Tuesday, 4 December 2018

Chapter 93 - Low Back Pain Exercises

Integrative Medicine (Fourth Edition) 2018, Pages 901-907.e1 Author links open overlay panelBrianDegenhardtDOColeenSmithDO Available online 28 April 2017. Get rights and content The management of patients who seek treatment for low back pain can be difficult for any practitioner. The cause of low back pain can be the skin, soft tissue, or skeletal components. Low back pain can be referred from other sources, even visceral structures, or it can be secondary to postural decompensation. History and physical findings should guide the practitioner to further evaluation and a treatment plan. Multidisciplinary treatment approaches are often necessary to facilitate healing for the patient with low back pain. Understanding of the patient’s belief system about his or her low back pain may be an important component of recovery.1 A treatment plan may include an exercise prescription. Movement, strengthening, and flexibility in patients with chronic lumbar back pain has demonstrated benefit.2 The traditional exercise prescription is a written description of the exercise, including the number of repetitions per set, number of sets per session, and frequency of sessions. This format is specific for strength exercises and has been applied to flexibility exercises. Many traditional exercise routines are assigned and performed too literally, without recognition of the subtle changes the patient experiences day to day in a healing exercise program. The goal of any complementary exercise recommendation is to encourage a dynamic interchange between the patient’s awareness and the body. With appropriate education, the patient can become more sensitive to information being generated from the body and perform the exercise program in a much more precise, safe, and effective manner. Attention to the body’s feedback mechanisms should be encouraged to allow the patient to modify any portion of the exercise prescription. This enables the patient to achieve optimal outcomes from the rehabilitation program. The outcomes of an exercise plan are to enhance flexibility, to minimize or to eliminate pain by reducing muscle tension, and to improve strength, thereby encouraging joint stability. A complementary exercise plan for a person with lumbar back pain should include the following approaches: • Breathing and relaxation training • Flexibility training • Strength training • Coordination training The National Institute of Health and Clinical Excellence (NICE) has reviewed the evidence of therapies that have been found to be most useful for low back pain. Of all therapies used for low back pain, the evidence for benefit with least harm supported an exercise program, manual therapy, and acupuncture.3 The Patient Handout at the end of this chapter contains examples of the exercises and approaches discussed here. Breathing and Relaxation Training Flexibility and relaxation techniques are often great starting points in a patient’s exercise prescription. They calm the patient and foster awareness of information from the body that helps guide and individualize the exercise prescription. These exercises enhance diaphragmatic function and improve oxygenation, lymphatic flow, and autonomic nervous system regulation. To begin this component of the exercise prescription, the patient should choose a comfortable position and minimize distraction, perhaps by listening to soothing background music. The patient must use the abdominal diaphragm while taking a slow, deep breath and both the diaphragm and the rib cage as inspiration continues (see Chapter 92, Breathing Exercises). The number of repetitions is likely to vary from day to day because stress and tightness also change daily. The patient needs to learn to recognize when the body is relaxed and ready to move on to other components of the exercise prescription. Once relaxation and focus have been obtained, participants should use deep breathing throughout all cycles of the exercise plan. Flexibility Training The flexibility portion of an exercise plan uses stretching to promote greater range of motion in all planes. Properly performed, stretching allows better neuromusculoskeletal function, promoting less pain and more motion. To stretch properly, the patient must move to the point of tension and then perform deep breaths to gently stretch the tight tissue. It is important to move slowly and gently in and out of stretches. Other models describe how to stretch, but this approach minimizes the chance of exacerbating a patient’s back pain by overstretching. Although an outline of a stretch gives the patient a guide to promote flexibility of specific areas of the body, the patient listens each day to the information the body is generating to determine where the tightness is. This approach allows the patient to modify a stretch and to maximize its effectiveness each day. The stretch is considered complete only after the patient