Exercise & Back Pain

Alleviating lower back pain): it's not so much the programme, more the activity itself
Most physiotherapists and doctors are now aware that exercise is important for rehabilitation of lower back pain symptoms. However, the research has not studied what kind of programme produces the best results (see also SIB 3, page 6). This study (Mannion et al, (1999). 'What programme is best for the lower back?' Spine, 24(23), pp2435-2448) looked at 148 lower back pain patients and split them into three groups: active physiotherapy, muscle conditioning and low-impact aerobics. Each subject performed their treatment/exercise twice a week for 12 weeks. At the end of the training period, pain and lumbar mobility tests were evaluated.

Surprisingly, the researchers found that all three groups improved to the same degree in terms of pain relief, pain frequency and ability to perform daily tasks. In addition, these effects were well maintained for up to nine months after the training programme had ended.

This suggests that for chronic lower back pain patients, it is inactivity that is the problem.

Alleviating lower back pain (2): spinal flexibility is not a priority

Spinal muscle flexibility is considered important for preventing and treating lower back pain. This new study (Kuukkanen and Malkia (2000). :'Does exercise therapy improve back mobility?' Physiotherapy Research International, 5(1), pp. 46-61) investigated the impact of therapeutic exercise on chronic lower back pain and spinal flexibility in patients with mild problems. 86 patients were included in the study and were divided into three groups: intensive training, home training and control. The training programme lasted for three months and tests were performed at the beginning and end of the training period, as well as three and nine months after the end of the programme to determine its long- term effects.

The results of this study showed that in this group of lower back patients with mild symptoms, spinal flexibility and pain were not related. The programme did improve flexibility, and these improvements did last long term in erector spinae but not in hamstrings.

Developing smoother back movements
So, the Copenhagen investigators decided to take a new tack. Instead of assuming, as almost all other researchers have done, that muscle-strengthening routines are the answer for low-back pain, the Danish researchers reasoned that healthy functioning in the low back does not depend on muscle strength, endurance, and flexibility alone - but also on the COORDINATION of movements involving the lower back. They theorised that individuals who moved clumsily might put inordinate strains on their low-back muscles, connective tissues, and spinal structures, even if their basic muscle strength was pretty decent, leading to the onset of pain. As a result, the Danes hypothesised that training to improve coordination - but not necessarily muscle strength - might help individuals develop smoother movements of the lower back, which would then decrease the risk of harmful stress on the low back and thereby reduce the risk of pain

Forty Copenhagenians aged 18 to 65 with chronic low back pain took part in the study. The subjects had all experienced low-back pain for at least three months in the preceding year, but none of the individuals suffered from serious problems such as osteoporosis, painful osteo-arthritis, inflammatory rheumatoid arthritis, or disc degeneration

The subjects were divided into two groups, each of which trained for one hour two times per week over a three-month period. One group carried out conventional endurance/strength training for the low back, while the other conducted the special coordination training. After a 10-minute warm-up, the endurance/ strength group completed four key exercises:
1) Leg lifts, in which subjects stood by the end of a table, leaned over into a prone position with the hips against the edge of the table and the chest flat on the table, and then lifted both legs behind them to the greatest possible height;
2) Trunk lifts, in which subjects lay prone on a table with their hips at the edge and the upper part of the body extending out over the edge of the table face-down (a strap over the calves kept individuals from toppling off the table). With hands behind their heads, the participants lowered their trunks and then lifted their trunks upward to the greatest possible extent (very much like traditional 'Roman-Chair' exercise);
3) Abdominal contractions (sit-ups), in which individuals lay on their backs with their knees flexed, feet on the floor, and arms behind their heads and then slowly 'sat up' in a straight- forward direction; and
4) Lat pull-downs, in which participants sat on a seat, grasped a weight lever, and then pulled the lever down behind their necks and shoulders, lifting a weight stack which was attached to the lever

During the strength/endurance workouts, subjects did as many repetitions of each exercise as possible (but no more than 100), with 30-second pauses after each set of 10 repetitions. At the end of the workout, participants completed about 10 total minutes of stretching, using 30-second static stretches of the various muscle groups

Like the strength/endurance people, the coordination-trained subjects started their workouts with 10 minutes of jogging and warm-up activity. They then completed four coordination exercises, including
1) 'Knee-elbow touches'' in which they started in an upright, standing position and then rotated their trunks to the right, lifted their right knees while standing on their left feet only, and touched their right knees with their left elbows. They then returned to the standing position, rotated their trunks to the left, lifted their left knees, and touched their left knees with their right elbows. This alternating pattern - left elbow touching right knee and right elbow touching left knee - continued for up to 40 repetitions;
2) 'Balancers,' in which subjects started out on all fours (hands and knees on the ground) and then extended their left legs straight back and their right arms straight ahead, while remaining in balance on their right knees and left hands. They then went back to the starting position and moved their left arms ahead and right legs back before alternating this pattern for a total of up to 40 reps;
3) Modified sit-ups, like No. 3 from the strength/endurance training except that instead of sitting up straight ahead, subjects moved forward alternately to the left and then to the right as they did their 'crunches'; and
4) Proprioceptive training, in which the participants stood on a wooden disk with a sphere attached to its undersurface. Subjects tried to keep balanced on the sphere without letting the edges of the disk touch the floor - while twisting their bodies and bending at the knees. Participants stood on both feet at the beginning of the study but progressed to one-footed balancing (alternating feet) after several weeks. Post-workout stretching was the same as for the strength/endurance group

And the results?
After three months of training, both groups had less lower back pain, better mobility of the low back, and less trouble carrying out their daily activities, and the coordination group improved just as much as the strength/endurance group. Consumption of drugs to control low-back pain was reduced by about two-thirds in both groups as well

Notably, back-muscle strength increased in the strength/endurance group but not in the coordination subjects, yet each group made similar improvements in low-back function, demonstrating that an upgrade in strength is not the only thing which can heal a 'bad back'. Supporting this idea is the fact that there was not a strong correlation between improved back strength and reduction in low-back pain in the Copenhagen research

What does the Danish research mean to you? If you suffer from low-back pain or want to minimise the risk of low-back pain in the future, improving your back-muscle strength is a decent idea, but it's not the complete answer. You should also carry out the coordination drills completed by the Danish athletes to 'smooth' and coordinate the functioning of your lower-back muscles and spine, and you should probably also improve the flexibility of your low back by stretching out your low-back muscles AFTER they are thoroughly warmed up. With improved strength, coordination, and flexibility in your low back, you should be able to exercise more efficiently and with less fatigue in your low-back area. In addition, the prevention of low-back pain should allow you to train more consistently, leading to higher-quality performances

Owen Anderson