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Rehabilitation for Low Back Pain

Original Editor - Wanda van Niekerk based on the course by Richard Jackson

Top Contributors - Wanda van Niekerk and Jess Bell  

Introduction

Low back pain is one of the most common musculoskeletal conditions[1] with an estimated global prevalence of 568 million people.[2] In many countries (160 out of 204 studied), it is the leading reason people seek rehabilitation. It is also the main reason for adults to leave the workforce early.[2] It is projected that the number of people with low back will continue to increase, particularly in low-and middle-income countries.[2]

Exercise and Education

Exercise as an Intervention in People with Acute and Chronic Low Back Pain

Table 1 summarises recent clinical practical guidelines[3] on exercise in people with acute and chronic low back pain.

Table 1. Summary of clinical practice guidelines on exercise in people with acute and chronic low back pain[3]
Patients Exercise
Patients with acute low back pain Exercise training interventions, including specific trunk muscle activation can be used
Patients with acute low back pain with leg pain Exercise training interventions, including trunk muscle strengthening, endurance and specific trunk muscle activation may be used
Patients with chronic low back pain Exercise training interventions should be used. These include: trunk muscle strengthening and endurance, multimodal exercise interventions, specific trunk muscle activation exercises, aerobic exercise, aquatic exercise and general exercise. Movement control exercise or trunk mobility exercise may be provided
Patients with chronic low back pain with leg pain Exercise training interventions which include specific trunk muscle activation and movement control may be used
Patients with chronic low back pain with movement control impairment Specific trunk muscle activation and movement control exercises should be provided
Older patients with chronic low back pain General exercise training should be used to reduce pain and disability

Patient Education as an Intervention in People with Acute and Chronic Low Back Pain

Clinical practice guidelines recommend the following[3]:

  • in patients with acute low back pain, active education strategies (e.g. one-on-one education on biopsychosocial contributors to pain; self-management strategies such as staying active, pacing strategies and back protection techniques) are recommended rather than passive strategies (e.g. providing access to educational materials only)
  • in patients with chronic low back pain, standard education and advice strategies, such as advice related to exercise and remaining active may be used, but not as a stand-alone treatment; pain neuroscience education (PNE) should be provided alongside other physical therapy interventions for patients

If you would like to read more about acute and chronic low back pain, please see Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021.

Classification Strategies for Low Back Pain

Various classification / stratification systems have been published to help clinicians choose an appropriate intervention. Examples of classification systems include[4]:

  • treatment-based classification
  • mechanical diagnosis and therapy
  • cognitive functional therapy
  • movement system impairment

Clinical practice guidelines recommend the following in relation to classification systems for low back pain[3]:

  • in patients with acute low back pain:
    • treatment-based classification (TBC) may be used to reduce pain and disability (moderate evidence)
    • mechanical diagnosis and therapy (MDT) system can be used (weak evidence)
  • in patients with chronic low back pain, the following systems may be used (moderate evidence):
    • mechanical diagnosis and therapy
    • prognostic risk stratification
    • pathoanatomic-based classification
  • there is weak evidence for the use of the following systems to reduce pain and disability in patients with chronic low back pain:
    • treatment-based classification
    • cognitive functional therapy
    • movement system impairment

These classifications are discussed in more detail here:

Biomechanics and Anatomy of the Lumbar Spine

Moments:

  • moment = the magnitude of force required to overcome an external load
  • moment arm = the distance an applied force is from a muscle
  • the moment arm determines the magnitude of force a muscle must generate

Spinal moments:

  • a spinal moment is the product of the load and its perpendicular distance to the spine
  • the further the force from the spine, the greater the contraction of the spinal extensors (hence the idea to "keep loads as close to the body as possible"[5])

If you would like a recap on functional anatomy of the lumbar spine and abdominal wall, please read here.

Spinal Rehabilitation

Richard Jackson advocates for clinicians to follow these steps when rehabilitating people with low back pain[5]:

  1. Recruit muscles
  2. Control spinal movement with recruited muscles
  3. Functional activities
  4. Endurance
  5. Strength

Low Back Injuries and Motor Changes

  • Patients with low back pain can have deficits in their motor control systems[6]
  • The presence of pain can prevent the re-establishment of "healthy" motor patterns[5]
  • Inappropriate motor patterns can also cause injury, "therefore, perturbed motor control systems both cause, and are a consequence of, injury"[5]

If you'd like, you can read this clinical commentary: Motor control changes in low back pain: divergence in presentations and mechanisms.[7]

You can also read more about motor control changes and pain here, if you are interested.