appreciates a change in the tension while holding the stretch. This change can occur after only one or two repetitions, or it may need more repetitions, as determined by the patient through attention to the body’s feedback system. Patients must stay within their pain limitations to prevent reflex muscle tightening and injury. In most patients with chronic low back pain, specific instruction is necessary for hip flexors and extensors. For recovery from muscle tightness and to decrease pain, it is also important to achieve greater flexibility as well as a balance of flexibility between the same muscles on the two sides of the body and between reciprocal muscles, particularly with the hamstring, iliopsoas, and piriformis muscles. Strength Training Strengthening exercises encourage active use of muscle groups, leading to better muscle tone and greater strength. It is important not to sacrifice flexibility for strength; the two are equally important for proper lumbar mechanics in patients with low back pain. The clinician can evaluate the patient’s strength clinically by having the patient perform isometric contractions against the physician’s resistance to determine whether there is gross asymmetry of strength. Asymmetry of strength may lead to or be secondary to hypertonicity in one muscle group and weakness in the opposing muscle groups. Once strength asymmetry or weakness has been diagnosed, specific instructions must be given first to stretch the hypertonic muscles and then to motivate the patient to exercise the weakened muscles. Patients are often unaware of this local muscle weakness. In many exercise programs, patients focus on rote repetition of exercises, strengthening hypertonic muscles rather than conditioning weakened muscle groups. It can be beneficial for the patient with hypertonic lumbar extensors to perform abdominal curl-ups to strengthen weakened antagonistic abdominal muscles after stretching the lumbar erector spinae muscles. Both exercises decrease hypertonicity in the lumbar extensor muscle group. In many cases of lumbar back pain, strengthening activities must start out as isometric exercises instead of the typical isotonic exercises because isometric exercises are safer. Isometric exercises allow the origin and insertion of the involved muscle to remain in constant position while the patient presses against a resisting force that is equal to the patient’s force. An example of an isometric exercise is pushing against a solid wall without moving. Isometric exercises are often useful for patients who have arthritis, in which joint movement causes pain and limitation. Coordination Training Differences in proprioception exist in individuals with and without back pain. Coordination training in patients with low back pain is based on the observation that the response of a patient’s spine to stress causes the postural muscles to tighten and the antagonist muscles to react with inhibition, weakness, and atrophy.4 Coordination training is imperative for improvement of overall postural balance in the patient with lumbar back pain. Proprioceptive education in patients with low back pain begins with improving ankle, knee, and pelvis coordination, perhaps through the use of a wobble board or fitness ball. The physician must remind the patient of safety precautions at the start of coordination training. Basic coordination exercises can usually be taught in the office and then performed by the patient independently. Advanced proprioceptive training usually requires supervision to ensure correct technique and safety. Key Web Resources The Egoscue technique addresses strengthening and balancing of the whole body unit to reduce back pain. A book that includes back stretching exercises from this method is Escogue P, Gitnes R: Pain Free: A Revolutionary Method for Stopping Chronic Pain. New York: Bantam Books; 2000. Video on how Feldenkrais therapy can be used for low back pain from the University of Wisconsin Integrative Medicine Program. Download full-size image Download full-size image Download full-size image Download full-size image Download full-size image References 1 M. Pfingsten, J. Hildebrandt, E. Leibing Effectiveness of a multimodal treatment program for chronic low-back pain Pain, 73 (1997), pp. 77-85 ArticleDownload PDFCrossRefView Record in ScopusGoogle Scholar 2 M. van Tulder, A. Malmivaara, R. Esmail, B. Koes Exercise therapy of low back pain: a systematic review within the framework of the Cochrane collaboration back review group Spine, 25 (2000), pp. 2784-2796 CrossRefView Record in ScopusGoogle Scholar 3 P. Savigny, P. Watson Underwood MGuideline Development Group. Early management of persistent non-specific low back pain: summary of NICE guidance BMJ, 338 (2009), p. b1805 CrossRefView Record in ScopusGoogle Scholar 4 M.L. Pollock, J.H. Wilmore Exercise in Health and Disease (ed 2), Saunders, Philadelphia (1990) Google Scholar Copyright © 2018 Elsevier Inc. All rights reserved.