Fitness and Low Back Pain: Difference between revisions
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== Introduction  ==
== Introduction  ==


[[Image:Back pain image.jpg|right|200px]]  
[[Image:Back pain image.jpg|right|200px]][[Low Back Pain|Low back pain]] (LBP) is an umbrella of conditions with 80% of adults estimated to experience LBP at some point during their life <ref name="Palmer et al 2000">Palmer KT, Walsh K, et al. Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years BMJ 2000</ref>. Low back pain refers to  pain between the bottom of the ribs and the buttock crease.


<br>  
* A high physical fitness level, and especially [[Endurance Exercise|muscle endurance]] in the [[Back Muscles|back muscles]], is associated with lower risk of back pain<ref>E spine Exercise and Fitness to Help Your Back Available:https://www.spine-health.com/wellness/exercise/exercise-and-fitness-help-your-back (accessed 1.2.2022)</ref>
* A harmful misconception is that [[Therapeutic Exercise|exercise]] should be avoided when LPB is present. Understandably, many patients are reluctant to exercise out of the fear that any exercises or [[stretching]] will aggravate their existing back pain. They may become reluctant to exercise and rely on [[Pain Medications|medications]].<ref name=":0">Andersen LB, Wedderkopp N, Leboeuf-Yde C. Association between back pain and physical fitness in adolescents. Spine. 2006 Jul 1;31(15):1740-4.Available: https://pubmed.ncbi.nlm.nih.gov/16816772/ (accessed 1.2.2022)</ref>
* [[Physical Activity|Physical activity]] (PA) to increase aerobic capacity and muscular [[Strength Training|strength]], especially of the lumbar extensor muscles, is important for patients with chronic LBP in assisting them to complete [[Activities of Daily Living|activities of daily living]].<ref>Gordon R, Bloxham S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934575/ A systematic review of the effects of exercise and physical activity on non-specific chronic low back pain.] InHealthcare 2016 Jun (Vol. 4, No. 2, p. 22). Multidisciplinary Digital Publishing Institute.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934575/ (accessed 21.2.2022)</ref>
This article focuses on non specific chronic low back pain (NSCLBP) and its relations with fitness.


The aim of this page is to present an overview of the relationship between Fitness and Low Back Pain and to establish to what extent being fit or having a high level of fitness affects your risk of developing back pain or prevents future episodes. <br> A brief introduction to back pain is provided with links to further reading on the topic. Relevant anatomy is dicussed with regards to structural sources of pain.&nbsp; <br> The various different aspects of physical fitness are discussed and their relationship with back pain making reference to best evidence to summarise into clinically significant conclusions. &nbsp; <br> <br><br>  
== Fitness&nbsp; ==
[[File:Minna-hamalainen-Mgx1oe2vlVY-unsplash.jpeg|thumb|Plank exercise, core activation]]
Physical fitness is a set of attributes that people have or achieve. Being physically fit has been defined as the ability to carry out daily tasks with vigour and alertness, without undue fatigue and with ample energy to enjoy leisure-time pursuits and meet unforeseen emergencies<ref>President's Council on Physical Fitness and Sports: Physical Fitness Research Digest. Series 1,No.1, Washington DC,1971.</ref>


== Defining Low Back Pain (LBP)  ==
Being physically fit depends on how well a person fulfils each of the components of being healthy.When it comes to fitness, these components are<ref name=":1">Medical news today What does being physically fit mean? Available:https://www.medicalnewstoday.com/articles/7181 (accessed 2.2.2022)</ref>:
# Cardiorespiratory Endurance - [[VO2 Max|VO2 max]] per Kg of body mass&nbsp;<ref>Mota, Jorge, et al. "Association of maturation, sex, and body fat in cardiorespiratory fitness." American Journal of Human Biology 14.6 (2002): 707-712.</ref> &nbsp;
# Muscular [[Endurance Exercise|Endurance]] - Currently no Gold Standard measurement for muscular endurance
# Muscular Strength - There are a number of ways to measure muscular strength. The [[Biering-Sorenson Test|Biering-Sorenson Test.]] is an easy to perform test for back strength. Isokinetic Dynamometry is the gold standard re back strength but is very expensive.&nbsp;<ref>Stark, Timothy, et al. "Hand-held dynamometry correlation with the gold standard isokinetic dynamometry: a systematic review." PM&amp;R 3.5 (2011): 472-479.</ref>
# [[Body Composition]]:- The current Gold Standard is a Four-Compartment model of measurements most commonly consisting of Mass, Total Body Volume, Total Body Water and Bone Mineral Content.<ref>Wilson, J. P., Mulligan, K., Fan, B., Sherman, J. L., Murphy, E. J., Tai, V. W., ... &amp; Shepherd, J. A. (2012). Dual-energy X-ray absorptiometry–based body volume measurement for 4-compartment body composition. The American journal of clinical nutrition, 95(1), 25-31.</ref>
# [[Flexibility]] - Optical Gold Standards such as the Vicon Motion Tracking System<ref>Mohamed, Abeer A., et al. "Comparison of Strain-Gage and Fiber-Optic Goniometry for Measuring Knee Kinematics During Activities of Daily Living and Exercise." Journal of biomechanical engineering 134.8 (2012).</ref>
The following sections will look at each of these components individually, relating it to LBP.


<br>• Low back pain is an umbrella of conditions with 80% of adults estimated to experience LBP at some point during their life ( <ref name="Palmer et al 2000">Palmer KT, Walsh K, et al. Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years BMJ 2000</ref> )<br>• Male and female individuals are affected equally ( <ref name="Helliovara, et al. 1989">Helliovaara, M. Risk factors for low back pain and sciatica. Annals of Medicine.1989</ref> ).<br>• Low back pain encompasses and pain between the bottom of the ribs and the buttock crease.<br>• Common subdivisions of LBP are acute, sub-acute or chronic/persistent and specific or non-specific<br>• The three most common diagnostic methods are (in no particular order) [http://www.physio-pedia.com/Maitland's_Mobilisations Maitland], [http://www.physio-pedia.com/Mckenzie_Method McKenzie] and a [http://www.physiopedia.com/Classification_Of_Low_Back_Pain_Using_Shirley_Sahrmann%E2%80%99s_Movement_System_Impairments,_An_Overview_Of_The_Concept Movement based assessment]. <br>• [http://www.physio-pedia.com/Low_Back_Pain_Guidelines Low back pain guidelines]
=== Cardiorespiratory Endurance  ===
[[Image:Cardiovascualar endurance.jpg|500x350px|right]]Cardiorespiratory endurance indicates how well the body can supply fuel during physical activity via the body’s circulatory and respiratory systems.


<br>  
Aerobic activities that help improve cardiorespiratory endurance are those that cause an elevated heart rate for a sustained period of time. eg swimming, brisk walking, jogging, cycling<ref name=":1" />


== Specific vs Non-specific  ==
LPB relevance


<br>Specific low back pain refers to the diagnosis of a specific cause/structure such as a malignancy, fracture, or disk bulge etc. Specific low back pain should be identified with appropriate triage and the appropriate investigations undertaking. ([http://www.physio-pedia.com/Red_Flags_in_Spinal_Conditions Red Flags] in spinal cases).  
* Aerobic exercise increases the [[Blood Physiology|blood]] flow and nutrients to the soft tissues, including those in the back, hastening the the [[Soft Tissue Healing|healing]] process.  
* Thirty minutes of aerobic exercise increases the body’s production of endorphins, a natural alternative for pain relief for the body. This helps with clients pain levels and may reduce reliance on medication for pain.


