lower back pain & exercise/movement - home - cor kinetic
TRANSCRIPT
Lower Back Pain & exercise/movement
Preven&onofLowBackPain
âThecurrentevidencesuggeststhatexercise
aloneorincombina6onwitheduca6onis
effec6veforpreven6ngLBP.Other
interven6ons,includingeduca6onalone,back
belts,andshoeinsoles,donotappearto
preventLBPâ
ASystema&cReviewandMeta-analysis-SteffensetalJAMA2016
Bardin,etal2017
"I'vebeenstudyingbackpainforthepast
50yrs,andifanyonesaystheyknowwhere
backpaincomesfrom,they'refullofshit.â
ANachemson
â˘âŻ Stress
â˘âŻ Sleep
â˘âŻ Beliefs
â˘âŻ Previous experiences
â˘âŻ Emotions
â˘âŻ Social and work factors
â˘âŻ Predicted expectation of recovery
Whathavewelearnedfromtenyearsoftrajectoryresearchinlow
backpain?
KongstedBMC2016
â˘âŻ Non-specificlowbackpain(LBP)isoFencategorisedasacute,
subacuteorchronicbyfocusingontheduraKonofthecurrent
episode.
â˘âŻ limitaKonofthatconceptisthatitdoesnotdifferenKatebetweena
recentonsetepisodeexperiencedforthefirstKmeandarecent
flare-upofrecurrentLBP
â˘âŻ InvesKgaKonsoftrajectoriesunderpinthenoKonthatdifferenKaKon
betweenacuteandchronicLBPisoverlysimplisKc,andwebelieveit
isKmetoshiFfromthisparadigmtoonethatfocusesontrajectories
overKme
â˘âŻ Lookatlongtermtrajectory
â˘âŻ BytreaKngpeopleacutelywithLBPdowekeepthem
chronic?
Beliefsaroundexerciseandmovement.
PracKKonerandperson!
Beliefs about the back pain Ben Darlow. 2016
â˘âŻ 69% of people believe they should take it easy
â˘âŻ 59% believe if an activity causes pain it should be avoided in the future
â˘âŻ 55% believe exercise risk outweighs the benefit
â˘âŻ 35% believe bed rest is mainstay of therapy
This is a PROBLEM for an active approach to back pain!
PeopleareWEAK!
â˘âŻ Theresultsof26prospecKvecohortstudies
â˘âŻ InvesKgateifthereisevidencethatlowmusclestrength,low
muscleendurance,orreducedspinalmobilityarepredictorsof
futurelowbackorneck/shoulderpain
â˘âŻ InconclusiveevidenceforarelaKonshipbetweenphysical
capacitymeasuresandtheriskofneck/shoulderpain
Asystema&creviewoftherela&onbetweenphysicalcapacityandfuturelowback
andneck/shoulderpain
HamburgvanReenenâPain2007
SomethingneedstochangetogetbeOer
â˘âŻ ThefindingsdonotsupportthenoKonthatthetreatmenteffectsof
exercisetherapyincLBParedirectlyaVributabletochangesinthe
musculoskeletalsystem.
â˘âŻ FutureresearchaimedatincreasingtheeffecKvenessofexercise
therapyincLBPshouldexplorethecoincidentalfactorsinfluencing
symptomimprovement.
Isaposi&veclinicaloutcomeaQerexercisetherapyforchronicnon-specificlowbackpain
con&ngentuponacorrespondingimprovementinthetargetedaspect(s)ofperformance?A
systema&creview
EuropeanSpineJournalApril2012
Thatthereisamagicexercise
â˘âŻ Despiteitbeingthemostcommonlyusedformofphysiotherapytreatment
withintheUKthereisalackofposiKveevidencetosupportitsuse.
â˘âŻ 29studieswereincluded
â˘âŻ ThereisstrongevidencestabilisaKonexercisesarenotmoreeffecKvethanany
otherformofacKveexerciseinthelongterm.
â˘âŻ Thelowlevelsofheterogeneityandlargenumberofhighmethodologicalquality
ofavailablestudies,atlongtermfollow-up,strengthenourcurrentfindings,and
furtherresearchisunlikelytoconsiderablyalterthisconclusion.
