, we can see that even within the official definition of pain, the problem exists.

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

The definition of pain above has been put together by a group of highly intelligent people (International Association for the Study of Pain), who have spent a large portion of their lives studying pain, it’s effects and how to treat it.

Unfortunately, there is one small problem, and it has nothing to do with the definition itself, but rather, the fact that pain is “described in terms of such damage”.

When we explain all pain in terms of tissue damage we paint a picture in people’s minds. Unfortunately, when it comes to pain, this picture is not only incorrect, but harmful.

One can assume this became part of the definition because of what takes place in the real world:

  • Your back hurts, people say you have strained a ligament/joint.
  • Your knee hurts, people say it must be arthritis.
  • You have a headache, must be wear and tear of the head. No, that last one doesn’t sound quite right.

So how exactly is this harmful?

When pain is described in terms of body tissues alone and combined with the type of language typically used (words like torn, strained, scarred, degenerative) to describe tissue based pain, irreversible damage in the form of nocebo* can be caused.

This can lead you to think that something is wrong with your body that needs to be fixed, when things are in actual fact, completely normal.

Additionally, thinking in terms of body tissues leads to a mechanistic view of the body, one that wears out over time and the association of this “wear” with pain. The body is a biologic organism, one that is always adapting as best it can, it doesn’t “wear out”, but rather fails to adapt. There are lots of reasons for this failed adaptation though, it’s not just the result of “getting older”.

Check out this Facebook post on from September:

"It's probably just WEAR AND TEAR"My oh my, does that saying get tossed about. Usually, it goes something like this:…

Posted by Integrative Osteopathy on Wednesday, 30 September 2015

*Nocebo, is basically the opposite of placebo, ie causing harm when no harm has been done.

The Solution

We need to rethink pain, to conceptualise it as a dynamic process, arising in the nervous system and governed by our brains.

Yes, pain is often a result of tissue damage. However, there are many cases of severe tissue damage with no pain experienced at all and vice versa.

Additionally, the intensity of pain is very poorly correlated with the severity of any tissue damage.

Finally, when tissue damage has occurred, there are three scenarios.

  1. It is quite severe and needs medical intervention at a hospital. Think of compound fractures, 3rd degree burns, deep cuts etc.
  2. It is not severe enough to require medical intervention beyond basic first aid.
  3. It is somewhere in the middle.

In all 3 cases, with time, the body will heal as best it can.

As long as there is adequate rest, nutrition and then re-loading of the tissues in a progressive manner as governed by the condition and individual requirements, you’ll get as full a recovery as possible.

So initially, once the need for medical intervention is ruled out, the important thing to do is treat the pain.

This goes against almost all manual therapy and allied health advertising to “treat the cause of your symptoms”.

Alleviating pain will, in many cases, sort out a lot of associated “findings”, the so called causes of your pain, and then beyond that, allow your body to heal.

If you came to us for treatment, here’s how we might do that:

  • Explain all of this information about pain, in a way that makes sense to you, so that you aren’t as stressed or anxious about it anymore.
  • Have a look at you stand and move and suggest ways that might make standing and moving less painful.
  • Get hands on and apply some really pleasurable manual techniques. There is no need to dig in deep for the sake of it. The goal isn’t to change the tissue, it’s to change the perception and get the brain releasing pain relieving chemicals.
  • Do some breathing techniques to help you relax. You’d be surprised at how poorly most people breathe, even when they are concentrating on doing it properly.

All of these techniques are based on the same principle – once the threat is reduced to an acceptable level, the brain will stop protective behaviours, which include pain and altered movement.

So to summarise a blog post in a sentence:

Pain is all about threat perception, it doesn’t mean damage and body tissues can’t produce pain, only the nervous system can**, so we must focus on the nervous system, including the brain, when describing and treating pain, so as to not cause further complications via nocebo.

 

 

**Yes, the nervous system is a body tissue, but for the sake of the argument we are using simple language.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

Integrative Osteopathy is an osteopathic practice located in the heart of Fitzroy North, within the reputable Healthy Fit gym. For all inquiries, call 0448 052 754, or to make an appointment online, click here.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.