Lower back pain: The low-load to high-load stabilizing exercise treatment revolution.

The University of QLD developed an approach to treating lower back pain with low-load stabilizing exercises. Despite the documented efficacy of their approach, it has not completely “caught on” in the health and fitness industry, where less effective high-load exercises still predominate. This article oultlines just what a major problem lower back pain is and the development of the low-load stabilizing exercise approach from the less effective higher-load approaches.

Lower back pain (LBP) is common.  Approximately 80% of people will suffer LBP in their lifetime (Freberger, 2009).  While 90% of LBP gets better in two to four weeks the incidence of recurrent episodes of LBP is high.  Hides, Richardson, & Jull. (1996) reported that 60 to 80% of people experiencing back pain for the first time will suffer a recurrence within a year.

Traditionally the medical approach to LBP was rest, advice on avoiding aggravating activities, pain relieving medication, or surgery, but not specific exercises (Allan and Wadell, 1989, Wadell, 1996).  This began to change in the 1970s at a hospital near Stockholm, where a Swedish psychotherapist developed an approach to treating LBP called the Swedish Back School, which included exercises (Gupta et al., 2010).  In the 1980s the Swedish Back School, or variations of it, was adopted in many centres around the world (Gupta et al., 2010).  The exercises comprised spinal flexion exercises (variations of sit-ups or curl-ups), spinal extension exercises (variations of bending backwards while lying face down on the floor), and high-load stability exercises (keeping the spine in a neutral position while loading it with limb movements, fit-ball exercises, and unstable surfaces) (Robinson, 1992; Saal, 1992).  Each of these exercises can be considered to be high load because they require the use of the big muscles in the trunk.  The efficacy of this high load trunk exercise approach for LBP is questionable and remains controversial (Nordin et al., 2006; Heymans  et al., 2005; Jolanda et al., 1992).  Despite their questionable efficacy, these high load types of exercises were also prescribed for LBP by physiotherapists in Australia (Key, 2000) and overseas (Jackson, Mark, & Brown, 1983)

By comparison physiotherapists at University of Queensland developed a different approach that is effective as determined by clinical trials (Hides, Jull, and Richardson, 2001; O’Sullivan, Twomey, and Allison, 1997).  In the 1990s research physiotherapists from University of Queensland noted that certain muscles were inhibited in LBP sufferers and did not start working again even when someone’s pain improved (Hides et al., 1994; Hides, Richardson, and Jull, 1996).  These muscles were the small deep muscles that stabilized individual spinal, pelvic, and hip joints.  They found the large superficial trunk “mobilizing” muscles were not inhibited.  Indeed they found that LBP sufferers often have overly developed and tight lower back and stomach muscles (Lee, 2006).  They also noted that the high load exercises commonly prescribed at the time, for example in the Swedish Back School, did not help to get the small deep stabilizing muscles working again (Lee, 2006).  The over-activity of the large trunk muscles frequently causes excessive back stiffness and increased pain (Lee, 2006).

The University of Queensland researchers used a technology called real-time ultrasound to investigate how to get the inhibited deep small stabilizing muscles working again in LBP sufferers.  They found that before moving the spine or placing it under any load, LBP sufferers needed to be taught how to recruit their deep stabilizing muscles using appropriate verbal cues and a great deal of concentration.  Only when these small stabilizing muscles could be successfully activated could their strength and endurance be developed with the application of low loads to the spine with small limb movements.   Any premature progression to higher load exercises risked losing the ability to maintain the activity of the deep stabilizing muscles (Lee, 2006).  Higher load stability exercises and functional movements, such as lifting technique exercises, could only be successfully introduced once a person had learned to activate and develop the endurance of the deep stabilizing muscles.

Clinical trials have shown that this approach is effective in relieving lower back pain in the short term and long term (Hides, Richardson, and Jull, 1996).  Study participants suffered less from subsequent episodes of LBP at follow up six years after the study was initiated (Hides, Jull, and Richardson, 2001).