Smithetal.Anupdateofstabilisa&onexercisesforlowbackpain:asystema&c
reviewwithmeta-analysisBMCMusculoskeletalDisorders2014
Itssomephysicalfactor!
â˘âŻ Sizeofthelumbarlordosis
â˘âŻ PelvicKlt
â˘âŻ Leglengthdiscrepancy
â˘âŻ Lengthofabdominal,hamstring,andiliopsoasmuscles
â˘âŻ Enduranceofthebackextensormuscleshadthehighest
associaKonwithLBP
â˘âŻ MuscleenduranceandweaknessareassociatedwithLBP
RelaKonshipbetweenmechanicalfactorsandincidenceoflowbackpain
Nourbakhshetal.JOSPTâ2002
Bendingisbad
â˘âŻ 198Danishblue-collarworkers
â˘âŻ âĽ30°,âĽ60°andâĽ90°
â˘âŻ ResultsofmulK-adjustedlogisKcregressionsindicatednosignificant
posiKveassociaKonsbetweenforwardbendingandLBPintensity.
â˘âŻ Onthecontrary,higherduraKonofforwardbendingofâĽ30°was
associatedwithlowerLBPintensityduringallday
Areforwardbendingofthetrunk
andlowbackpainassociatedamong
Danishblue-collarworkers?
VillumsenErgonomics2014
Peoplejustneedmoremovement/load
â˘âŻ BeingphysicallyacKveisoFensuggestedtobeimportantinthe
prevenKonandmanagementoflowbackpain.Thissimpleview
doesnottakeintoaccountthattherelaKonbetweenthelevel
ofacKvityandbackpainmaybeaU-shapedcurve-i.e.both
inacKvityandexcessiveacKviKespresentanincreasedrisk
â˘âŻ AmoderateincreasedriskforCLBPwasfoundforboth
parKcipantswithasedentarylifestyleandforthosebeing
involvedinphysicalstrenuousacKviKes
Physicalac&vityandlowbackpain:aU-shapedrela&on?
Heneweeretal-Pain2009
â˘âŻ Alongitudinalcohortstudyoveroneyearincluding124paKents
withsub-acuteLBP.
â˘âŻ ResultsshowedthatonlyinasubgroupofpaKentsadecrease
hadoccurredaFertheonsetofpain,whereasnosignsofphysical
decondiKoningwerefound.
â˘âŻ assumpKonthatpaKentswithCLBPsufferfromdisuseand
physicaldecondiKoningempiricalevidenceissKlllacking.
DisuseandphysicaldecondiKoninginthefirstyearaFertheonsetofbackpain
Bousema2007
FearofmovementisnotassociatedwithobjecKveandsubjecKvephysicalacKvitylevelsin
chronicnon-specificlowbackpain
Carvalho2016APMR
Thatwecanusegeneralisedphysical
interven&onsforspecificproblems
â˘âŻ NoneoftheobjecKvemeasuresofphysicalacKvitywere
associatedwithfearofmovementâInacKvitynotassociated.
â˘âŻ Fearofmovementwasassociatedwithdisability(Roland-
Morris)
â˘âŻ SuggeststhatpeopleDOusetheirbodiesAPARTfromspecific
movements
â˘âŻ Generaliseduseofthebodymaynothaveanfurthereffect
Dopeoplewithlowerbackpainhavedifferent
movementhabits?
Tsang-BMC2017
â˘âŻ MuchlowerlevelsofvariabilitywithLBP
â˘âŻ Theabilitytoregulatethelumbo-pelvicmovementpaVernduringthe
bendingtaskthatexecutedatvariousspeedlevelswasshownonlyin
pain-freeindividualsbutnotinthosewithlowbackpain(over3
months)
â˘âŻ Individualswithlowbackpainmovedwithastereotypedstrategyat
theirlumbarspineandhipjoints
â˘âŻ Contributetomaintenanceandchronicity
Theeffectsofbendingspeedon
thelumbo-pelvickinema&csand
movementpaOernduringforward
bendinginpeoplewithand
withoutlowbackpain
Tsang-BMC2017
Theeffectsofbendingspeed
onthelumbo-pelvic
kinema&csandmovement
paOernduringforward
bendinginpeoplewithand
withoutlowbackpain
Differencesinlumbarspineandlower
extremitykinemaKcsduringastep
downfuncKonaltaskinpeoplewith
andpeoplewithoutlowbackpain
Hernandez2017
â˘âŻ Subjectswithlowbackpaindisplayedlesslumbar
spinemovementthancontrolsacrossallthreeplanes
ofmovement
â˘âŻ AredistribuKonofacKvityto
differentregionsofthe
lumbarerectorspinaewas
observedwhenpain-free
individualsperformeda
repeKKveliFingtask.