<br>Non-specific low back pain is much more common and evidence suggests it accounts for approx. 95% of back pain, ( <ref name="CSAG 1994">Clinical Standards Advisory Group. NHS 1994</ref> )
* A low aerobic fitness level is associated with CLBP
* Maximum oxygen consumption (VO2max) is found to be significantly lower by 10 mL/kg in men and by 5.6 mL/kg in women with CLBP compared to men/women without.<ref name=":0" />
=== Muscular Endurance&nbsp;  ===
[[Image:Sorrenson.jpg|500x350px|alt=|thumb|Biering-Sorenson Test]]


<br> [[Image:SPinal2.png]] <ref>The Royal College of General Practitioners. fckLRfckLRDiagnostic Triage Flow Chart of a patient presenting with low back pain with or without leg pain. Found at : http://www.chiro.org/LINKS/GUIDELINES/FULL/Royal_College/backpain12.html</ref>  
Fitness also includes muscular endurance, which is the ability of a muscle to continue exerting force without tiring.<ref name=":1" />


<br>  
* Patients with low back pain have reduced [[Manual Muscle Testing: Hip Extension|lumbar extensor]] muscular endurance in comparison with non-sufferers.<ref name="Andersen">Andersen, J. S. (2007). Physical fitness and low back pain: Performance-based and self-assessed physical fitness as risk indicator of low back pain among health care workers and students. Det Nationale Forskningscenter for Arbejdsmiljø; Københavns universitet. Det Sundhedsvidenskabelige fakultet.</ref> <ref name="Biering-Sorenson">Biering-Sorenson, F. (1984). Physical measurements as risk indicators for low back trouble over a one-year period. Spine, 9, 106-119.</ref>See [[Biering-Sorenson Test|Biering-Sorenson Test.]]
* [[Abdominal Muscles|Abdominal]] muscular endurance in low back pain sufferers is significantly decreased in contrast to those in the normal health population <ref name="Foster Fulton">Foster, D. N. &amp; Fulton, M. N. (1991). Back pain and the exercise prescription. Clinics in Sports Medicine, 10, 187-209.</ref>
* Lumbar [[Muscle Fatigue|fatigue]] as a result of low muscular endurance has been shown to reduce the person’s ability to sense the positioning of the [[Lumbar Anatomy|lumbar spine]]. People with chronic LBP have impaired ability in controlling the position of the lumbar spine after a fatiguing task, leading to [[Lumbar Instability|lumbar instability]].<ref name="Taimela">Taimela, S., Kankaanpää, M., &amp; Luoto, S. (1999). The effect of lumbar fatigue on the ability to sense a change in lumbar position: a controlled study. Spine, 24(13), 1322.fckLRChicago (lumbar positioning)</ref>
* Patients with lower back pain, have a higher percentage of [[Muscle Fibre Types|fast type I glycolytic fibres]] compared to the slow oxidative fibres. Fast twitch fibers contract quickly but get tired quickly, rendering them less resistant to fatigue. This makes these people more susceptible to back injury. Non-LBP people have a much higher percentage of slow twitch fibers, which are best for endurance work, as they can carry out tasks without getting tired, and are present in core muscles.<ref name="Mannion">Mannion, A. F., Weber, B. R., Dvorak, J., Grob, D., &amp; Müntener, M. (1997). Fibre type characteristics of the lumbar paraspinal muscles in normal healthy subjects and in patients with low back pain. Journal of Orthopaedic Research, 15(6), 881-887.</ref><ref name=":1" />


==  Acute/Sub-acute and Chronic Low Back Pain ==
== Strength and Low Back Pain ==
[[File:Lower back extension.jpeg|thumb|Back extensors at work.]]
The [[Core Muscles|core]] is the group of trunk and [[hip]] muscles that surround the spine, abdominal viscera and hip. Core muscles are essential for proper load balance within the spine, [[pelvis]], and [[Kinetic Chain|kinetic chain]]. [[Core Strengthening|Core strengthening]]<ref>Park HS, Park SW, Oh JK. Effect of adding abdominal bracing to spinal stabilization exercise on lumbar lordosis angle, extensor strength, pain, and function in patients with non-specific chronic low back pain: A prospective randomized pilot study. Medicine. 2023 Oct 13;102(41):e35476.</ref>  has a strong theoretical basis in treatment and prevention of [[Low Back Pain|LBP]], as well as other musculoskeletal afflictions. A reduction in core strength can lead to [[Lumbar Instability|lumbar instability]].<ref name=":0" /> Muscle strengthening exercises form part of the NICE treatment guidelines for Early management of persistent non-specific low back pain.


<br>Alongside specific and non-specific, back pain is also defined by its duration. (See figure 1)
The importance of the core relate to its function ie sparing the spine from excessive load and transfer force from the lower body to the upper body and vice versa.


<br>Figure 1: Time scales in non-specific low back pain for first episode: <ref name="Hayden et al 2005">Hayden J, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database of Systematic Reviews 2005</ref> <br><br> [[Image:Back pain timescales graphic.jpg]] <br> See also&nbsp;: [http://www.physio-pedia.com/Chronic_Low_Back_Pain Chronic Low Back Pain&nbsp;]  
* Having a strong, stable core helps us to prevent injuries and allows us to perform at our best.
* In order to protect the back, ideally we want to create 360 degrees of stiffness around the spine as we move, run, jump, throw, lift objects and transfer force throughout our body.
* We do this when all of the muscles in our hips, torso and shoulders work together<ref>Physiopedia [[Core Stability]] Available:https://www.physio-pedia.com/index.php?title=Core_Stability&utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal (accessed 1.2.2022)</ref>
* Exercises to activate the deep abdominal muscles including the superficial muscles, [[Transversus Abdominis|transversus abdominis muscle]] and the [[Lumbar Multifidus|multifidus]] are important for CLBP patients<ref name=":0" />.


[http://www.physio-pedia.com/Chronic_Low_Back_Pain]


<br>


Chronic Low Back Pain is a complex topic in itself and beyond the scope of this page however the link above has more information.
Measures of Back Strength: For information here look at Physiotherapy Assessment section of [[Core Stability]]


== Relevant anatomy to fitness and LBP  ==
Few of us will have access to a isokinetic machine to measure trunk strength, as shown in video below.  
 
{| width="100%" cellspacing="1" cellpadding="1"
==  Overview  ==
|-
 
|{{#ev:youtube|xEhLr5y0wBE|380}} <ref>Isokinetic System Con-Trex. 08 Isokinetic measurement trunk on Con-Trex TP trunk module.mov. Available from: http://www.youtube.com/watch?v=xEhLr5y0wBE [last accessed 29/11/15]</ref>
[[Image:Anatomy of spine.jpg|right|300px]] As you can see from the diagram there are several sections of the spine; cervical, thoracic, lumbar and sacral. The majority of Lower back pain (LBP) is related to issues originating in the lumbosacral region.<br>The lumbar spine consists of 5 segmental vertebrae (L1-L5) each separated by an intervertebral disc. The sacrum is also made of 5 vertebras but these fuse together starting at 16 and are completely fused by 34.Although it is widely thought that in lower back pain cases it isn’t possible to differentiate the causes, this will explain the various relevant anatomy that is commonly thought to lead to LBP.
|}
 
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== Arthrogenic structures  ==
 
[[Image:Arrthrogenic.jpg|right|300px]]
 