This approach has been taught to University of Queensland physiotherapy students for over a decade and I am aware of attempts to teach it to personal trainers in the health and fitness industry.  Despite the documented efficacy of the approach, in my experience it has not completely caught on in the wider health and fitness community, where high-load trunk exercises including fit-ball exercises predominate.  I think the reason for this lies in the subtlety of the low-load approach.  From the perspective of an onlooker the low-load stability exercises don’t look like much exercise is being performed at all, much less like exercises normally performed in a gym.  Furthermore, the deep stabilizing muscles don’t give the body much feedback.  It can be challenging to tell whether these small muscles are working or not.  This is in contrast with the large muscles of the trunk, which can be felt just under the skin.  Most people can easily tell if these large muscles are working or not.

Many personal trainers may not receive the detailed anatomical training required to understand the theory behind the low-load approach.  Nor is the training given to personal trainers specifically oriented towards an understanding of the needs of clients with pain or injury.  Even physiotherapists recently graduated from the University of Queensland might not really understand the value of this approach.  This may be particularly true for some of the younger recent graduates who never experienced LBP themselves.  They would never have had the chance to determine the effectiveness of these exercises first hand on their own bodies.

I have experienced nagging and somewhat debilitating LBP and felt for myself the efficacy of the low-load stabilizing exercise approach.  Before being taught this approach and before I trained as a physiotherapist, I tried many types of therapy including manual therapy from osteopaths and physiotherapists, massage therapy, and high-load stability exercises.  Each provided comparatively short term relief that did not accumulate to substantial improvement.  In contrast after about ten days of performing the low-load stability exercises I noticed marked improvement in terms of pain and function.  Ten years later I continue to do these low-load stability exercises daily and before any high-load exercise.   I can personally vouch for their efficacy.

 

References:

Allan DB, Waddell G (1989) An historical perspective on low back pain and disability. Acta Orthop Scand Suppl 234: 1-23

Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS (2009) The rising prevalence of chronic low back pain. Arch Intern Med. 169(3):251-258.

Gupta R, Kalsotra N, Kamal Y, Motten TL, Gupta RK, Singh D: Relevance Of Back School Therapy In Conservative Management Of Low Back Pain (2010) The Internet Journal of Spine Surgery.  5 (1). DOI: 10.5580/43e

Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes BW (2005) Back schoos for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 30(19):2153-63

Hides JA, Jull GA, Richardson CA (2001) Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 26(11):E243–8.

Hides JA, Richardson CA, Jull GA (1996) Multifidus muscle rehabilitation decreases recurrence of symptoms following first episode low back pain. In:Proceedingsof the National Congress of the Australian Physiotherapy Association.  Brisbane

Hides JA, Richardson CA, Jull GA (1996)  Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine 21(23):2763–9.

Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH (1994) Evidence of lumbar multifidusmuscle wasting ipsilateral to symptoms in patients with acute/subacute lowback pain. Spine 19(2):165–72.

Jackson CP, Mark D, Brown MD (1983) Analysis of current approaches and a practical guide to prescription of exercise. Clinical Orthopaedics and Related Research 179: 46-54

Jolanda F. E. M. Keijsers, Lex M. Bouter, Ree M. Meertens andGerjo J K (1992) The efficacy of the back school for patients with non-specific low back pain: An overview. Physiotherapy Theory and Practice 8, 85 88

Key S (2000) Back Sufferers’ Bible. Allen & Unwin, St Leonards NSW, Australia

Nordin M, Balague F,Cedraschi C (2006) Non-specific lower-back pain: Surgical versus nonsurgical approaches.  Clinical Orthopaedics and Related Research 443: 156-167.

Lee LJ (2006) Is it possible to be too stable? Orthopaedic Division Review, an official publication of the Orthopaedic Division of the Canadian Physiotherapy Association. Nov/Dec :19-23

O’Sullivan PB,Twomey LT, Alison GT (1997) Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiological diagnosis of sponylolysis of spondylolisthesis. Spine 22: 2959-2967

Robinson R (1992) The new back school prescription: stabilization training part 1. Occupational Medicine 7(1): 17-31

Saal JA (1992) The new back school prescription: stabilization training part 2. Occupational Medicine 7(1): 33-42

Wadell G (1996) Low back pain: a twentieth century health care enigma. Spine 21(24): 2820-2825

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