Low Back Pain and Exercise

Most people are quick to cite heart disease, cancer, or diabetes as global health concerns, but perhaps surprisingly, one of the most overlooked and costly ailments affecting everyone from children to the elderly is common low back pain (LBP).  Chances are that any number of people reading this have experienced some form of LBP at one point in their lives.  Personally speaking, I first hurt my lower back when I was 16 coming down from a rebound during a basketball game.  The instant I hit the ground, a shooting pain went down my lower left back and I fell to the ground.  The pain was so excruciating that I could hardly walk a few feet.  I was confined to the couch and underwent weeks of physical therapy.

The pain I experienced isn’t unlike what many others have felt.  As I stated, the prevalence of LBP is quite amazing.  In the United States, nearly 149 million days of work per year are lost because of LBP, and this comes with a near $200 billion price tag when lost wages and productivity are accounted for (1).  Lucky for me, years of training have kept my back healthy for the most part, although I have to pay close attention to signs that my body might need more rest, a re-focus, or a complete change in routine.  My hope here is to provide a concise overview of LBP and discuss exercise strategies that will help keep your back healthy and strong.  LBP is a complicated topic to cover because the cause is multifactorial and pain itself isn’t fully understood.

Based on the duration, LBP can be categorized as acute (<6 weeks), sub-chronic/sub acute (6-12 weeks), or chronic (>12 weeks) (1).  It’s important to understand that LBP is merely the symptom of a root cause.  Trauma to the back from an accident as well as osteoporosis (bone thinning), tumors, and infections are in the minority of causal factors (1).  Other conditions such as degenerative disc disease and spinal stenosis (narrowing of the canal in which the spinal cord runs, putting pressure on the cord and surrounding nerves) can also cause LBP.  Degenerative disc disease results from wear and tear on the intervertebral discs which act as shock absorbers and help protect the spine.  These discs may also herniate, commonly known as a slipped disc and affect nearby nerve fibers.  Although, with that said it should be noted that people who are asymptomatic of LBP may still have abnormalities of the lumbar spine as shown by Jensen et al. (4).  Unfortunately, nearly 85% of the patients with LBP cannot be given a precise diagnosis and therefore non-specific terms such as strains and sprains are used (2).  Muscles, ligaments and other soft tissues when strained produce a rapid release of inflammatory chemicals that spread and stimulate the nerve fibers causing pain (1).

Developing some form of LBP may depend on any number of risk factors.  According to the National Institute of Health, some of these risks include age, as the onset of LBP usually occurs between the ages of 30-40, occupations that involve heavy lifting, pushing, pulling, and twisting, and even cigarette smoking which may increase the risk of experiencing LBP and LBP with sciatica (3).  Of course, not surprisingly, another major risk factor for LBP is a low level of fitness (3).  It has been documented that low impact cardiovascular exercise supports intervertebral disc health and that strength training is crucial to better support the spine (3).  While habitual exercise is an important part of keeping your back healthy, it is also an area where many can go wrong and actually wind up doing more harm than good.

Risk vs. Reward

I often remind clients that above all else, an exercise plan needs to be safe because we have to be in it for the long haul.  Given the innumerable amount of exercises that exist; choosing your plan of attack should not be without rhyme or sound reason.  This starts with an individual risk/reward assessment of the exercise before implementing it into a program.  I say individual because most of the inherent risk of an exercise is based on the health and fitness status of the person performing the movement as well as the training variables (sets, reps, load, intensity, rest).  Keeping a healthy back in the forefront of my mind, here are some specific recommendations I came up with that I think might be helpful when stepping into the gym.

* Proper warm-up.  Walking into the gym on a cold winter day and heading straight to a heavy squat is not a good idea.  Take 10-15 minutes of light-moderate cardiovascular exercise and get your heart pumping.  As core temperature rises, muscle elasticity and joint fluid production increase.  A dynamic warm-up involving skips, hops, and stretches will prime your central nervous system for action.

* Avoid the rotary torso machine.  You’ll see it performed as a seated or kneeling twist exercise against resistance while the upper body remains stationary, or vice versa with the lower body stationary.  There may be an aggregate affect of twisting against resistance in this position that could damage the spine, especially when poor execution and too much weight is used.  Also, remember that core muscles act to prevent rotation by stabilizing, and I believe this is a better way to train.  Exercises such as plank variations and iso holds activate deep abdominal muscles.  This is not to say we shouldn’t rotate, but I think a better approach is to do so in the form of standing cable or medicine ball exercises and focus the rotation to originate from the thoracic and not the lumbar spine.

* Modify the straight leg captain’s chair (hanging leg raise) by keeping the knees bent and work to flex the trunk.  Lifting straight legs in the air from a hanging position is not an abdominal exercise, it’s a psoas, or hip flexor exercise.  The abdominal muscles isometrically contract to stabilize the pelvis.  Overtraining this muscle group can lead to overly tight hip flexors which may contribute to LBP.

* Watch out for the leg press.  It’s a staple in all gyms, but truthfully it can compromise the lower back if the correct position isn’t used and the execution is poor, further exacerbated with too much weight.  On top of that it’s not a ground-based move and has little functional carry over.  In total, I don’t see the leg press being useful for most individuals especially with all the other lower body strength exercises available.

* Say good bye to superman.  The superman is done in the prone position on the floor.  With legs straight and arms straight overhead, the person lifts all four limbs off the floor and isometrically holds.  This limited range of motion exercise does little to strengthen your back and exceeds the National Institute for Occupational Safety and Health’s lower limit of spinal compression force (5).  A better alternative is a quadruped.  In a table top position (hands and knees on the floor, aligned under the hips and shoulders respectively, and the back flat), extend the arm and opposing leg straight out and hold.  Drawn the naval in and keep the core tight. Switch sides.

A good training program is user defined, meaning we are all individuals with different strengths and weaknesses, imbalances, and body mechanics.  Too often people either blindly follow exercise suggestions without questioning the efficacy and safety, or they don’t place the exercise within the framework of their ability.  Eventually, an injury may occur.  Exercise for me has always been about tuning into my body and continuously assessing what works and what doesn’t.

At the end of the day follow proper progression.  Pay attention to mobility and good form before loading with heavy resistance.  Incorporate all components of fitness, and lastly just keep working out because the benefits greatly outweigh any potential risks.

-Chris

References

1. Duthey, B. Background paper 6.24 low back pain. Priority Medicines for Europe and the World “A Public Health Approach to   Innovation.” 2013 March

2. Deyo RA, Weinstein JN. Low back pain. The New England Journal of Medicine 2001 Feb 1;344(5):363–70.

3. National Institute of Arthritis and Musculoskeletal and Skin Disease. Handout on health: back pain. (retrieved 2014) http://www.nih.gov

4. Jensen, M.C., Brant-Zawadzki M.N., Obuchowski, N., Modic, M.T., Malkasian, D., Ross, J.S. Magnetic resonance imagine of the lumbar spine in people without back pain. The New England Journal of Medicine. 1994 Jul 14;331(2):69-73.

5. McGill, S. Low Back Disorders: Evidence Based Prevention and Rehabilitation. Human Kinetics, 2002.