Exercise Therapy for Low Back Pain

Ellen McGough

Joyce M. Engel

Exercise is a frequently prescribed nonpharmacologic intervention for low back pain (LBP).¹^,² Exercise for therapeutic purposes is defined as the systematic, planned performance of bodily movements, postures, or physical activities.³ Regular exercise improves general fitness, results in a sense of well-being, and is associated with lower incidence and severity of comorbid conditions such as depression, fatigue, and insomnia, which are often associated with persistent pain.⁴ The purpose of this chapter is (1) to describe clinical evaluation and decision making for the development of exercise interventions for individuals with LBP, (2) to discuss physical and psychosocial elements of exercise interventions that ultimately impact outcomes, and (3) to present available evidence for exercise therapy approaches across stages of LBP.

LBP of musculoskeletal origin is a common problem and a major cause of disability. More than 56% of American adults (125 million) had a musculoskeletal pain complaint in 2012.⁵ Eighty percent of the population report LBP at some time during their lives,⁶ and LBP is the most common cause of work-related disability in people under 45 years of age.⁷ Annual financial costs (direct medical expenses, lost income, lost productivity) of all persistent pain syndromes exceed $500 billion annually.⁸ Over and above the financial cost of LBP, the human cost, in terms of suffering and impact upon quality of life, cannot be estimated.

According to the American Chronic Pain Association, “persistent” pain is a more accurate description than “chronic” pain, as the former includes information on how pain can interrupt functioning, well-being, and quality of life.⁹ The term persistent pain therefore is used throughout this chapter. LBP is considered a condition, rather than a disease,⁶ with multiple physical and psychosocial factors that impact the prognosis for recovery across the continuum of acute to persistent LBP conditions.¹⁰ LBP not originating from serious spinal pathology or nerve root pain is often classified as “nonspecific LBP” due to our current inability to identify pathologic changes.¹¹ However, several classification systems have been developed to provide a framework for selecting rehabilitation interventions for the treatment of musculoskeletal LBP, including approaches to exercise.¹²^,¹³^,¹⁴^,¹⁵ Despite the fact that the majority of patients with isolated LBP cannot be given a precise pathoanatomic diagnosis, exercise interventions hold promise for reduction of pain and disability.¹^,¹⁶^,¹⁷

Exercise for musculoskeletal LBP is just one component of a multimodal treatment program which often includes education of anatomy and pathomechanics, postural modification, body mechanics training, manual therapy, functional training, and physical modalities (e.g., thermotherapy, cryotherapy, electrical stimulation). Due to the complex nature of persistent pain, multidisciplinary interventions are often indicated which typically include exercise, relaxation training, cognitive restructuring, vocational counseling, and medication management.¹⁸^,¹⁹^,²⁰

Designing an individualized exercise program is a dynamic process initially based on the patient’s impairments and exercise tolerance and then adapted to address functional goals. Specific exercises are used for the purpose of addressing LBP symptoms and physical impairments. A specific exercise approach is often selected based on a movement-based diagnosis or theory of contributing pathophysiology, for example, disk pathology,²¹ lack of segmental motor control,²²^,²³^,²⁴^,²⁵ or dysfunction in joint mechanics.²⁶^,²⁷ Exercise interventions designed to address body region impairments are often based on theories of movement dysfunction and muscle imbalance that contribute to mechanically induced LBP and focuses on the correction of postural alignment, modifications of faulty movement patterns, and improvement of neuromuscular control.¹⁵^,²⁸

As acute symptoms subside, patients should transition from specific exercises to global exercise that emphasizes fitness and prevention of relapse. Global exercise programs include components of aerobic, flexibility, strengthening, coordination, and agility exercises. A progressive exercise prescription should be incorporated as soon as the patient demonstrates adequate tolerance and regional movement control, with the ultimate goal of integrating regular exercise into the patient’s daily routine.

The overall goal of rehabilitation programs for individuals with LBP is to restore function, assist patients in returning to activity and social participation, and prevent recurrence. Functional restoration involves not only improving physical performance but also the integration of skills into the individual’s social and physical environments. In addition to physical factors, psychosocial, environmental, and personal factors should be taken into consideration when prescribing exercise.²⁹^,³⁰^,³¹

There is broad agreement that LBP and disability should be managed according to a biopsychosocial model which includes health-related, personal, psychological, and social dimensions and the interactions between them.¹⁰^,¹⁹^,³¹ Although the origin of LBP and disability may be caused by a biologic condition, the development of persistent LBP and incapacity are subject to dominant psychosocial influences.¹⁰ The International Classification of Functioning Disability and Health model is a biopsychosocial model designed to measure health and disability at the individual and population levels.³²