â˘âŻ PeoplewithLBPperformed
therepeKKvetaskby
increasingtheacKvaKonof
thesameregionsofthe
muscleovertheduraKonof
thetask,thatis,without
variabilityinmuscleacKvityâ
Reducedtask-inducedvariaKonsinthedistribuKonof
acKvityacrossbackmuscleregionsinindividualswithlow
backpainâ Falla.Pain2014
Comparinglumbo-pelvickinema&csinpeoplewithand
withoutbackpain:asystema&creviewandmeta-analysis
LairdBMC2014
â˘âŻ 43studies
â˘âŻ Onaverage,peoplewithLBPhavereducedlumbarROM
andpropriocepKon,andmovemoreslowlycomparedto
peoplewithoutLBP.
â˘âŻ WhetherthesedeficitsexistpriortoLBPonsetis
unknown
Changesinthemechanicalproper&esofthe
trunkinlowbackpainmaybeassociatedwith
recurrence
Hodges2009JofBiomechanics
â˘âŻ N=14(RecurringLBP)N=17(healthy)
â˘âŻ LBPgrouptrunksKffnesswasincreased
â˘âŻ AugmentedtrunkmuscleacKvityandchangesin
reflexcontroloftrunkmuscles
â˘âŻ Consequencesforpainandrecurrence
Lowbackpainstatusaffectspelvis-trunkcoordina&onand
variabilityduringwalkingandrunningSeayetalClinBiomech2011
â˘âŻ CollecteddataduringwalkingandrunningofcoordinaKonofthoraxandpelvisin3
planes.
3groups
â˘âŻ ChronicLBP
â˘âŻ Singleboutofbackpainresolved
â˘âŻ Nobackpain
â˘âŻ TheywereabletoidenKfyeachgroupbylevelofvariabilitythatdecreasedwith
chronicity
â˘âŻ CliniciansneedtolookbeyondtheresoluKonofpainwhenprescribing
rehabilitaKonforlowbackpain
Pelvis-thoraxcoordina&oninthetransverse
planeduringwalkinginpersonswith
nonspecificlowbackpainâLamoth2002Spine
â˘âŻ IncomparisonwithhealthyparKcipants,the
gaitofpaKentswithlowbackpainwas
characterizedbyamorerigid,lessflexible
pelvis-thoraxcoordinaKon
Mechanicalcouplingbetweentransverse
planepelvisandthoraxrota&onsduringgaitis
higherinpeoplewithlowbackpainâVandenHoorn2012
â˘âŻ Theseresultssupporttheargumentthat
peoplewithLBPadoptaprotecKve
movementstrategy,possiblybyincreased
trunksKffness.
Takehomes
â˘âŻ Peoplewithchronicbackpainappeartomovedifferently
â˘âŻ ThisischaracterisedbylessvariaKon&lessmovement
â˘âŻ Morelikelytobeaneffectratherthanacause
â˘âŻ Couldthismaintaintheproblem?CondiKonedbehaviorsandcoupledpain?
â˘âŻ Especiallyasstrength/condiKoning/acKvitymaynotbetheproblemformany
people
Sowhatdowedowiththisinfo?
â˘âŻ Encouragerelaxed,free,flowingmovement&variedmovementtasks?
â˘âŻ Lookatpremovementbehaviorssuchasbracing
â˘âŻ DonâttryandmeasureorworryaboutchangingâItmaynotmaVer!
Whichexerciseworksbestforlowerback
pain?
