Lower Back Pain & exercise/movement - Home - Cor Kinetic
Transcript of Lower Back Pain & exercise/movement - Home - Cor Kinetic
Lower Back Pain & exercise/movement
Preven&onofLowBackPain
“Thecurrentevidencesuggeststhatexercise
aloneorincombina6onwitheduca6onis
effec6veforpreven6ngLBP.Other
interven6ons,includingeduca6onalone,back
belts,andshoeinsoles,donotappearto
preventLBP”
ASystema&cReviewandMeta-analysis-SteffensetalJAMA2016
Bardin,etal2017
"I'vebeenstudyingbackpainforthepast
50yrs,andifanyonesaystheyknowwhere
backpaincomesfrom,they'refullofshit.”
ANachemson
• Stress
• Sleep
• Beliefs
• Previous experiences
• Emotions
• Social and work factors
• Predicted expectation of recovery
Whathavewelearnedfromtenyearsoftrajectoryresearchinlow
backpain?
KongstedBMC2016
• Non-specificlowbackpain(LBP)isoFencategorisedasacute,
subacuteorchronicbyfocusingontheduraKonofthecurrent
episode.
• limitaKonofthatconceptisthatitdoesnotdifferenKatebetweena
recentonsetepisodeexperiencedforthefirstKmeandarecent
flare-upofrecurrentLBP
• InvesKgaKonsoftrajectoriesunderpinthenoKonthatdifferenKaKon
betweenacuteandchronicLBPisoverlysimplisKc,andwebelieveit
isKmetoshiFfromthisparadigmtoonethatfocusesontrajectories
overKme
• Lookatlongtermtrajectory
• BytreaKngpeopleacutelywithLBPdowekeepthem
chronic?
Beliefsaroundexerciseandmovement.
PracKKonerandperson!
Beliefs about the back pain Ben Darlow. 2016
• 69% of people believe they should take it easy
• 59% believe if an activity causes pain it should be avoided in the future
• 55% believe exercise risk outweighs the benefit
• 35% believe bed rest is mainstay of therapy
This is a PROBLEM for an active approach to back pain!
PeopleareWEAK!
• Theresultsof26prospecKvecohortstudies
• InvesKgateifthereisevidencethatlowmusclestrength,low
muscleendurance,orreducedspinalmobilityarepredictorsof
futurelowbackorneck/shoulderpain
• InconclusiveevidenceforarelaKonshipbetweenphysical
capacitymeasuresandtheriskofneck/shoulderpain
Asystema&creviewoftherela&onbetweenphysicalcapacityandfuturelowback
andneck/shoulderpain
HamburgvanReenen–Pain2007
SomethingneedstochangetogetbeOer
• ThefindingsdonotsupportthenoKonthatthetreatmenteffectsof
exercisetherapyincLBParedirectlyaVributabletochangesinthe
musculoskeletalsystem.
• FutureresearchaimedatincreasingtheeffecKvenessofexercise
therapyincLBPshouldexplorethecoincidentalfactorsinfluencing
symptomimprovement.
Isaposi&veclinicaloutcomeaQerexercisetherapyforchronicnon-specificlowbackpain
con&ngentuponacorrespondingimprovementinthetargetedaspect(s)ofperformance?A
systema&creview
EuropeanSpineJournalApril2012
Thatthereisamagicexercise
• Despiteitbeingthemostcommonlyusedformofphysiotherapytreatment
withintheUKthereisalackofposiKveevidencetosupportitsuse.
• 29studieswereincluded
• ThereisstrongevidencestabilisaKonexercisesarenotmoreeffecKvethanany
otherformofacKveexerciseinthelongterm.
• Thelowlevelsofheterogeneityandlargenumberofhighmethodologicalquality
ofavailablestudies,atlongtermfollow-up,strengthenourcurrentfindings,and
furtherresearchisunlikelytoconsiderablyalterthisconclusion.
Smithetal.Anupdateofstabilisa&onexercisesforlowbackpain:asystema&c
reviewwithmeta-analysisBMCMusculoskeletalDisorders2014
Itssomephysicalfactor!
• Sizeofthelumbarlordosis
• PelvicKlt
• Leglengthdiscrepancy
• Lengthofabdominal,hamstring,andiliopsoasmuscles
• Enduranceofthebackextensormuscleshadthehighest
associaKonwithLBP
• MuscleenduranceandweaknessareassociatedwithLBP
RelaKonshipbetweenmechanicalfactorsandincidenceoflowbackpain
Nourbakhshetal.JOSPT–2002
Bendingisbad
• 198Danishblue-collarworkers
• ≥30°,≥60°and≥90°
• ResultsofmulK-adjustedlogisKcregressionsindicatednosignificant
posiKveassociaKonsbetweenforwardbendingandLBPintensity.
• Onthecontrary,higherduraKonofforwardbendingof≥30°was
associatedwithlowerLBPintensityduringallday
Areforwardbendingofthetrunk
andlowbackpainassociatedamong
Danishblue-collarworkers?