Disability is an umbrella term for impairments, activity limitations, and participation restrictions.³³ Three dimensions related to functioning and disability include (1) body functions and structures, (2) activities at the individual level, and (3) participation in society. Impairments of body functions and structures are defined as problems with physiologic functions and/or anatomic parts, such as loss of joint range of motion or reduced muscle strength. Activity restrictions are problems with executing a task or action and reduced participation includes lessened involvement in lived situations such as work, recreation, or social activities. Contextual factors include aspects of the human-built, social, and attitudinal environments that create the lived experience of functioning and disability as well as personal factors such as sex, age, coping styles, social background, education, and overall behavior patterns that may influence how disablement is experienced by the individual.³⁰ Environmental factors may include physical or social barriers or facilitators to activity and participation.³²

Changes in attitudes and beliefs may have as much impact as physiologic changes, resulting from exercise, on the activity and participation of individuals.¹⁰^,³⁴^,³⁵^,³⁶ This indicates that physical, psychosocial, environmental, and personal factors should all be considered when designing individualized exercise programs (Fig. 93.1).

FIGURE 93.1 Patient evaluation.

Individualized Exercise Programs

MUSCULOSKELETAL EXAMINATION FOR LOW BACK PAIN

A systematic musculoskeletal examination involves the patient’s history, a systems review, special tests, and measurements.³⁷ The goals of the clinical examination include (1) to identify contributing impairments; (2) to screen for serious medical problems and precautions related to physical activity; (3) to implement validated outcome measures; (4) to establish baseline status and assess their response to intervention; (5) to establish baseline exercise tolerance; (6) to identify barriers to activity and participation; and (7) to understand the patient’s goals, preferences, and resources to successfully follow through with in exercise program.³⁸

TABLE 93.1 Elements of Exercise Programs

Exercises		Coping	Education
Specific exercise modes		Cognitive restructuring	Anatomy
	Neuromuscular control	Reduce fear of moving	Pathomechanics
	Spinal stabilization	Clarify misconceptions	Body mechanics
	Movement directional preference	Self-management	Postural alignment
	Submaximal strengthening	Self-efficacy	Exercise technique
	Regional mobility/flexibility		Kinesthetic awareness
	Symptom reduction		Exercise progression
Global exercise modes			Activity modification
	Aerobic conditioning		Pacing
	Progressive resistance
	Endurance training
	General stretching
	Coordination and agility training
	Aquatic therapy
	Balance training
	Pilates
	Yoga

In addition to questions regarding pain patterns and the nature of the back problems, the examination should include inquiry related to medical history (including previous musculoskeletal problems and interventions used), psychosocial issues, and environmental barriers to activities and participation. A systems review is also conducted to screen for red flags and to identify potential problem areas. Screening of the neurologic system through testing of key muscles, sensation, and reflexes is an essential component of an LBP evaluation. Current guidelines also emphasize attention to psychosocial factors, at acute through chronic stages of nonspecific LBP, that may impact rehabilitation prognosis and intervention planning.¹¹^,³⁹ Learning about the patient’s understanding and beliefs related to their back problem is important. For example, screening for yellow flags, psychosocial factors including fear, unhelpful beliefs in severity of health conditions, catastrophizing, and poor problem solving is helpful in identifying patients at risk for persistent pain and disability.⁴⁰^,⁴¹

Anatomical structures that may contribute to pain should be tested with a systematic approach including tests of active and passive movement, tissue palpation, end range testing, repeated movements, and sustained postures.²¹^,³⁷^,⁴² Examination of a patient’s postural alignment, willingness to move, body mechanics, and movement patterns should also be incorporated to gain an understanding of problems related to posture and general mobility.³⁷ Functional performance tests and task analysis provide information related to the ability to perform activities needed to return to activity and participation, including employment.³⁷^,⁴²

The results of a comprehensive musculoskeletal examination are used to identify physical impairments and psychosocial factors for which purposeful exercise interventions can be aimed. Key elements of an individualized prescription, including exercise interventions, coping strategies, and education, are based on evaluation (Table 93.1). The patient’s ability to perform specific exercises serves as an additional source of feedback for both the patient and clinician. During the acute stage of management, specific exercises are selected and modified based on the patient’s responses to body position, direction of movement, and dose (intensity, duration, and frequency).