<br>The main synovial joint between each vertebrae is the facet joint (zygapophyseal joint), this is a saddle joint, between the upper segment’s inferior articular facet and the lower segment’s superior articular facet. These are differently shaped to the Thoracic and cervical facets, as lumbar facets run parallel rather than on top of each other and this is why the lumbar spine has a more prominent role in flexing and extending but very limited rotational and side flexion range. This joint can often be a major cause of LBP as there is evidence showing that the facet joint pain can be responsible for up to 27% of cases in the lumbar spine.&lt;/span&gt;
 
<span style="line-height: 1.5em;">There are several adverse pathological mechanisms that can lead to facet joint pain:- the first being arthritic changes that can occur due to abnormal spinal loading or degenerative changes that occur with age, hence the common presentation within the elderly population. There are a number of ligamentous structures that can contribute to the presentation of LBP. Running continuously along the posterior aspect of the spinous process’(SP) is the supraspinous ligament. Connecting corresponding SP's is the interspinous ligament, the anterior longitudinal ligament and posterior longitudinal ligament run respectively along the anterior and posterior surface of the vertebral bodies (the posterior longitudinal ligament can be found in the vertebral canal).</span><span style="line-height: 1.5em;">&nbsp;The ligament flavum, which runs between the laminae of adjacent vertebrae, (often associated with zygapophyseal joint arthiritis) can become hypertrophied and lead to [[Www.physio-pedia.com/Spinal Stenosis|spinal stenosis]].&nbsp;</span>
 
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== Intervertebral Disc  ==
 
<br>The intervertebral disc consists of the Annulus fibrosis and the Nucleus Pulposus.<br>The annulus fibrosis is the outer ring of collagen fibres that form a protective layer around the nucleus pulposus, which is situated at the centre of the disc and is in the majority responsible for absorbing compressive forces.<br>There has been theoretical connections made between heavy lifting and LBP caused by a disc prolapse or bulge. This is where tears form or there is a trauma to the annulus fibrosis which results in the Nucleus pulposus bulging or even protruding out of the annulus fibrosis. This can lead to complications of spinal chord or nerve root compression, leading to the presentation of sciatica or other neurological pain. [http://www.physio-pedia.com/Disc_Herniation Disc Herniation.] The IV disc will naturally degenerate over time which often starts disc dehydration, which can reduce the shock absorbing ability of the lumbar spine region and reduce intervertebral space increasing the probability of arthritic injury or osteophytic growth within the joint space. For further info see [http://www.physio-pedia.com/Degenerative_Disc_Disease disc disease].<br><br>
 
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==  Muscles  ==
 
[[Image:Multifidi.png|right|300px]]
 
When referring to the muscles that assist in stabilisation of the lumbar spine the "core" muscles are frequently discussed. The “core” is comprised of several groups of muscles including the transversus abdominus, multifidus, diaphragm and pelvic floor muscles. The multifidi is a bilateral muscle and originates from the posterior sacral surface, PSIS and posterior sacroiliac ligament as well as each transverse process of the vertebrae inferior to the segment it inserts into. It inserts into the spinous process of each superior vertebrae.
 
<br>Advances in the understanding of the biomechanics of LBP have highlighted the importance of muscular stabilization within the "neutral zone" which is a range of motion in the lower back at which none of the spinal structures are under passive stretch. Multifidus muscles in the lumbar spine are important stabilisers of this neutral zone, and dysfunction in these muscles is strongly associated with LBP.&nbsp;<ref name="Freeman et al">Freeman MD, Woodham MA, Woodham AW The role of the lumbar multifidus in chronic low back pain: a review. PM R. 2010</ref>
 
&lt;bThe pattern of multifidus muscle atrophy in chronic LBP patients is localised rather than generalised. Furthermore, bilateral asymmetry may be seen in chronic LBP patients presenting with a unilateral pain distribution.&nbsp;&lt;/span&gt;<ref name="Hides et al">Hides J, Gilmore C, Stanton W, Bohlscheid E fckLRMultifidus size and symmetry among chronic LBP and healthy asymptomatic subjects. 2008 Manual Therapy</ref>
 
<br>The transverse abdominus (TvA) is the deepest of the abdominal muscles and is also a stabiliser of the spine.&nbsp;It has been found to be in a weakened state in those who have chronic back pain or problems. Its normal action along with the action of the the lumbar multifidus muscles function together to form a deep internal corset that acts to stabilise the spine during movement. This pattern of protection is disrupted in patients with low back pain.<br>It is uncertain why these muscles become dysfunctional after a low back injury, but specific exercises focusing on co-contraction of these two muscles will improve the protective stabilising ability of the spinal muscles, reduce pain intensity, and improve activities of daily living as well as improve body awareness and posture.
<div>The TvA originates at the iliac crest, inguinal ligament, thoracolumbar fascia, and costal cartilages 7-12 and it inserts at the Xiphoid process, Linea alba, pubic crest and pectin pubis via conjoint tendon. It’s fibres run in a transverse direction (hence the name) and it is the innermost of the flat muscles of the abdomen, being placed immediately beneath the internal oblique muscle.</div><div>There are also the muscles that play a larger role in the moving of the lumbar spine (and the spine as a whole) rather than in predominantly stabilising role, these muscles are prone to strains.&nbsp;Lumbar muscle strains often originate in any of the following muscles erector spinae (iliocostales, longissimus, spinalis) semispinales, multifidi, rotatores, quadratus lumborum and serratus posterior.</div>
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== Fitness&nbsp;  ==
 
<br>Physical fitness is a set of attributes that people have or achieve. Being physically fit has been defined as:- the ability to carry out daily tasks with vigour and alertness, without undue fatigue and with ample energy to enjoy leisure-time pursuits and meet unforeseen emergencies<ref>President's Council on Physical Fitness and Sports: Physical Fitness Research Digest. Series 1,No.1, Washington DC,1971.</ref><br>In accordance with Hales in 2010, these are the five components of physical fitness and the Gold Standards for measuring each of these aspects:-<br>1) Cardiorespiratory Endurance - VO2 max per Kg of body mass&nbsp;<ref>Mota, Jorge, et al. "Association of maturation, sex, and body fat in cardiorespiratory fitness." American Journal of Human Biology 14.6 (2002): 707-712.</ref> &nbsp;<br>2) Muscular Endurance - Currently no Gold Standard measurment for muscular endurance<br>3) Muscular Strength - Isokinetic Dynamometry&nbsp;<ref>Stark, Timothy, et al. "Hand-held dynamometry correlation with the gold standard isokinetic dynamometry: a systematic review." PM&amp;R 3.5 (2011): 472-479.</ref>&nbsp;[http://www.topendsports.com/testing/norms/vo2max.htm VO2 max normative values]<br>4) Body Composition:- The current Gold Standard is a Four-Compartment model of measurements most commonly consisting of Mass, Total Body Volume, Total Body Water and Bone Mineral Content. There are however other potential methods such as Dual-energy Xray Absorptiometry (DEXA) and Air-Displacement Plethsymology which are being trialled to measure body composition&nbsp;<ref>Wilson, J. P., Mulligan, K., Fan, B., Sherman, J. L., Murphy, E. J., Tai, V. W., ... &amp; Shepherd, J. A. (2012). Dual-energy X-ray absorptiometry–based body volume measurement for 4-compartment body composition. The American journal of clinical nutrition, 95(1), 25-31.</ref><br>5) Flexibility - Optical Gold Standards such as the Vicon Motion Tracking System<ref>Mohamed, Abeer A., et al. "Comparison of Strain-Gage and Fiber-Optic Goniometry for Measuring Knee Kinematics During Activities of Daily Living and Exercise." Journal of biomechanical engineering 134.8 (2012).</ref> <br><br>1) &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;3) &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 5) <br> [[Image:TriageGoldStandard.jpg|689x159px]]
 