VillumsenErgonomics2014
Peoplejustneedmoremovement/load
• BeingphysicallyacKveisoFensuggestedtobeimportantinthe
prevenKonandmanagementoflowbackpain.Thissimpleview
doesnottakeintoaccountthattherelaKonbetweenthelevel
ofacKvityandbackpainmaybeaU-shapedcurve-i.e.both
inacKvityandexcessiveacKviKespresentanincreasedrisk
• AmoderateincreasedriskforCLBPwasfoundforboth
parKcipantswithasedentarylifestyleandforthosebeing
involvedinphysicalstrenuousacKviKes
Physicalac&vityandlowbackpain:aU-shapedrela&on?
Heneweeretal-Pain2009
• Alongitudinalcohortstudyoveroneyearincluding124paKents
withsub-acuteLBP.
• ResultsshowedthatonlyinasubgroupofpaKentsadecrease
hadoccurredaFertheonsetofpain,whereasnosignsofphysical
decondiKoningwerefound.
• assumpKonthatpaKentswithCLBPsufferfromdisuseand
physicaldecondiKoningempiricalevidenceissKlllacking.
DisuseandphysicaldecondiKoninginthefirstyearaFertheonsetofbackpain
Bousema2007
FearofmovementisnotassociatedwithobjecKveandsubjecKvephysicalacKvitylevelsin
chronicnon-specificlowbackpain
Carvalho2016APMR
Thatwecanusegeneralisedphysical
interven&onsforspecificproblems
• NoneoftheobjecKvemeasuresofphysicalacKvitywere
associatedwithfearofmovement–InacKvitynotassociated.
• Fearofmovementwasassociatedwithdisability(Roland-
Morris)
• SuggeststhatpeopleDOusetheirbodiesAPARTfromspecific
movements
• Generaliseduseofthebodymaynothaveanfurthereffect
Dopeoplewithlowerbackpainhavedifferent
movementhabits?
Tsang-BMC2017
• MuchlowerlevelsofvariabilitywithLBP
• Theabilitytoregulatethelumbo-pelvicmovementpaVernduringthe
bendingtaskthatexecutedatvariousspeedlevelswasshownonlyin
pain-freeindividualsbutnotinthosewithlowbackpain(over3
months)
• Individualswithlowbackpainmovedwithastereotypedstrategyat
theirlumbarspineandhipjoints
• Contributetomaintenanceandchronicity
Theeffectsofbendingspeedon
thelumbo-pelvickinema&csand
movementpaOernduringforward
bendinginpeoplewithand
withoutlowbackpain
Tsang-BMC2017
Theeffectsofbendingspeed
onthelumbo-pelvic
kinema&csandmovement
paOernduringforward
bendinginpeoplewithand
withoutlowbackpain
Differencesinlumbarspineandlower
extremitykinemaKcsduringastep
downfuncKonaltaskinpeoplewith
andpeoplewithoutlowbackpain
Hernandez2017
• Subjectswithlowbackpaindisplayedlesslumbar
spinemovementthancontrolsacrossallthreeplanes
ofmovement
• AredistribuKonofacKvityto
differentregionsofthe
lumbarerectorspinaewas
observedwhenpain-free
individualsperformeda
repeKKveliFingtask.
• PeoplewithLBPperformed
therepeKKvetaskby
increasingtheacKvaKonof
thesameregionsofthe
muscleovertheduraKonof
thetask,thatis,without
variabilityinmuscleacKvity”
Reducedtask-inducedvariaKonsinthedistribuKonof
acKvityacrossbackmuscleregionsinindividualswithlow
backpain– Falla.Pain2014
Comparinglumbo-pelvickinema&csinpeoplewithand
withoutbackpain:asystema&creviewandmeta-analysis
LairdBMC2014
• 43studies
• Onaverage,peoplewithLBPhavereducedlumbarROM
andpropriocepKon,andmovemoreslowlycomparedto
peoplewithoutLBP.
• WhetherthesedeficitsexistpriortoLBPonsetis
unknown
Changesinthemechanicalproper&esofthe
trunkinlowbackpainmaybeassociatedwith
recurrence
Hodges2009JofBiomechanics
• N=14(RecurringLBP)N=17(healthy)
• LBPgrouptrunksKffnesswasincreased
• AugmentedtrunkmuscleacKvityandchangesin
reflexcontroloftrunkmuscles
• Consequencesforpainandrecurrence
Lowbackpainstatusaffectspelvis-trunkcoordina&onand
variabilityduringwalkingandrunningSeayetalClinBiomech2011
• CollecteddataduringwalkingandrunningofcoordinaKonofthoraxandpelvisin3
planes.
