Fitness and Low Back Pain: Difference between revisions

No edit summary
(REVIEW , AND UP-TO-DATE REFERENCE)
 
(12 intermediate revisions by 4 users not shown)
Line 5: Line 5:
== Introduction  ==
== Introduction  ==


[[Image:Back pain image.jpg|right|200px]][[Low Back Pain|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>. Low back pain refers to  pain between the bottom of the ribs and the buttock crease.
[[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.


* A high physical fitness level, and especially muscle endurance in the 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 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 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.<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>
* 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 (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 [[ADLs|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>
* [[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.
This article focuses on non specific chronic low back pain (NSCLBP) and its relations with fitness.


== Fitness&nbsp; ==
== 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>
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>


The five components of physical fitness and the Gold Standards for measuring are:
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;
# 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 measurment for muscular endurance
# Muscular [[Endurance Exercise|Endurance]] - Currently no Gold Standard measurement for muscular endurance
# 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]
# 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>
# [[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><br>
# [[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.
 
=== Cardiorespiratory Endurance  ===
=== Cardiorespiratory Endurance  ===
[[Image:Cardiovascualar endurance.jpg|500x350px|right]]Aerobic exercise stimulated the cardiovascular system. Aerobic exercise can benefit CLBP as it increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that results in back pain. 30–40 min of aerobic exercise increases the body’s production of endorphins. Increasing the body’s endorphin production is a natural alternative for pain relief for the body and can reduce CLBP. Rehabilitation involving aerobic exercise are a conservative method for reducing CLBP, and could prevent patients relying on medication for pain reduction.
[[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.
 
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" />
 
LPB relevance
 
* 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.


* A low aerobic fitness level is associated with CLBP  
* 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. 
* 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" />
 
<span style="line-height: 1.5em;">Smokers have a higher rates of CLBP due in part to a decreased in arterial oxygen to the core muscles, leading to muscle fatigue and pain.<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>  
=== Muscular Endurance&nbsp;  ===
=== Muscular Endurance&nbsp;  ===
[[Image:Sorrenson.jpg|500x350px|alt=|thumb|Biering-Sorenson Test]]
[[Image:Sorrenson.jpg|500x350px|alt=|thumb|Biering-Sorenson Test]]


Muscular Endurance is the ability of the muscle to exert a submaximal force repeatedly over a sustained period of time.   
Fitness also includes muscular endurance, which is the ability of a muscle to continue exerting force without tiring.<ref name=":1" />  


* Patients with low back pain have reduced 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.]]
* 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 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>
* [[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 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>
* 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>
* Physiologically in patients with lower back pain, it has been shown they have a higher percentage of [[Muscle Fibre Types|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 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>  
* 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" />


== Strength and Low Back Pain ==
== Strength and Low Back Pain ==
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|Core strengthening]] 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.
[[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.


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.
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.
Line 46: Line 55:
* 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.
* 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>
* 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 muscle and the multifidus are important for CLBP patients<ref name=":0" />.  
* 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" />.
 


=== <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 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.  
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.
{| width="100%" cellspacing="1" cellpadding="1"
|-
|{{#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>
|}
 
==<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. 
 
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.  


* 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.
* 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
* 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.


It is the common belief that 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 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]]
=== Flexibility  ===
Relevance to CLBP 
Stretching the soft tissues in the back, legs and buttock eg hamstrings, erector muscles and hip flexor muscles, ligaments and tendons can help to mobilise the spine, and improve the range of motion of the spine, decreasing back pain.   
 
* 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>


An improved range of motion assists with ability to complete activities of daily living 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>.
== 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.


* 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.<ref name=":0" />
==== Aerobic exercise ====
* Tightness in the hip flexors and hamstrings can lead to a [[Low Back Pain Related to Hyperlordosis|Lumbar hyperlordosis]], predisposing patients to lumbar facet sydnrome<ref>Swedan, N. (2001) Women's Sports Medicine and Rehabilitation, Lippincott Williams &amp; Wilkins, UK.</ref>
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.


.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.<br><br> <br> <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}}
* Exercise like walking or cycling help to improve circulation, strengthen the muscle of legs and back, reducing the stiffness and pain in the back.
== Measures of Back Strength  ==


[[Image:Strength image.jpg|right|300px]]
* swimming is another great aerobic exercise that improve cardiovascular endurance, a full body workout which improve flexibility and muscular endurance.  


There are a variety of measures targeted at assessing muscular strength e.g. one rep max, isokinetic dynamometry, manual muscle testing etc.  
==== Stretching and Strengthen Exercise ====
postural exercises have improved pain control and improve functional mobility on low back patient.


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 the 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> )<br>
# Knee to Chest Stretch
{| width="100%" cellspacing="1" cellpadding="1"
# Bridges Exercise
|-
# Cat and Cow Stretch
| {{#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>
# Seated Lower Back Rotational Stretch
|}
# lumbar rotation


== Evidence Review  ==
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>


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 summarised 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 sports 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">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> 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;
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" />
[[File:Critique_table.jpg|center]]


==   Clinical Relevance  ==
== 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:


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.
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" />
== Bottom Line  ==


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.  
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" />


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.
== References  ==
== References  ==


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, Wanda van Niekerk, 127.0.0.1, WikiSysop, Shaimaa Eldib, Aminat Abolade, Fahad Bin Aftab and Admin

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).


Retrieved from "https://www.physio-pedia.com/index.php?title=Fitness_and_Low_Back_Pain&oldid=348550"