== Cardiorespiratory Endurance -  ==
 
Cardiovascular Endurance is the ability of the circulatory and respiratory systems to supply fuel during sustained physical activity and eliminate fatigue products after supplying fuel. The pain relieving mechanics of aerobic exercise on lower back pain are not clear, since the intensity of the muscular contractions are not intense enough to promote muscular hypertrophy. <br>Cardiovascular (CV) fitness theoretically has many different influences on prevention of lower back pain. Cardiovascular fitness may help prevent any unfavourable adaptations to the body associated with neuromuscular health, muscular endurance, muscular strength and general loading through the lumbar spine. <br>The majority of these tend to be indirect effects as the association between cardiovascular fitness and LBP is not as discernible as that seen with muscular weakness, reduced flexibility and reduced muscular endurance. <br>However a more direct link to why high CV fitness can prevent lower back pain is that due to the avascular nature of the intervertebral discs they rely on osmosis for transport of nutrients and the removal of waste products. The improved efficiency in circulation that directly stems from good CV fitness, will facilitate the osmosis required to maintain disc hydration therefore delaying the process of disc degeneration and reducing the risk of LBP.<ref name="Plowman" />
 
Although VO2 max is the gold standard for measuring cardiovascular endurance there is no evidence that specifically associates VO2 max in the prevalence of LBP <ref name="battie">BATTIÉ, M. C., BIGOS, S. J., FISHER, L. D., HANSSON, T. H., NACHEMSON, A. L., SPENGLER, D. M., ... &amp; ZEH, J. (1989). A prospective study of the role of cardiovascular risk factors and fitness in industrial back pain complaints. Spine, 14(2), 141-147.</ref>. It is used in more of the evidence surrounding deconditioning syndrome related to chronic LBP.
 
<span style="line-height: 1.5em;">Smoking has also been shown to increase the likelihood of LBP. The causality of which can partially be explained by the physiological effects that smoking has on the CV system. The decreased arterial oxygen to the paraspinal muscles of the lower back will lead to muscle fatigue and increase the use of the lactic acid system, therefore lactic may build up and stimulate the pain sensors in the area, also as mentioned in Muscular endurance, the muscular fatigue increases the likelihood of low back pain too.<ref name="Power">Power, C., Frank, J., Hertzman, C., Schierhout, G., &amp; Li, L. (2001). Predictors of low back pain onset in a prospective British study. American Journal of Public Health, 91(10), 1671-1678.</ref></span>
 
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[[Image:Cardiovascualar endurance.jpg|center|500x350px]]<br>
 
== Muscular Endurance&nbsp;  ==
 
Muscular Endurance is the ability of the muscle to exert a submaximal force repeatedly over a sustained period of time. In a study conducted by Biering-Sorenson in 1984<ref name="Biering-Sorenson">Biering-Sorenson, F. (1984). Physical measurements as risk indicators for low back trouble over a one-year period. Spine, 9, 106-119.</ref>, it was discovered that patients with low back pain had reduced levels of muscular endurance in the lumbar extensors in comparison with non-sufferers, recent research by authors such as Andersen (2007)<ref name="Andersen">Andersen, J. S. (2007). Physical fitness and low back pain: Performance-based and self-assessed physical fitness as risk indicator of low back pain among health care workers and students. Det Nationale Forskningscenter for Arbejdsmiljø; Københavns universitet. Det Sundhedsvidenskabelige fakultet.</ref> supports this as they showed a similar association in a large sample of healthcare workers and students.
 
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[[Image:Sorrenson.jpg|center|500x350px]]&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; (Sorenson test)
 
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Studies have also reported that abdominal muscular endurance in low back pain sufferers is significantly decreased in contrast to those in the normal health population <ref name="Foster Fulton" />, although a more recent study by Lewis (2009)<ref name="Lewis">Lewis, F. (2011). The association between trunk muscle endurance and lumbar-pelvic instability in adolescent LBP (Doctoral dissertation).</ref> showed that adolescents with LBP presented with significantly higher trunk flexor muscle endurance compared to adolescents without LBP. The argument is made that the ratio between flexor’s and extensor’s muscular endurance is more important in terms of LBP than endurance and strength measurements alone <ref name="Barr">Barr, K. P., Griggs, M., &amp; Cadby, T. (2007). Lumbar stabilization: a review of core concepts and current literature, part 2. American Journal of Physical Medicine &amp; Rehabilitation, 86(1), 72-80.</ref>. The increase in flexion endurance and decrease in extension endurance, could be linked to having a poor posture and loss of the neutral position, therefore leading to LBP. (<ref name="Freeman et al" />)
 
Lumbar fatigue as a result of low muscular endurance has been shown to reduce the person’s ability to sense the positioning of the lumbar spine and that 25% of people with chronic LBP (n=57) had severely impaired ability in controlling the position of the lumbar spine after a fatiguing task.<ref name="Taimela">Taimela, S., Kankaanpää, M., &amp; Luoto, S. (1999). The effect of lumbar fatigue on the ability to sense a change in lumbar position: a controlled study. Spine, 24(13), 1322.fckLRChicago (lumbar positioning)</ref> This loss of control again links back to the fact that not being able to hold a neutral position is strongly associated with LBP. (<ref name="Freeman et al" />)
 
Physiologically in patients with lower back pain it has been shown they have a higher percentage of fast type I glycolytic fibres compared to the slow oxidative fibres, this can be expected to render them less resistant to fatigue, where-as non LBP people have a much higher percentage of the type II glycolytic fibres giving them better muscular endurance helping prevent lower back pain.<ref name="Mannion">Mannion, A. F., Weber, B. R., Dvorak, J., Grob, D., &amp; Müntener, M. (1997). Fibre type characteristics of the lumbar paraspinal muscles in normal healthy subjects and in patients with low back pain. Journal of Orthopaedic Research, 15(6), 881-887.</ref><br><br>
 
== <span style="line-height: 1.5em;">Body Composition &nbsp;</span>  ==
 
This is the relative amounts of muscle, fat, bone and other vital organs in the body. The prevalence of low back is undoubtedly related most commonly with body fat content/obesity. Numerous studies have been conducted highlighting the relationship between increased fat content and the likelihood/prevalence of lower back pain. A study conducted in 2003 <ref>Bener, A., Alwash, R., Gaber, T. and Lovasz,G. 2003. Obesity and Low Back Pain. Coll. Antropol. 27 (2003) 1: 95–104</ref> found that there was a moderate positive relationship between obesity and lower back pain, however the results were based on the BMI calculation which does not definitively measure body fat content. In a study conducted by Urquhart 2011 <ref>Urquhart, D.M. 2011, Higher Body Fat Linked to Increased Back Pain. Spine 9/1/2011 Edition. Lippincott Williams and Wilkins, Philadelphia</ref> , it was also evident that there was a relationship between obesity and lower back pain. The difference with this study however is that not only was the BMI calculation used as a measure of obesity but Lean Fat Mass and Lean Muscle Mass were also calculated to determine whether it was fat content or general increase weight that was directly proportional to the potential for LBP. It is the common belief that an increase in body weight alters spinal biomechanics and loading creating excess strain to be put through certain structures. This picture displays how obesity can lead to altered body positions such as exaggerated lumbar lordosis which will cause an alteration in spinal loading mechanics.<br>
 
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[[Image:Obese small.jpg|left|600x400px]]<br>
 