3groups
• ChronicLBP
• Singleboutofbackpainresolved
• Nobackpain
• TheywereabletoidenKfyeachgroupbylevelofvariabilitythatdecreasedwith
chronicity
• CliniciansneedtolookbeyondtheresoluKonofpainwhenprescribing
rehabilitaKonforlowbackpain
Pelvis-thoraxcoordina&oninthetransverse
planeduringwalkinginpersonswith
nonspecificlowbackpain–Lamoth2002Spine
• IncomparisonwithhealthyparKcipants,the
gaitofpaKentswithlowbackpainwas
characterizedbyamorerigid,lessflexible
pelvis-thoraxcoordinaKon
Mechanicalcouplingbetweentransverse
planepelvisandthoraxrota&onsduringgaitis
higherinpeoplewithlowbackpain–VandenHoorn2012
• Theseresultssupporttheargumentthat
peoplewithLBPadoptaprotecKve
movementstrategy,possiblybyincreased
trunksKffness.
Takehomes
• Peoplewithchronicbackpainappeartomovedifferently
• ThisischaracterisedbylessvariaKon&lessmovement
• Morelikelytobeaneffectratherthanacause
• Couldthismaintaintheproblem?CondiKonedbehaviorsandcoupledpain?
• Especiallyasstrength/condiKoning/acKvitymaynotbetheproblemformany
people
Sowhatdowedowiththisinfo?
• Encouragerelaxed,free,flowingmovement&variedmovementtasks?
• Lookatpremovementbehaviorssuchasbracing
• Don’ttryandmeasureorworryaboutchanging–ItmaynotmaVer!
Whichexerciseworksbestforlowerback
pain?
Cri&cisms
• Test2exerciseswithnocontrol–Regressiontothe
mean
• Externalvalidity–Takesawayadherenceissues
• Singlefactorthinking
• Canbesedentarygroups
• Todetermine,foradultswithchroniclowbackpain,which
exerciseintervenKonsarethemosteffecKveatreducingpain
comparedtoothertreatments.
• Combinedmeta-analysisrevealedsignificantlylowerchroniclow
backpainwithintervenKongroupsusingexercisecomparedtoa
controlgrouporothertreatmentgroup
• Ourresultsfoundabeneficialeffectforstrength/resistanceand
coordinaKon/stabilisaKonexerciseprogramsoverother
intervenKonsinthetreatmentofchroniclowbackpain
Exerciseinterven&onsforthetreatmentofchroniclowbackpain:a
systema&creviewandmeta-analysisofrandomisedcontrolled
trials–Clinicalrehabilita&on2015
• IndividuallyaddressedtheparKcipant’sthoughtsandbeliefsabouttheirLBPin
relaKontomovement.
• BothintervenKonsreducedpainintensityandincreaseperformanceintestsofliF
strengthandsometestsoftrunkmuscleendurance,overKmewithnodifference.
• Trainingwithahigh-loadliFingexercise,thedeadliF,seemsbeneficialmainlyto
paKentswithaniniKallylowerpainintensityandhigherperformance.
DeadliFtrainingforpaKentswithmechanicallow
backpain
Acomparisonoftheeffectsofahigh-loadliFing
exerciseandindividualizedlow-loadmotorcontrol
Exercises.
LarsBerglund2015
• Comparedtogeneralexercise,corestabilityexerciseis
moreeffecKveindecreasingpainandmayimprove
physicalfuncKoninpaKentswithchronicLBPinthe
shortterm.
• However,nosignificantlong-termdifferencesinpain
severitywereobservedbetweenpaKentswhoengaged
incorestabilityexerciseversusthosewhoengagedin
generalexercise.
• Whynotlongterm?
• ExpectaKonofaclinicallymeaningfultreatment?
WangXetal.Ameta-analysisofcorestabilityexerciseversusgeneralexercisefor
chroniclowbackpain.PLoSOne.2012
•
Anaerobicwalkingprogrammeversusmusclestrengthening
programmeforchroniclowbackpain:arandomizedcontrolledtrial
Shaynaderman–2013
• FiFy-twosedentarypaKents,aged18-65yearswithchroniclowbackpain.
• Moderateintensetreadmillwalking;control'exercise'group:specificlowback
exercise;both,twiceaweekforsixweeks.
• Six-minutewalkingtest,Fear-AvoidanceBeliefQuesKonnaire,backand
abdomenmuscleendurancetests,OswestryDisabilityQuesKonnaire,LowBack
PainFuncKonalScale(LBPFS)
• Significantimprovementswerenotedinalloutcomemeasuresinbothgroups
withnon-significantdifferencebetweengroups.
• Asix-weekwalktrainingprogrammewasaseffecKveassixweeksofspecific
strengtheningexercisesprogrammeforthelowback
NoCLEARsuperiority
• WhatacKviKesdopeopleENJOY?
• Howeasyisitforthemtodo?
• HowrelevantisittotheirfuncKonal
outcomemeasures?
• Aretheyeasilyabletoaccessthenecessary
equipmentorneedspecialistinstrucKon?
w y ?
Keystoagreatrehab
program
Fitsinwithworkandfamilylife
Asfewexercisesaspossible
Minimal/easily
availableequipment
InsKllsconfidenceandsenseofselfefficacy
Takesintoaccount
preferencesUKlisesbestavailableevidence
Caneasilyberegressedorprogressed
Ismeaningfulandrelevant
CanbeperformedinanylocaKon