Programme design for low back pain
Course Lead for Exercise Management of Low Back Pain
Any programme of exercise for the client with low back pain (LBP) should have an emphasis on education, rehabilitation, and continued management. The use of ‘active rehabilitation’ or so called ‘reactivation’ is strongly advocated and serves as a useful model for the exercise
professional; within this approach there should be an emphasis on patient/client
responsibility and on-going self-management.
Why is self-management of LBP important?
If health and fitness professionals are to appreciate how chronic pain and disability develops
they will be better placed to play an active role in the prevention and management
of low back pain. Key to this is understanding the distinction between a biomedical and a
The traditional biomedical model makes the assumption that an individual’s symptoms must result from a specific disease state or tissue dysfunction; a diagnosis is based on objective testing of physical damage and impairment.
Once the pathology is identified treatment is targeted at correcting the dysfunction with the expectation that function will be restored and disability resolved.
Many experts argue that the traditional biomedical model of back pain is not effective enough, and suggest that there is a need for a new approach. The biopsychosocial model places close attention on the psychosocial factors involved in the development
and maintenance of disability. Under this model, musculoskeletal pain on its
own is not the issue; it is the pain and associated disability. Decreasing pain levels will help people to avoid incapacity only if it results in a return to their pre-injury/prepaint activities
as soon as possible.
It is important to understand that physical assessment and treatment are still important aspects of a multidimensional approach to back pain. Any health and fitness professional must, the refore consider both the physical and psychosocial situation of the individual complaining of low back pain.
Biopsychosocial model of low back disability
Functional approach to exercise management
Some active rehabilitation approaches to the management of LBP point towards a generalised approach to exercise prescription. However, what is clear in all approaches to back care, is the design of a programme that is matched to the current and individual capabilities of that client. Such programmes should emphasise the importance of a functional approach to rehabilitation, in favour of one that is ‘problem area’ focussed.
» » » Load
It’s important for the exercise professional to understand that the majority of low back pain
clients will be seeking health-related objectives, such as pain relief or restoration of daily activities. To meet these objectives, exercise training will initially need to be performed at
low tissue loads, and in a low risk environment.
Clients seeking performance enhancement (e.g. return to sport) will invariably require greater
overload, which naturally carries a higher risk; in all cases, the exercise professional will need
to adopt a systematic yet flexible approach.
» » » Functional range of motion
Maintenance of the spine in a functional range when exercising is often incorrectly termed
‘neutral’ spine position. It is important to understand that most individuals do not have
a ‘neutral range’ but instead have a functional range. The potential of this range will vary
considerably between different individuals. The main concern is to provide an individualised
training approach which limits motion to an identified functional range.
» » » Sensitivities
Posture - clients with postural sensitivities will need to sit or stand in a particular way in order to avoid pain. As an example, a client with a flexion bias may avoid standing for any period of time because they cannot tolerate the lumbar extension force that this imposes. As a
coping strategy they might use a foot stool to introduce some degree of spinal flexion.
Movement - movement sensitivities result in pain during certain activities. A client who experiences pain on a day-to-day basis when they bend to put on their socks or tie shoelaces, may have an extension bias. This individual does not cope well with spinal flexion.
Weight-bearing - weight-bearing sensitivities are often referred to as a gravity intolerance, which may be indicated by pain that is aggravated by sitting or standing and relieved by rest.
General principles of exercise progression
» » » Stages of progression
The basic principles of corrective exercise should be considered when designing a
practical system of exercise progression. There are three basic steps to consider:
1. Freeing any identified restrictions - where necessary, restrictions in range of motion
(e.g. ankle, hip, shoulder) should be managed prior to functional progressions; if ignored, these restrictions may cause increased range of motion at another joint, resulting in compensatory movement. This can usually be achieved using joint mobilisations and stretching of muscles that are contributing to restrictions.
2. Re-balancing muscles - re-balancing muscles may also include activation of underactive/weak muscles; such exercises should emphasise co-contraction of the torso/abdominal wall muscles.
3. Re-educating movement finally, once restrictions have been freed up and mobilised, and overactive/ underactive muscles have been addressed, the client will be ready to move through exercise progressions. These should begin with simple motor control strategies that can be further challenged through the use of progressive exercise sequences. As the client
develops muscular endurance and control of the abdominal wall, complex exercises can
be introduced that mimic the demands and movements of daily life. These may include
movements such as squatting, bending and lifting, as well as more advanced movements
that involve balance and coordination.
The above stages provide a systematic structure for all those working in exercise management of low back pain, and while the exercise-based content may be influenced by the instructor’s own training and qualifications, as well as the context of delivery, the underlying rationale should remain clear. It is important for the exercise professional to understand that for almost all LBP clients, a return to ADL is a primary objective, and as such, exercise prescription
should always strive towards functional movement patterns that build stabilisation mechanisms into already familiar movements.
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