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The theory behind why back pain was less prevalent in those with high lean muscle mass was that the increase muscle mass was there to compensate for the excess spinal loading and therefore would not alter loading mechanics. The studies conducted however have all been cross-sectional studies and longitudinal studies will need to be completed to assess if a higher fat mass predisposes the development of lower back pain later in life. There has been a meta-analysis completed&nbsp;<ref>Shiri, R., Karppinen, J., Leino-Arjas, P., Solovieva, S., &amp; Viikari-Juntura, E. (2010). The association between obesity and low back pain: a meta-analysis. American journal of epidemiology, 171(2), 135-154.</ref> reviewing the literature surrounding obesity and low back pain. In the cross-sectional studies analysed, there was a strong link between obesity and increased prevalance of LBP in the last 12 months, subjects seeking LBP care and chronic LBP sufferers. There was an increase in prevalance for overweight subjects in comparison with the non-overweight subjects however subjects classified as obese had the highest incidence rate of LBP. Of the cohort studies there was only a relationship highlighted between obesity on LBP. Results were adjusted for publication bias and only studies who controlled for potential confounding variables were included. The results remained the same after being subjected to these criterion.&nbsp; There have also been a number of studies investigating the relationship between bone mineral density (BMD) and the predisposition to low back pain. In a study conducted in 2011 <ref>Snider, K. T., Johnson, J. C., Degenhardt, B. F., &amp; Snider, E. J. (2011). Low back pain, somatic dysfunction, and segmental bone mineral density T-score variation in the lumbar spine. The Journal of the American Osteopathic Association, 111(2), 89.fckLRChicago</ref> ,relationships were discovered between positional asymmetry, motion restriction and objective measurable increases in the BMD of affected vertebrae. Further on this page it will be explained how positional asymmetry and motional restriction can predispose people to LBP. Increased BMD was also found in the subjects suffering from chronic LBP however due to the inherently small differences in density the evidence could well have been circumstantial. Further investigations are required to assess the reproductability of the results and to clarify the reasoning for the increased BMD.&nbsp;
 
The studies conducted however have all been poor quality cross-sectional studies, and to truly assess the implications of each aspect of body composition on the prognosis of LBP, longitudinal studies will need to be completed to investigate the subjects over as longer period of time.
 
<br>
 
== Flexibility  ==
 
[[Image:SWay back posture.jpg|right|250px]]
 
<br> This is the range of movement available at any particular joint of the body. Patients presenting with low back pain often display significant reductions in degrees of several movements at the pelvis and trunk. Adequate flexibility of the lumbar spine enhances functional mechanical advantage, while spasmodic or shortened back muscles adversely affect spinal mechanics <ref>Farfan, H. F. (1975). Muscular mechanism of the lumbar spine and the position of power and efficacy. Orthopaedic Clinics of North American, 6, 135-144.</ref>. Tightness in the hip flexors can reduce pelvic mobility and therefore put excess strain on the lumbar spine during certain disciplines of movement – especially into flexion, following that, tight hamstring and hip extensors can also contribute to an exaggeration in the lordotic curve, which can potentially effect spinal loading mechanisms and lead to injury <ref name="Foster Fulton">Foster, D. N. &amp; Fulton, M. N. (1991). Back pain and the exercise prescription. Clinics in Sports Medicine, 10, 187-209.</ref><ref name="Plowman">Plowman, S. A. (1992). Physical activity, physical fitness, and low back pain. In J. O. Holloszy (Eds.), Exercise and Sport Sciences Reviews (pp. 221-242). Baltimore: Williams &amp; Wilkins.</ref>. The tightness in hip flexors and hamstrings can lead to a Sway Back posture (see figure). In this posture the muscular tightness causes an anterior pelvic tilt and therefore excessive lumbar extension which compresses the lumbar vertebra - this position can predispose patients to lumbar facet sydnrome<ref>Swedan, N. (2001) Women's Sports Medicine and Rehabilitation, Lippincott Williams &amp; Wilkins, UK.</ref>.
 
The relationship between flexibility and lower back pain however is still largely based around theory and there are yet to be a number of high quality experiments/investigations to either support or refute this hypothesis.
 
== Strength and Low Back pain  ==
 
<br>Muscle strength is the contractile force a muscle is able to produce. <br> The large muscles of the back (See anatomy section) are often thought of as synomous with back strength.<ref name="Lee et al 2012">Lee HJ, Lim WH, Park JW, Kwon BS, Ryu KH, Lee JH, Park YG. The Relationship between Cross Sectional Area and Strength of Back Muscles in Patients with Chronic Low Back Pain. Ann Rehabil Med. 2012</ref> It is a commonly held belief that having 'strong' back muscles will support the back and prevent back pain however there is conjecture in the literature surrounding this theory.&nbsp;<br> <br> Many common exercises such as prone extensions, dead lifts and low-rows are thought to strengthen the back muscles and 'stabalize' the spine and help prevent future back pain. &nbsp;
 
Muscle strengthening exercises form part of the NICE treatment guidelines for Early management of persistent non-specific low back pain.<ref name="NICE 2009">NICE : CG88 Low back pain: Early management of persistent non-specific low back pain 2009</ref><br>
 
<br> <br> [[Image:Back pain strength.jpg|580x200px]]<br>
 
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<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;{{#ev:youtube|033ogPH6NNE}}<br>
 
<br> '''This section will look to;'''
 
*Introduce different methods of measuring back strength
*Evaluate the literature surrounding the area
*Summarise the findings
 
== Measures of Back Strength  ==
 
[[Image:Strength image.jpg|right|300px]]


There are a variety of measures targeted at assessing muscular strength e.g. one rep max, isokinetic dynamometry, manual muscle testing etc.  
==<span style="line-height: 1.5em;">Body Composition &nbsp;</span>==
[[Image:Obese small.jpg|300x300px|alt=|thumb|Obesity can lead to altered body positions eg exaggerated lumbar lordosis]]The body is composed of water, [[Proteins|protein]], minerals, and [[Adipose Tissue|fat]]. A person can potentially maintain the same weight but radically change the ratio of each of the components that make up their body.


Muscle strength with regards to the lower back is commonly researched as a proxy measure of ‘physical capacity’ which also includes muscle endurance and joint mobility ( <ref name="Hamberg-van Reenen et al 2007">Hamberg-van Reenen HH, Ariëns GAM, Blatter BM, Mechelen W, Bongers PM. A systematic review of the relation between physical capacity and future low back and neck/shoulder pain. Pain. 2007</ref> ) although there is a lack of sufficient high quality evidence surrounding reproducibility of current physical capacity measures in healthy subjects and in patient groups. ( <ref name="Essendrop et al 2002">Essendrop M, Maul I, Läubli T, Riihimäki H, Schibye B. Measures of low back function: a review of reproducibility studies. Clinical Bio-mechanics (Bristol, Avon). 2002</ref> ). When researching lower back strength in relation to prevalence of LBP, isokinetic maximal flexion and extension, calculated with an isokinetic dynamometer, isoinertial dynamic testing and isokinetic lifting force are commonly used ( <ref name="Takala et al 2000">Takala E P, Viikari‐Juntura E. Do functional tests predict low back pain? Spine 2000</ref> There is some evidence to show that isokinetic measurement is reproducible and valid ( <ref name="Dvir et al 2001">Dvir Z, Keating J. The reproducibility of isokinetic trunk extension: a study using very short range of motion. 2001 Clin Biomech</ref> )
A two-component model of [[Body Composition|body composition]] divides the body into a fat component and fat-free component. Body fat (storage fat) in excess can increase susceptibility to [[Chronic Disease|chronic illness]], health complications, and LBP. Numerous studies have been conducted highlighting the relationship between increased fat content and the likelihood/prevalence of lower back pain.  