Clinical Guidelines

Richard Jackson suggests the following approach[5]:

  • consider the postural and functional causes of persistent pain
    • a recent study investigating the relationship between movement, posture and low back pain in individuals with non-specific low back pain reported the following[8]:
      • multidimensional factors contribute to low back pain and these factors vary between individuals[9]
      • clinicians, the public and researchers believe that movement and posture is important to investigate[10]
      • individuals with low back move their back slower, have less range of motion and more tensed back muscles ('protective' of their back)
      • other reviews have also reported that "improvements in low back pain are less related to changes in movement or posture than what we currently believe",[8] but there are limitations in how these investigations were done
      • changes to individually relevant movements and postures are often (but not always) related to improvements in pain and activity limitation
      • in cases where there was a positive relationship, movement and posture appeared to return to less protective levels
      • movements and posture vary from person to person and this highlights the importance of an individualised, person-centered management approach
  • match current capabilities of the patient with their training programme
  • train initially for:
    • motor control[11]
    • endurance
    • strength
    • maintenance of spinal stability for all tasks in all postures under varying loads[9]
  • integration of prevention and rehabilitation
    • remove the aggravation
  • establish slow, continuous improvement in function and pain reduction
    • rehabilitation is cyclical
  • establish positive slope
  • when new activity aggravates symptoms, return to basics
    • core and "big three": McGill curl-up, side bridge and bird-dog[12][13]
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[14]

  • low back exercises are most beneficial when done daily
  • add walking to the routine
  • avoid bending early in the morning
  • endurance is primary, strength is secondary through phase 3
  • be patient, don't rush, master each phase

If you'd like, you read can more here: Designing Back Exercise: from Rehabilitation to Enhancing Performance.[15]

References

  1. ↑ Zaina F, Cote P, Cancelliere C, Di Felice F, Donzelli S, Rauch A, Verville L, Negrini S, Nordin M. A systematic review of clinical practice guidelines for persons with non-specific low back pain with and without radiculopathy: identification of best evidence for rehabilitation to develop the WHO's package of interventions for rehabilitation. Archives of physical medicine and rehabilitation. 2023 Nov 1;104(11):1913-27.
  2. ↑ 2.0 2.1 2.2 Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020 Dec 19;396(10267):2006-17.
  3. ↑ 3.0 3.1 3.2 3.3 George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA, Gilliam JR, Hendren S, Norman KS, Beattie PF, Bishop MD. Interventions for the management of acute and chronic low back pain: revision 2021: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of orthopaedic physical therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2021 Nov;51(11):CPG1-60.
  4. ↑ Bastos RM, Moya CR, de Vasconcelos RA, Costa LO. Treatment-based classification for low back pain: systematic review with meta-analysis. Journal of Manual & Manipulative Therapy. 2022 Jul 4;30(4):207-27.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Jackson R. Rehabilitation for Low Back Pain Course. Plus. 2024.
  6. ↑ Abdelaty EM, Shendy S, Lotfy O, Hassan KA. The difference in multifidus muscle morphology and motor control in non‐specific low back pain with clinical lumbar instability and healthy subjects: A case‐control study. Physiotherapy Research International. 2024 Jan;29(1):e2047.
  7. ↑ Van Dieën JH, Reeves NP, Kawchuk G, Van Dillen LR, Hodges PW. Motor control changes in low back pain: divergence in presentations and mechanisms. Journal of Orthopaedic & Sports Physical Therapy. 2019 Jun;49(6):370-9.
  8. ↑ 8.0 8.1 Wernli K, O'Sullivan P, Smith A, Campbell A, Kent P. Movement, posture and low back pain. How do they relate? A replicated single‐case design in 12 people with persistent, disabling low back pain. European Journal of Pain. 2020 Oct;24(9):1831-49.
  9. ↑ 9.0 9.1 Frizziero A, Pellizzon G, Vittadini F, Bigliardi D, Costantino C. Efficacy of core stability in non-specific chronic low back pain. Journal of functional morphology and kinesiology. 2021 Apr 22;6(2):37.
  10. ↑ van Dijk MJ, Smorenburg NT, Heerkens YF, Mollema J, Kiers H, Nijhuis-van der Sanden MW, Visser B. Assessment instruments of movement quality in patients with non-specific low back pain: A systematic review and selection of instruments. Gait & Posture. 2020 Feb 1;76:346-57.
  11. ↑ Niederer D, Mueller J. Sustainability effects of motor control stabilisation exercises on pain and function in chronic nonspecific low back pain patients: A systematic review with meta-analysis and meta-regression. PloS one. 2020 Jan 15;15(1):e0227423.
  12. ↑ Nwodo OD, Ibikunle PO, Ogbonna NL, Ani KU, Okonkwo AC, Eze CJ, Onwudiwe CU, Ezeja GU, Maduanusi IA. Review of core stability exercise versus conventional exercise in the management of chronic low back pain. African Health Sciences. 2022 Dec 22;22(4):148-67.
  13. ↑ Ghorbanpour A, Azghani MR, Taghipour M, Salahzadeh Z, Ghaderi F, Oskouei AE. Effects of McGill stabilization exercises and conventional physiotherapy on pain, functional disability and active back range of motion in patients with chronic non-specific low back pain. Journal of physical therapy science. 2018;30(4):481-5.
  14. ↑ Squat University.The 3 Best Core Exercises [Do These Every Day]. Available from: https://www.youtube.com/watch?v=2_e4I-brfqs [last accessed 26/08/2024]
  15. ↑ McGill S. Designing Back Exercise: from Rehabilitation to Enhancing Performance (2012).
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