Jenn Littrell

Overview  Definition  Epidemiology  Clinical Aspects  Treatment  Effects of exercise  Exercise Testing  Exercise Prescription  Summary & Conclusions  References

Definition: pain and discomfort, localized below the costal margin and above inferior gluteal folds, with or without leg pain. Non-specific LBP: pain not attributed to known specific pathology/injury (i.e. tumor, fracture, osteoporosis, etc.) may occur suddenly and unclear in onset (acute) may result from major trauma (acute) may result from multiple episodes of micro trauma (chronic)

LBP is one of the most widely experienced health- related problems in the world. Lifetime: 58-70% Yearly: 15-37% Most people will have at least 1 LBP episode in their lives. (specifically, 4 out of 5 people) 5 th most common reason for doctor visits in the United States.

Symptoms Pain localized (axial or mechanical LBP) referred (sciatica) Pain is characterized by type (sharp or dull) and where it is felt (groin, buttocks, upper thigh) Pain is also classified by what antagonizes it positions, activities, etc.

Chronic LBP: focused and detailed patient history and physical examination. Initial evaluation flow sheet Evaluation of gait, assessment of lower extremities Acute LBP: diagnostic imaging (MRI) Severe or progressive neurologic deficits Known etiology CT evaluation for possible surgical candidates

Recurrence Disability Loss of work Increased use of health care system Reduced quality of life Inactivity Sciatica

Acute: Rest (return to activity asap) Ice Heat Support Physical Therapy NSAIDs Muscle relaxants Opiates

The United States has the highest rate of spinal surgery, 5 x that of Great Britain. Immediate surgery indicated for LBP cases with sensorimotor changes in legs or urinary retention Also patients with worsening neurologic deficits or intractable pain that is unresponsive to conservative treatment. 2 types of possible surgeries: Discectomy Spinal fusion

Standing alone, has no effect on ability to exercise Use caution with position: i.e.. standing or sitting Use a variety of exercise modalities Limiting Factors Pain Fatigue Psychological Sociological

NSAIDs: No effect (caution for GI distress) Muscle relaxants & Opiates: Drowsiness Vertigo Weakness Loss of balance and muscle control Constipation (long term) Overuse & addiction

In asymptomatic patient: Improve ROM, particularly in the trunk, hips and spine Increase exercise tolerance Decrease occurrence of future episodes of LBP Can trigger an episode of LBP Inactivity Unwillingness to exercise

Significantly more effective than rest Increase incentive, willingness to exercise Increased strength, flexibility, ROM Pain-free exercise Weight loss Decrease frequency and intensity of LBP episodes **Can “cure” LBP within 3-4 months

Similar to that for a healthy individual, follow ACSM guidelines Max or sub-max testing not necessary, focus on strength and flexibility Any testing may be symptom-limiting Allow client to choose time of day and, if applicable, modality for sub-max or max. Allow for a longer warm up

Goal: improve health and well being, limit exacerbations of LBP, increase in activity, facilitate exercise in life Similar to exercise prescription for healthy individuals, especially for clients with intermittent acute LBP episodes. During acute episode, make adjustments to intensity (low), avoid hip and back muscle work for approx. 2 weeks

Focus on rehabilitative exercises first. Core strength, flexibility and coordination Hip flexibility Leg strength Gradually build strength in trunk, back, gluteus and legs starting with body weight, slowly adding light resistance (bands) and adding weight as allowed. Build abdominal strength and low back strength simultaneously Teach proper body mechanics, i.e.. Neutral spine, lower back pressed into floor, stacking shoulders, knees, bracing the core, etc.

Clients with LBP may have a fear of exercise, and may be unwilling to try exercise they feel will exacerbate an episode. Allow client as much control as possible in choosing modalities, position and especially weight selection. Small victories will allow for increases in intensity. Client teaching is paramount! Warm up ROM Alignment Posture ***Knowing when to stop***

LBP is characterized primarily by pain Exercise will be symptom-limiting Generally, testing is similar to that for healthy individuals Prescription is also similar to healthy individuals, make adjustments as needed on a daily basis Be sensitive to psychological factors **The best treatment for low back pain is exercise**

American Academy of Orthopaedic Surgeons, Low Back Exercise Guide. Atul T. Patel, MD, Abna A. Ogle, MD. Diagnosis and Management of Acute Low Back Pain. American Family Physician, March 15, Chicagotribune.com, How to Take the Strain off Back Pain. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and th eAmerican Pain Society. Annals of Internal Medicine, 2007;147: Light, Kristen J. The Lowdown on low back pain. Biomechanics Vol. XVI, Number 2, February McGill, Stuart. Low Back Disorders Human Kinetics, Champaign, IL. Simmonds, Maureen J. PhD, Derghazarian, PT. Lower Back Pain Syndrome. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. Human Kinetics,