<br>  
* A study conducted in 2003 <ref>Bener, A., Alwash, R., Gaber, T. and Lovasz,G. 2003. Obesity and Low Back Pain. Coll. Antropol. 27 (2003) 1: 95–104</ref> found that there was a moderate positive relationship between [[obesity]] and lower back pain, however the results were based on the [[Body Mass Index|BMI]] calculation which does not definitively measure body fat content.
* In a study conducted by Urquhart 2011 which took into account the amount of body storage fat<ref>Urquhart, D.M. 2011, Higher Body Fat Linked to Increased Back Pain. Spine 9/1/2011 Edition. Lippincott Williams and Wilkins, Philadelphia</ref> and it was evident that there was a relationship between obesity and lower back pain
* An increase in body weight alters spinal [[Biomechanics of Lumbar Intervertebral Disc Herniation|biomechanics]] and loading, creating excess strain to be put through certain structures eg Obesity can lead to altered body positions such as exaggerated lumbar lordosis which will cause an alteration in spinal loading mechanics.
=== Flexibility  ===
[[Flexibility]] refers to the range of movement across a joint.


{| width="100%" cellspacing="1" cellpadding="1"
Flexibility is important because it improves the ability of the [[Kinetic Chain|kinetic chain]] to work smoothly and can help prevent injuries. It is specific to each joint and depends on a number of variables, including the tightness of [[Ligament|ligaments]] and [[Tendon Biomechanics|tendon]]<nowiki/>s.[[File:Stretching leg.jpeg|thumb|Stretching|alt=|350x350px]]
|-
Relevance to CLBP 
| {{#ev:youtube|xEhLr5y0wBE|380}} <ref>Isokinetic System Con-Trex. 08 Isokinetic measurement trunk on Con-Trex TP trunk module.mov. Available from: http://www.youtube.com/watch?v=xEhLr5y0wBE [last accessed 29/11/15]</ref>
|}


== Evidence Review  ==
* Stretching the soft tissues in the trunk and lower limb eg Back and thigh muscles and the regions ligaments and tendons. This can help to mobilize the spine, and improve the range of motion of the spine, decreasing back pain. Stretching exercises decrease the muscle stiffness as a result of changes in viscoelastic properties, due to the decreased [[Muscle Proteins|actin-myosin]] cross-bridges and the [[Reflexes|reflex]] muscle inhibition.<ref name=":0" /> 
* Improved range of motion assists in the spine and related areas improves the ability to complete ADLs eg [[lifting]] and bending which require trunk flexion, a complex interaction combining lumbar and hip motion<ref name=":0" />. Spasmodic or shortened back muscles adversely affect the complex spinal mechanics <ref>Farfan, H. F. (1975). Muscular mechanism of the lumbar spine and the position of power and efficacy. Orthopaedic Clinics of North American, 6, 135-144.</ref>.
* Tightness in the hip flexors and hamstrings can lead to a [[Low Back Pain Related to Hyperlordosis|Lumbar hyperlordosis]], predisposing patients to lumbar facet syndrome<ref>Swedan, N. (2001) Women's Sports Medicine and Rehabilitation, Lippincott Williams &amp; Wilkins, UK.</ref>


<br>A systematic review from 2007 <ref name="Hamberg-van Reenen et al 2007" /> <span style="line-height: 1.5em;">&nbsp;evaluated evidence on the relationship between physical capacity and future low back and neck/shoulder pain. It was the first systematic review of longitudinal studies assessing the link between physical capacity and LBP.</span> <br> Thirteen high quality studies reported no association between trunk muscle strength and future risk of low back pain. The risk ratios were insignificant between low and high isometric strength (0.6 and 1.2 respectively), however five high quality studies have shown that poor trunk muscle strength is a significant predictor of LBP and two other high quality studies found high strength as a risk factor. The results of this systematic review therefore are inconclusive one way or another in terms of the relationship between trunk strength and LBP.&nbsp;The review is further summaried in the table below.<br> <br>A more recent study looking into LBP in male adolescents found isometric and isoinertial trunk performance was not significantly associated with LBP although they did find that regular sport participation was associated with LBP (93.9%:67.9% LBP + sport: No LBP + sport) <ref name="Balagué et al 2010">Balagué F, Bibbo E, Mélot C, Szpalski M, Gunzburg R, Keller TS. The association between isoinertial trunk muscle performance and low back pain in male adolescents. Eur Spine J. 2010;</ref> .&nbsp; <br> Another paper by <ref name="Lee et al 2012" /> evaluating the strength and cross sectional area of extensor muscles in chronic LBP patients states that ‘weakness of the back muscles can lead to LBP’. The evidence this paper has used to support their own research actually contradicts the basis of their paper and is highlighted here as a good example of low quality research in the area based on commonly held beliefs rather than evidence based theory.&nbsp;
== Exercises to Decrease Low Back Pain ==
It has been showed by numerous studies that exercise therapy decrease low back pain and improve overall functional mobility. Here  are some methods which help to decrease low back pain.


<br>
==== Aerobic exercise ====
Aerobic exercise increases the [[Blood Physiology|blood]] flow and nutrients to the soft tissues, including those in the back, hastening the [[Soft Tissue Healing|healing]] process. low impact exercise elevates the heart rate without worsening the back pain.


==  [[Image:Critique table.jpg]]  Clinical Relevence  ==
* Exercise like walking or cycling help to improve circulation, strengthen the muscle of legs and back, reducing the stiffness and pain in the back.


<br>The research is inconclusive with regards to strength and low back pain however there is good evidence that poor trunk muscle strength is a risk factor for LBP. The evidence has so far failed to establish causality. Clinical guidance e.g. NICE guidelines still recommend strength exercises as part of a rehab program for BP.  
* swimming is another great aerobic exercise that improve cardiovascular endurance, a full body workout which improve flexibility and muscular endurance.  


<br>
==== Stretching and Strengthen Exercise ====
postural exercises have improved pain control and improve functional mobility on low back patient.


== Bottom Line  ==
# Knee to Chest Stretch
# Bridges Exercise
# Cat and Cow Stretch
# Seated Lower Back Rotational Stretch
# lumbar rotation


<br>An argument can be made for or against using strengthening exercises as a preventative measure for back pain More high quality research is needed to determine if either low or high strength is a risk factor for LBP.  
In acute low‐back pain, exercise therapy is as effective as either no treatment or other conservative treatments.<ref name=":2">Hayden J, Van Tulder MW, Malmivaara A, Koes BW. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000335.pub2/full?highlightAbstract=back%7Cexercise%7Cpain%7Cexercis%7Clow Exercise therapy for treatment of non‐specific low back pain]. Cochrane database of systematic reviews. 2005(3).</ref>


<br>  
Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low‐back pain, particularly in healthcare populations.<ref name=":2" />


Overall we have found that there is insufficient high quality evidence in the area of fitness and prognosis of future back pain due to the lack of prospective studies. Many of the studies fail to use gold standard measures as a reference, though we have shown with lower quality evidence that obesity, low isometric strength and reduced muscular endurance are related to LBP however the literature is indecisive of the causality.
== Conclusions ==
[[File:Physiotherapy Exercise and Physical Activity Image.png|thumb|470x470px|Importance of Fitness]]
A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain concluded thus:


<br>  
A general exercise programme that combines muscular strength, flexibility and aerobic fitness is beneficial for rehabilitation of non-specific chronic low back pain. Increasing core muscular strength can assist in supporting the lumbar spine. Improving the flexibility of the muscle-tendons and ligaments in the back increases the range of motion and assists with the patient’s functional movement. Aerobic exercise increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that can result in back pain.<ref name=":0" />


