Sports Medicine Research: In the Lab & In the Field: Low Back Pain? Work It Out (Sports Med Res)
Monday, April 13, 2015

Low Back Pain? Work It Out

Exercise interventions for the treatment of chronic low back pain: A systematic review and meta-analysis of randomized controlled trials

Searle A, Spink M, Ho A, Chuter V. (2015). Clinical Rehabilitation.
doi: 10.1177/0269215515570379

Take Home Message:  Exercise reduces pain in patients with nonspecific low back pain.  Exercise protocols involving strength training and stabilization with a whole-body approach appear to provide the greatest relief.

Chronic low back pain affects up to 70% of adults and a majority do not know the underlying cause of this pain. There is some evidence in the literature that exercise can help improve low back pain. However, there is little about which specific exercises or exercise protocols are most effective at reducing pain. Therefore the purpose of this meta-analysis was to determine specific exercises that are more effective than other interventions or control protocols to reduce pain.  The authors searched electronic databases for randomized control trials related to low back pain and exercise interventions.  Studies were only included if the patients had low back pain from a non-specific origin. The authors performed a meta-analysis on the extracted articles to determine if exercise interventions were effective when compared with other treatment methods to reduce back pain. An exploratory subgroup analysis was performed on four separate groups of trials: 1) coordination/stability exercises, 2) strength/resistance exercises, 3) cardiorespiratory exercises, and 4) combined trials. The exploratory analyses enabled the authors to determine the exercise intervention with the greatest benefits. Ultimately, 39 studies with 4109 participants were included in the meta-analysis. 30 of 39 studies demonstrated exercises positively influenced back pain. The results showed that exercise has a small but significant benefit for the treatment of nonspecific chronic low back pain and is more effective than conservative treatment. Based on the subgroup analysis, strength/resistance and coordination/stabilization exercise interventions proved to have a small but significant effect.  The authors found the largest effect sizes for studies that used strength/resistance exercises with a focus on the whole body and trunk.

Determining effective protocols to treat low back pain is compromised by not knowing the specific underlying mechanism. This study demonstrates exercise interventions can improve low back pain even when the exact source of pain is unknown. The results of the study are encouraging for clinical settings because strength/resistance and coordination/stability training can be useful interventions to alleviate low back pain. Weakness and altered muscle activation firing patterns may contribute to non-specific low back pain. Increasing core strength and stability through implementing whole-body resistance and coordination programs may assist in improving these deficiencies and reduce pain. This study only sought to assess the effect of clinical interventions on pain.  Further research needs to be completed to determine if exercise interventions improved specific measurable outcomes such as strength, stiffness, balance, etc.  In addition a follow-up study is necessary to determine the length of time, frequency of interventions, number of exercises, and intensity of exercises it takes for interventions to reduce the pain to meaningful levels, as this was not reported and not an aim of the current study. In the meantime, sports medicine clinicians should continue to provide therapeutic exercises to patients with nonspecific low back pain, especially coordination/stabilization exercises and strength/resistance (for example, whole body and trunk exercises).

Questions for Discussion: What programs do you use for chronic, non-specific low back pain? Besides clinical interventions, what advice do you give patients with low back problems to assist in pain reduction?

Written by:  Danielle Schindler and Adam Rosen
Reviewed by: Jeffrey Driban

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Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment of chronic low back pain: A systematic review and meta-analysis of randomised controlled trials Clinical Rehabilitation DOI: 10.1177/0269215515570379

3 comments:

Alexander Dailey, ATC said...

In order to combat chronic, non-specific low back pain, I would utilize a combination of programs to address the underlying reasons for the low back pain.
One of the first aspects to be addressed would include alignment and posture. For posture, I would utilize supine 1/2 foam roller (FR) posture stretching. This way, one can emphasize posture, breathing, activation of the transverse abdominis and pelvic floor. The importance of posture cannot be understated, as important cues as "sit up straight" and "breath" can allow for the intrinsic muscles in the core to work properly. Alignment also plays a factor, especially in the innominates, sacroiliac joint and lumbar spine. Assessment and correction of somatic dysfunctions has its place in intervention.
In addition to posture and alignment, muscular balance through activation and stretching can be beneficial. Activation of the transverse abdominis through FR posture stretching and abdominal draw-ins provide a framework to build off of. Core stabilization such as the activation of the pelvic floor, diaphragm, and the other intrinsic core muscles can further diminish low back pain. Core stabilization can allow the global movers (rectus abdominis, errector spinae, rectus femoris, iliopsoas, hamstrings, etc.) to move effectively without having to stabilize. Core stabilization can also include dead bugs, prone, quadruped, bridges, wall slides, and ball slide exercises to activate both the core and global movers. Mobility (such as stretching), in particular the psoas muscles (which originate on transverse processes T12-L5), are crucial to help alleviate pain while maintaining mobility throughout the core and lower extremities.
The method of treating the patient with chronic, non-specific low back pain would involve a disability-model approach. The approach would consider the structures involved (lumbar spine, innominates, sacroiliac, transverse abdominis, pelvic floor, errector spinae, iliopsoas, etc), activity limitations (inability to bend down to pick up a ball), participation (unable to play catch) along with the environmental and personal factors of the individual. The interventions of posture, alignment, activation, strengthening and mobility can help address the deficits seen in the patient with back pain.

Adam Rosen said...

Alexander, thanks again for the insightful response. You definitely provide some great recommendations for clinicians. It seems as though your protocols and clinical expertise are in-line with Searle and Colleagues. It seems like the strength/resistance in the core and trunk are the keys to providing the most long-term relief for LBP. Could you provide some links for the 1/2 foam roller (FR) posture stretching? I think some visuals would be helpful for other clinicians. Also, what advice do you give patients outside your in-house treatments with LBP to assist in their pain reduction?

Candace Bernitt said...

I agree with Alex, that when managing patients with LBP it is important to incorporate various different interventions to address various potential problems. I think that the problem with treating LBP is that there are many different causes of it that vary from person to person. Many clinicians resort to strengthening core muscles as the primary treatment for back pain. However, as Alex pointed out there are a variety of different ways to intervene. I think that the most valuable approach is to start with a full body evaluation that includes biomechanics, posture, breathing control, muscular balances, and other functional activity. This way, we can seek to treat the cause of the cause and hopefully provide longterm relief for the patient.

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