Individualizing the exercise program by mutual goal setting, to meet both physical and psychosocial needs, is essential in maximizing adherence and achieving patient satisfaction.⁴³ Supervision and adequate compliance are common aspects of randomized clinical trials that have demonstrated positive outcomes for exercise interventions for persistent LBP.²

DESIGNING INDIVIDUALIZED EXERCISE PROGRAMS

The purpose of exercise interventions refers to the patient’s and clinician’s goals: (1) specific exercises designed for symptom reduction or addressing physical impairment, for example, impaired muscle performance, joint mobility, flexibility, or kinesthetic awareness and (2) global exercises for improving overall strength, flexibility, and endurance. It is important to adapt an individualized program for the stage of management and exercise capacity.³⁸^,⁴⁴

Depending on the stage of management, an exercise program for LBP may comprise specific exercises alone, specific and global exercises, or primarily global exercises. At any stage of management, matching the patient’s baseline exercise and pain tolerance is essential to facilitate program adherence.⁴³

EXERCISE RECOMMENDATIONS BASED ON THE CLINICAL COURSE

Acute Lower Back Pain

Acute pain is often defined on the basis of the duration of an episode of LBP as well as the suspicion of inflammation because signs and symptoms including pain, muscle guarding, and tissue irritability are typically present.¹¹^,⁴⁵ The acute episode is generally considered to be within 4 to 6 weeks; however, relapse or recurrence is common. During acute episodes of LBP, advice to stay active is recommended over bed rest because inactivity does not promote recovery and may even be detrimental to recovery.¹⁰^,¹¹ Moderate-quality evidence exists for small improvements in pain relief and functional status in favor of advice to stay active in patients with acute LBP, but minimal effect has been reported in patients with sciatica.⁴⁶ In general, advice to continue typical activities and participation including work, when reasonable, is also recommended for the management of acute LBP¹¹; however, modification to reduce compressive and tensile forces on injured tissues is often needed.

During the acute stage, low-intensity and specific exercises are recommended including direction-specific and submaximal isometric muscle contractions performed in a neutral spine position or within the pain-free ROM.¹¹^,²⁴^,³⁸^,⁴⁵^,⁴⁷ Moderate- to strong-intensity muscle contractions are poorly tolerated due to pain and inflammation.¹¹^,⁴⁵ Gentle active and/or passive exercises specific for symptom reduction are recommended during the acute stage of LBP.³⁸^,⁴⁸^,⁴⁹ Additional treatments such as manual therapy, electrical stimulation, and cryotherapy may be used for symptom management during the acute stage of management.³⁸^,⁴⁵

Subacute Lower Back Pain

Subacute pain is defined as LBP persisting 4 to 12 weeks and/or reduced tissue irritability and increased tolerance for movement.¹¹^,⁴⁵ As acute pain and muscle guarding subside, impairment may persist in muscle function, motor control, postural awareness, and functional activities.⁵⁰ The patient is encouraged to gradually increase activity, performing exercises in the pain-free range to avoid further tissue irritation. Submaximal strengthening and gentle stretching can be incorporated. Progression to postural and kinesthetic awareness and education in body mechanics, ergonomics, and relaxation can also be progressed at this stage of management.³⁸ In addition, education on relapse prevention and self-management of acute pain episodes is important.³⁸ Manual therapy, electrical stimulation, and cryotherapy may be used for symptoms management during the subacute stage of management.³⁸^,⁴⁵

RECURRENT LOWER BACK PAIN STAGE OF MANAGEMENT

Relapse of LBP after an acute episode is frequently reported.³⁸^,⁵¹^,⁵² In an acute exacerbation or recurring LBP exercise interventions of neuromuscular reeducation to promote dynamic (muscular) stability to maintain the involved lumbosacral structures in less symptomatic, midrange position is indicated.³⁸ Specific exercises to reduce symptoms and promote trunk mobility and coordination, are indicated along with promotion of activity and education to reduce the frequency and intensity of symptoms.³⁸

PERSISTENT LOWER BACK PAIN STAGE OF MANAGEMENT

Persistent pain and disability are associated with physical deactivation and deconditioning, influenced by both physical and psychosocial factors.⁵³ Guidelines for persistent LBP emphasize promotion of activity and participation rather than a focus on protection of structures and pain relief. Supervised exercise, cognitive-behavioral therapy, body mechanics education, and progressive general fitness programs are recommended.³⁸^,³⁹ Current evidence suggests that exercise is an intervention with few adverse events that may improve physical function in individuals with persisting pain of musculoskeletal origin.⁵⁴ Progressive moderate- to high-intensity exercise is recommended for patients without generalized pain (due to neural sensitivity), and low- to moderate-intensity exercise for patients with conditions associated with generalized pain.³⁸ Behavioral interventions aimed at improving coping strategies and assisting patients in changing beliefs and attitudes about their pain in conjunction with exercise prescription are highly recommended.³⁸^,³⁹ In general, individualized exercise programs with regular clinician follow-up and a higher exercise dosage are associated with clinically significant improvement in function in patients with persistent LBP.¹

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