 
And remember the important message is that embarking on any regular exercise will be of benefit to an overall person’s health including reducing back pain. With exercise they will look and feel better.<ref name=":1" />
<br>  


== References  ==
== References  ==


<references /> <br>  
<references /> <br>
 
[[Category:Nottingham University Spinal Rehabilitation Project]]
[[Category:Conditions]]  
[[Category:Lumbar Spine]]
[[Category:Lumbar Spine]]  
[[Category:Interventions]]
[[Category:Lumbar Spine - Conditions]]  
[[Category:Lumbar Spine - Interventions]]
[[Category:Low_Back_Pain]]  
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Sports Medicine]]
[[Category:Sports Medicine]]

Latest revision as of 17:10, 8 January 2024

Original Editor ­ - Peter Copeland, George Smith, Bryn Roberts as part of the Nottingham University Spinal Rehabilitation Project
Top Contributors - Peter Copeland, George Smith, Lucinda hampton, Bryn Roberts, Kim Jackson, Laura Ritchie, Evan Thomas, 127.0.0.1, WikiSysop, Wanda van Niekerk, Fahad Bin Aftab, Admin, Shaimaa Eldib and Aminat Abolade

Introduction[edit | edit source]

Back pain image.jpg

Low back pain (LBP) is an umbrella of conditions with 80% of adults estimated to experience LBP at some point during their life [1]. Low back pain refers to pain between the bottom of the ribs and the buttock crease.

  • A high physical fitness level, and especially muscle endurance in the back muscles, is associated with lower risk of back pain[2]
  • A harmful misconception is that exercise should be avoided when LPB is present. Understandably, many patients are reluctant to exercise out of the fear that any exercises or stretching will aggravate their existing back pain. They may become reluctant to exercise and rely on medications.[3]
  • Physical activity (PA) to increase aerobic capacity and muscular strength, especially of the lumbar extensor muscles, is important for patients with chronic LBP in assisting them to complete activities of daily living.[4]

This article focuses on non specific chronic low back pain (NSCLBP) and its relations with fitness.

Fitness [edit | edit source]

Plank exercise, core activation

Physical fitness is a set of attributes that people have or achieve. Being physically fit has been defined as the ability to carry out daily tasks with vigour and alertness, without undue fatigue and with ample energy to enjoy leisure-time pursuits and meet unforeseen emergencies[5]

Being physically fit depends on how well a person fulfils each of the components of being healthy.When it comes to fitness, these components are[6]:

  1. Cardiorespiratory Endurance - VO2 max per Kg of body mass [7]  
  2. Muscular Endurance - Currently no Gold Standard measurement for muscular endurance
  3. Muscular Strength - There are a number of ways to measure muscular strength. The Biering-Sorenson Test. is an easy to perform test for back strength. Isokinetic Dynamometry is the gold standard re back strength but is very expensive. [8]
  4. Body Composition:- The current Gold Standard is a Four-Compartment model of measurements most commonly consisting of Mass, Total Body Volume, Total Body Water and Bone Mineral Content.[9]
  5. Flexibility - Optical Gold Standards such as the Vicon Motion Tracking System[10]

The following sections will look at each of these components individually, relating it to LBP.

Cardiorespiratory Endurance[edit | edit source]

Cardiovascualar endurance.jpg

Cardiorespiratory endurance indicates how well the body can supply fuel during physical activity via the body’s circulatory and respiratory systems.

Aerobic activities that help improve cardiorespiratory endurance are those that cause an elevated heart rate for a sustained period of time. eg swimming, brisk walking, jogging, cycling[6]

LPB relevance

  • Aerobic exercise increases the blood flow and nutrients to the soft tissues, including those in the back, hastening the the healing process.
  • Thirty minutes of aerobic exercise increases the body’s production of endorphins, a natural alternative for pain relief for the body. This helps with clients pain levels and may reduce reliance on medication for pain.
  • A low aerobic fitness level is associated with CLBP
  • Maximum oxygen consumption (VO2max) is found to be significantly lower by 10 mL/kg in men and by 5.6 mL/kg in women with CLBP compared to men/women without.[3]

Muscular Endurance [edit | edit source]

Biering-Sorenson Test

Fitness also includes muscular endurance, which is the ability of a muscle to continue exerting force without tiring.[6]

  • Patients with low back pain have reduced lumbar extensor muscular endurance in comparison with non-sufferers.[11] [12]See Biering-Sorenson Test.
  • Abdominal muscular endurance in low back pain sufferers is significantly decreased in contrast to those in the normal health population [13]
  • Lumbar fatigue as a result of low muscular endurance has been shown to reduce the person’s ability to sense the positioning of the lumbar spine. People with chronic LBP have impaired ability in controlling the position of the lumbar spine after a fatiguing task, leading to lumbar instability.[14]
  • Patients with lower back pain, have a higher percentage of fast type I glycolytic fibres compared to the slow oxidative fibres. Fast twitch fibers contract quickly but get tired quickly, rendering them less resistant to fatigue. This makes these people more susceptible to back injury. Non-LBP people have a much higher percentage of slow twitch fibers, which are best for endurance work, as they can carry out tasks without getting tired, and are present in core muscles.[15][6]

Strength and Low Back Pain[edit | edit source]

Back extensors at work.

The core is the group of trunk and hip muscles that surround the spine, abdominal viscera and hip. Core muscles are essential for proper load balance within the spine, pelvis, and kinetic chain. Core strengthening[16] has a strong theoretical basis in treatment and prevention of LBP, as well as other musculoskeletal afflictions. A reduction in core strength can lead to lumbar instability.[3] Muscle strengthening exercises form part of the NICE treatment guidelines for Early management of persistent non-specific low back pain.

The importance of the core relate to its function ie sparing the spine from excessive load and transfer force from the lower body to the upper body and vice versa.

  • Having a strong, stable core helps us to prevent injuries and allows us to perform at our best.
  • In order to protect the back, ideally we want to create 360 degrees of stiffness around the spine as we move, run, jump, throw, lift objects and transfer force throughout our body.
  • We do this when all of the muscles in our hips, torso and shoulders work together[17]
  • Exercises to activate the deep abdominal muscles including the superficial muscles, transversus abdominis muscle and the multifidus are important for CLBP patients[3].


Measures of Back Strength: For information here look at Physiotherapy Assessment section of Core Stability

Few of us will have access to a isokinetic machine to measure trunk strength, as shown in video below.

[18]

Body Composition  [edit | edit source]

Obesity can lead to altered body positions eg exaggerated lumbar lordosis

The body is composed of water, protein, minerals, and fat. A person can potentially maintain the same weight but radically change the ratio of each of the components that make up their body.

A two-component model of body composition divides the body into a fat component and fat-free component. Body fat (storage fat) in excess can increase susceptibility to chronic illness, health complications, and LBP. Numerous studies have been conducted highlighting the relationship between increased fat content and the likelihood/prevalence of lower back pain.

  • A study conducted in 2003 [19] found that there was a moderate positive relationship between obesity and lower back pain, however the results were based on the BMI calculation which does not definitively measure body fat content.
  • In a study conducted by Urquhart 2011 which took into account the amount of body storage fat[20] and it was evident that there was a relationship between obesity and lower back pain
  • An increase in body weight alters spinal biomechanics and loading, creating excess strain to be put through certain structures eg Obesity can lead to altered body positions such as exaggerated lumbar lordosis which will cause an alteration in spinal loading mechanics.

