1. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 6 Resistance-Training Strategies for Individuals with Low Back Pain

2. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Low Back Pain Non-specific, chronic Acute low back pain –Activity intolerance of less than three month’s duration due to pain in low back Complex and misunderstood interaction of physical, social, and psychological factors

3. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Low Back Pain Individuals should see physician prior to beginning resistance training Exercise may cause more harm than good if performed incorrectly

4. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Prevalence of Low Back Pain Affects more than 80 percent of people in the world at some point in lifetime More than 35 percent of population suffers from some form of low back pain dysfunction at any given time Average adult can expect between one to three episodes annually

5. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Prevalence of Low Back Pain Dysfunction progresses to permanent disability in up to 15 percent of people Recurrence occurs within one year for 60 percent of people with low back pain

6. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Prevalence of Low Back Pain Almost 90 percent of people recover to previous level of activities of daily living within one month Implementation of exercise and resistance training after initial pain subsides reduces incidence and intensity of pain

7. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Economic Impact of Low Back Pain Between $60 to 90 billion spent annually treating low back pain More than $27 billion spent annually related to permanent disability Costs make it most expensive disorder Most common cause of disability for Americans under age 45

8. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Etiology of Low Back Pain Potential etiology enormous due to number of muscles, joints, ligaments, etc. involved Improper movement or body mechanics Combination of two or more defective structures can result in pain Weakness of trunk musculature

9. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Etiology of Low Back Pain Compromised proprioceptive acuity –Awareness of body position Muscle adaptation to injury and immobilization Susceptibility to re-injury even when performing simplistic activities of daily living

10. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Symptoms of Low Back Pain Localized or generalized pain of variable duration, frequency, and intensity Pain may radiate along course of irritated nerve

11. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Symptoms of Low Back Pain Associated symptoms include lower extremity weakness, numbness, or other sensory changes in lower extremities Some symptoms may be due to specific pathology

12. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Risk Factors Poor muscular endurance of back extensor muscles Decreased flexibility of back and lower extremities Decreased low back and abdominal muscle strength

13. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Risk Factors Obesity Sedentary occupations Improper body mechanics during occupational and recreational activities Prolonged sitting

14. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Risk Factors Occur over time, contributing to higher incidence in individuals over age 30 Structural deformities –E.g., herniated intervertebral disc, spondylolysis, spondylolisthesis

15. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Treatment Options Rest Medications and injections Exercise programs Surgery to correct structural deformities Surgery when other treatments fail

16. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Notes about Back Braces Worn by individuals postoperatively Prolonged use may cause additional loss of abdominal/back extensor strength and muscular endurance

17. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Notes about Back Braces Replaces actual muscle in controlling spine during activities of daily living Can compromise acuity of proprioceptors –Placing individual at greater risk for future injuries

18. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Resistance Training Helps address: –Poor muscular endurance of back extensor muscles –Decreased flexibility of back and lower extremities –Decreased low back and abdominal muscle strength –Poor proprioception

19. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Four Classifications of Research Literature 1.Therapeutic exercise training as part of physical therapy rehabilitation program 2.Dynamic resistance training 3.Lumbar spine stability training 4.Isometric resistance training programs

20. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Research Supports Resistance Training Demonstrates positive effect on physical impairments and functional limitations As few as two, 15- to 20-minute training sessions can reduce complications Incorporating resistance training into comprehensive fitness program reduces low back pain

21. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Research Supports Resistance Training Modifications to common resistance training exercises reduce low back pain and prevent back injury Core training programs strengthen trunk muscles and prevent injury

22. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Research Supports Resistance Training Individually designed, supervised training may significantly reduce pain and increase compliance Dynamic resistance training in conjunction with pelvic stabilization exercises show significant increases in strength of lumbar extensor musculature

23. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Limitations of Clinical Trials Existence of vast differences in etiology and severity of low back pain Subject pool changes rapidly due to re- injury or noncompliance

24. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Limitations of Clinical Trials Initial subject evaluation difficult due to stage of low back pain Length of typical 12-week exercise program may be too short

25. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Program Design Considerations Obtain physician clearance –Including information on etiology of individual’s low back pain Avoid movements that cause pain until performed through pain-free ROM

26. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Program Design Considerations Avoid overtraining severely deconditioned person –Undertraining preferred Always use proper form during movements Some exercises may be contraindicated based on etiology of particular low back pain

27. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Program Design Considerations Pharmaceutical interactions may occur between individual’s pain medications and other medications

28. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Two Options for Exercise Testing 1.Rule of 20 –Find weight that can be lifted safely and with proper form for 20 repetitions 2.Omnibus (OMNI) RPE scale –10-point scale similar to RPE Borg scale –Traditional testing utilizing 1 RM protocol contraindicated for low back pain

29. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Use of Lifting Belt Wear belt during resistance training exercises when: –Trunk loaded –Stress placed on low back –Lifting maximal or near maximal loads

30. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Use of Lifting Belt Remove belt when performing resistance training exercises that do not load trunk or stress lumbar spine

31. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Use of Lifting Belt Discuss use of lifting belt when performing activities of daily living or occupational activities with physician or physical therapist (PT) –Use controversial

32. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Program Components Entire body, periodized training program to enhance muscular strength development and muscular endurance development May include stability balls, balance boards, or other proprioceptive training devices Involves slow progression to accommodate individual’s likely deconditioning

33. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Program Components Emphasizes performing exercise safely and without pain/further injury Manipulates training variables Usually divided into three phases –Each phase eight weeks long –First phase critical to learning proper techniques and laying foundation for muscular strength and endurance Review sample 24-Week Program

34. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Exercise Selection ACSM and National Strength and Conditioning Association (NSCA) recommend 1 to 3 sets of 8 to 15 repetitions with one to two minutes rest between sets Select pain-free exercises or only include pain-free ROM