Cri&cisms
â˘âŻ Test2exerciseswithnocontrolâRegressiontothe
mean
â˘âŻ ExternalvalidityâTakesawayadherenceissues
â˘âŻ Singlefactorthinking
â˘âŻ Canbesedentarygroups
â˘âŻ Todetermine,foradultswithchroniclowbackpain,which
exerciseintervenKonsarethemosteffecKveatreducingpain
comparedtoothertreatments.
â˘âŻ Combinedmeta-analysisrevealedsignificantlylowerchroniclow
backpainwithintervenKongroupsusingexercisecomparedtoa
controlgrouporothertreatmentgroup
â˘âŻ Ourresultsfoundabeneficialeffectforstrength/resistanceand
coordinaKon/stabilisaKonexerciseprogramsoverother
intervenKonsinthetreatmentofchroniclowbackpain
Exerciseinterven&onsforthetreatmentofchroniclowbackpain:a
systema&creviewandmeta-analysisofrandomisedcontrolled
trialsâClinicalrehabilita&on2015
â˘âŻ IndividuallyaddressedtheparKcipantâsthoughtsandbeliefsabouttheirLBPin
relaKontomovement.
â˘âŻ BothintervenKonsreducedpainintensityandincreaseperformanceintestsofliF
strengthandsometestsoftrunkmuscleendurance,overKmewithnodifference.
â˘âŻ Trainingwithahigh-loadliFingexercise,thedeadliF,seemsbeneficialmainlyto
paKentswithaniniKallylowerpainintensityandhigherperformance.
DeadliFtrainingforpaKentswithmechanicallow
backpain
Acomparisonoftheeffectsofahigh-loadliFing
exerciseandindividualizedlow-loadmotorcontrol
Exercises.
LarsBerglund2015
â˘âŻ Comparedtogeneralexercise,corestabilityexerciseis
moreeffecKveindecreasingpainandmayimprove
physicalfuncKoninpaKentswithchronicLBPinthe
shortterm.
â˘âŻ However,nosignificantlong-termdifferencesinpain
severitywereobservedbetweenpaKentswhoengaged
incorestabilityexerciseversusthosewhoengagedin
generalexercise.
â˘âŻ Whynotlongterm?
â˘âŻ ExpectaKonofaclinicallymeaningfultreatment?
WangXetal.Ameta-analysisofcorestabilityexerciseversusgeneralexercisefor
chroniclowbackpain.PLoSOne.2012
â˘âŻ
Anaerobicwalkingprogrammeversusmusclestrengthening
programmeforchroniclowbackpain:arandomizedcontrolledtrial
Shaynadermanâ2013
â˘âŻ FiFy-twosedentarypaKents,aged18-65yearswithchroniclowbackpain.
â˘âŻ Moderateintensetreadmillwalking;control'exercise'group:specificlowback
exercise;both,twiceaweekforsixweeks.
â˘âŻ Six-minutewalkingtest,Fear-AvoidanceBeliefQuesKonnaire,backand
abdomenmuscleendurancetests,OswestryDisabilityQuesKonnaire,LowBack
PainFuncKonalScale(LBPFS)
â˘âŻ Significantimprovementswerenotedinalloutcomemeasuresinbothgroups
withnon-significantdifferencebetweengroups.
â˘âŻ Asix-weekwalktrainingprogrammewasaseffecKveassixweeksofspecific
strengtheningexercisesprogrammeforthelowback
NoCLEARsuperiority
â˘âŻWhatacKviKesdopeopleENJOY?
â˘âŻ Howeasyisitforthemtodo?
â˘âŻ HowrelevantisittotheirfuncKonal
outcomemeasures?
â˘âŻ Aretheyeasilyabletoaccessthenecessary
equipmentorneedspecialistinstrucKon?
w y ?
Keystoagreatrehab
program
Fitsinwithworkandfamilylife
Asfewexercisesaspossible
Minimal/easily
availableequipment
InsKllsconfidenceandsenseofselfefficacy
Takesintoaccount
preferencesUKlisesbestavailableevidence
Caneasilyberegressedorprogressed
Ismeaningfulandrelevant
CanbeperformedinanylocaKon