Flexibility[edit | edit source]

Flexibility refers to the range of movement across a joint.

Flexibility is important because it improves the ability of the kinetic chain to work smoothly and can help prevent injuries. It is specific to each joint and depends on a number of variables, including the tightness of ligaments and tendons.

Stretching

Relevance to CLBP

  • Stretching the soft tissues in the trunk and lower limb eg Back and thigh muscles and the regions ligaments and tendons. This can help to mobilize the spine, and improve the range of motion of the spine, decreasing back pain. Stretching exercises decrease the muscle stiffness as a result of changes in viscoelastic properties, due to the decreased actin-myosin cross-bridges and the reflex muscle inhibition.[3]
  • Improved range of motion assists in the spine and related areas improves the ability to complete ADLs eg lifting and bending which require trunk flexion, a complex interaction combining lumbar and hip motion[3]. Spasmodic or shortened back muscles adversely affect the complex spinal mechanics [21].
  • Tightness in the hip flexors and hamstrings can lead to a Lumbar hyperlordosis, predisposing patients to lumbar facet syndrome[22]

Exercises to Decrease Low Back Pain[edit | edit source]

It has been showed by numerous studies that exercise therapy decrease low back pain and improve overall functional mobility. Here are some methods which help to decrease low back pain.

Aerobic exercise[edit | edit source]

Aerobic exercise increases the blood flow and nutrients to the soft tissues, including those in the back, hastening the healing process. low impact exercise elevates the heart rate without worsening the back pain.

  • Exercise like walking or cycling help to improve circulation, strengthen the muscle of legs and back, reducing the stiffness and pain in the back.
  • swimming is another great aerobic exercise that improve cardiovascular endurance, a full body workout which improve flexibility and muscular endurance.

Stretching and Strengthen Exercise[edit | edit source]

postural exercises have improved pain control and improve functional mobility on low back patient.

  1. Knee to Chest Stretch
  2. Bridges Exercise
  3. Cat and Cow Stretch
  4. Seated Lower Back Rotational Stretch
  5. lumbar rotation

In acute low‐back pain, exercise therapy is as effective as either no treatment or other conservative treatments.[23]

Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low‐back pain, particularly in healthcare populations.[23]

Conclusions[edit | edit source]

Importance of Fitness

A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain concluded thus:

A general exercise programme that combines muscular strength, flexibility and aerobic fitness is beneficial for rehabilitation of non-specific chronic low back pain. Increasing core muscular strength can assist in supporting the lumbar spine. Improving the flexibility of the muscle-tendons and ligaments in the back increases the range of motion and assists with the patient’s functional movement. Aerobic exercise increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that can result in back pain.[3]

And remember the important message is that embarking on any regular exercise will be of benefit to an overall person’s health including reducing back pain. With exercise they will look and feel better.[6]

References[edit | edit source]

  1. ↑ Palmer KT, Walsh K, et al. Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years BMJ 2000
  2. ↑ E spine Exercise and Fitness to Help Your Back Available:https://www.spine-health.com/wellness/exercise/exercise-and-fitness-help-your-back (accessed 1.2.2022)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Andersen LB, Wedderkopp N, Leboeuf-Yde C. Association between back pain and physical fitness in adolescents. Spine. 2006 Jul 1;31(15):1740-4.Available: https://pubmed.ncbi.nlm.nih.gov/16816772/ (accessed 1.2.2022)
  4. ↑ Gordon R, Bloxham S. A systematic review of the effects of exercise and physical activity on non-specific chronic low back pain. InHealthcare 2016 Jun (Vol. 4, No. 2, p. 22). Multidisciplinary Digital Publishing Institute.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934575/ (accessed 21.2.2022)
  5. ↑ President's Council on Physical Fitness and Sports: Physical Fitness Research Digest. Series 1,No.1, Washington DC,1971.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Medical news today What does being physically fit mean? Available:https://www.medicalnewstoday.com/articles/7181 (accessed 2.2.2022)
  7. ↑ Mota, Jorge, et al. "Association of maturation, sex, and body fat in cardiorespiratory fitness." American Journal of Human Biology 14.6 (2002): 707-712.
  8. ↑ Stark, Timothy, et al. "Hand-held dynamometry correlation with the gold standard isokinetic dynamometry: a systematic review." PM&R 3.5 (2011): 472-479.
  9. ↑ Wilson, J. P., Mulligan, K., Fan, B., Sherman, J. L., Murphy, E. J., Tai, V. W., ... & Shepherd, J. A. (2012). Dual-energy X-ray absorptiometry–based body volume measurement for 4-compartment body composition. The American journal of clinical nutrition, 95(1), 25-31.
  10. ↑ Mohamed, Abeer A., et al. "Comparison of Strain-Gage and Fiber-Optic Goniometry for Measuring Knee Kinematics During Activities of Daily Living and Exercise." Journal of biomechanical engineering 134.8 (2012).
  11. ↑ Andersen, J. S. (2007). Physical fitness and low back pain: Performance-based and self-assessed physical fitness as risk indicator of low back pain among health care workers and students. Det Nationale Forskningscenter for Arbejdsmiljø; Københavns universitet. Det Sundhedsvidenskabelige fakultet.
  12. ↑ Biering-Sorenson, F. (1984). Physical measurements as risk indicators for low back trouble over a one-year period. Spine, 9, 106-119.
  13. ↑ Foster, D. N. & Fulton, M. N. (1991). Back pain and the exercise prescription. Clinics in Sports Medicine, 10, 187-209.
  14. ↑ Taimela, S., Kankaanpää, M., & Luoto, S. (1999). The effect of lumbar fatigue on the ability to sense a change in lumbar position: a controlled study. Spine, 24(13), 1322.fckLRChicago (lumbar positioning)
  15. ↑ Mannion, A. F., Weber, B. R., Dvorak, J., Grob, D., & Müntener, M. (1997). Fibre type characteristics of the lumbar paraspinal muscles in normal healthy subjects and in patients with low back pain. Journal of Orthopaedic Research, 15(6), 881-887.
  16. ↑ Park HS, Park SW, Oh JK. Effect of adding abdominal bracing to spinal stabilization exercise on lumbar lordosis angle, extensor strength, pain, and function in patients with non-specific chronic low back pain: A prospective randomized pilot study. Medicine. 2023 Oct 13;102(41):e35476.
  17. ↑ Physiopedia Core Stability Available:https://www.physio-pedia.com/index.php?title=Core_Stability&utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal (accessed 1.2.2022)
  18. ↑ Isokinetic System Con-Trex. 08 Isokinetic measurement trunk on Con-Trex TP trunk module.mov. Available from: http://www.youtube.com/watch?v=xEhLr5y0wBE [last accessed 29/11/15]
  19. ↑ Bener, A., Alwash, R., Gaber, T. and Lovasz,G. 2003. Obesity and Low Back Pain. Coll. Antropol. 27 (2003) 1: 95–104
  20. ↑ Urquhart, D.M. 2011, Higher Body Fat Linked to Increased Back Pain. Spine 9/1/2011 Edition. Lippincott Williams and Wilkins, Philadelphia
  21. ↑ Farfan, H. F. (1975). Muscular mechanism of the lumbar spine and the position of power and efficacy. Orthopaedic Clinics of North American, 6, 135-144.
  22. ↑ Swedan, N. (2001) Women's Sports Medicine and Rehabilitation, Lippincott Williams & Wilkins, UK.
  23. ↑ 23.0 23.1 Hayden J, Van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non‐specific low back pain. Cochrane database of systematic reviews. 2005(3).


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