Persons with chronic nonspecific low back pain (CNSLBP) often experience physical activity intolerance, physical deconditioning, and follow a more sedentary lifestyle than individuals without CNSLBP (6,17,18,20). New physical activity (PA) guidelines for apparently healthy adults can apply to individuals with CNSLBP and provide exercise professionals with evidence-based tools and scientific rationale to help their clients adopt a more physically active lifestyle (1,3,19). This column will discuss PA/exercise program recommendations for medically cleared clients with CNSLBP who have been discharged from formal physical therapy and rehabilitation. Exercise professionals who ignore their client's reports of new or worsening symptoms or fail to refer them to their physician and/or health care provider can be held negligent. Clients with CNSLBP can participate in and benefit from the same types of exercise programs as persons without CNSLBP (7–11,15,17).
Because many persons with CNSLBP are sedentary and experience physical activity intolerance, other health issues (e.g., hypertension and type 2 diabetes) may be present in this population. Clients should complete a thorough preactivity screening with an exercise professional (1). Exercise professionals should determine client's risk(s) according to the guidelines set by the American College of Sports Medicine (1). Depending on their level of risk, the client may need a medical examination and/or a physician-supervised graded exercise test before being medically cleared to begin an exercise program.
Preactivity exercise testing helps exercise professionals determine their client's physical fitness, physical activity tolerance levels, functional capacity, and establish realistic PA/physical fitness program goals (1). Client symptoms, tolerance and comfort should dictate which exercise testing modes and protocols are selected (5,15,17).
Cardiorespiratory fitness testing using either a treadmill, bicycle, or step ergometer with either a ramp or incremental protocol has been well tolerated and is an effective evaluation tool for persons with CNSLBP (5,15). In addition, the 6-minute walk test has been proven an effective field test of cardiorespiratory fitness in persons with CNSLBP (15). Muscle strength testing using a multiple repetition maximum has been well tolerated and an effective tool for measuring current strength levels, determining training loads and measuring postprogram strength increases in clients with CNSLBP (8–10). The use of standard ratings of perceived exertion (RPE) or the OMNI rating of perceived exertion for resistance exercise (OMNI-RES 10) can approximate intensity of client effort during both strength testing and resistance training (RT), respectively (1,16). The “timed up and go” and multiple repetition sit to stand tests are appropriate tools for measuring neuromotor performance in older individuals (60 years and older) with CNSLBP. The inability to tolerate prolonged sitting, standing, frequent bending (trunk flexed postures), and pain exacerbations can negatively affect client test tolerance and performance effort(s) (16).
Aerobic training (AT) has been well tolerated in persons with CNSLBP (9,12). Walking, cycling, step ergometry, swimming, elliptical and aquatic exercises are acceptable forms of AT (15,17). An appropriate goal for clients with CNSLBP is to try and accumulate ≥30 minutes of moderate intensity AT on most (≥5) days of the week. Initially, this goal might be best tolerated in 10-minute episodes, 2–3 times per day in more deconditioned persons. Subsequently, total daily time in a single episode can be increased over a few weeks (15). Focus on increasing duration before intensity, building to longer periods of sustained aerobic activity (e.g., 30 continuous minutes or more). An exercise intensity equivalent to an RPE of between 12 and 15 (6–20 scale) is appropriate for persons with CNSLBP. Client pain and discomfort, other symptoms, and most comfortable postural positions should dictate exercise mode selections and modifications.
Clients with CNSLBP are encouraged to follow RT guidelines for apparently healthy sedentary individuals (1,3,15). Clients should perform 8–10 exercises, emphasizing all major muscle groups, using a variety of modalities (free weights, machines, resistance exercise tubing, and body weight/calisthenics). Initially, RT should be performed on 2–3 nonconsecutive days per week (1–3,15). An initial training intensity that is equivalent to either an RPE of 12–13 (of 20) or 3–5 (of 10) on the OMNI RES scale is appropriate. If tolerated, progress to an intensity level equivalent to a 14–16 RPE or 4–5 OMNI RES scale. Clients with CNSLBP are advised to use lower intensity higher repetition protocols to maximize muscular endurance, to avoid exercising initially on unstable surfaces (BOSU Balls, etc.) and to maintain proper exercise technique and posture (15). Load and intensity progressions should be dictated by client tolerance. Lumbar extension resistance exercises increase back extensor muscle strength and should be included in conditioning programs for persons with CNSLBP (15). Extension exercises can be progressed from easier (lying prone on floor with arms at sides) to more challenging (the swimmer and superman on the floor or a stability ball), to “Bird-dogs” on the floor in quadruped position (15). Periodized, progressive, multiple set RT programs have produced significant increases in strength in persons with CNSLBP that were comparable to apparently healthy individuals (8–10). Clients with CNSLBP are encouraged to follow an intensity progression protocol similar to the “two for two” rule (increase intensity after 2 or more repetitions per exercise set are performed beyond the goal repetitions for 2 consecutive sessions) if tolerated (2). Although single set RT exercise protocols have produced significant strength increases in sedentary and untrained individuals, progressing to a protocol of 2–4 sets per exercise is recommended as tolerated (1–3). For additional resources that discuss both CNSLBP management and back conditioning exercises refer to McGill (13,14).
FLEXIBILITY AND NEUROMOTOR TRAINING
A series of flexibility activities for each major muscle-tendon unit is recommended. Clients should hold each stretch for between 10 and 30 seconds and accumulate a total stretch time of at least 60 seconds per exercise. Longer stretching durations of between 30 and 60 seconds per repetition may be warranted for older individuals. Stretches should be preceded by light aerobic activity (11–13 RPE or 4–5 OMNI Scale) for 8–10 minutes. Static, dynamic, and proprioceptive neuromuscular facilitation stretching are all acceptable as tolerated (1,3). Hamstring, hip flexors, and anterior shoulder girdle muscle flexibility exercises should be emphasized (1,15). In addition, clients with CNSLBP generally should:
- Avoid flexion (trunk bending) exercises soon after awakening.
- Avoid standing toe touch exercises/stretches.
- Emphasize balance spinal flexor and extensor muscle range of motion exercises (15).
- Exercise programs should be modified if clients experience increasing symptoms with either flexion or extension.
Exercises, which improve balance, gait, and proprioception, such as tai chi and yoga, are recommended for older individuals to maintain independent physical function and prevent falls. Training sessions lasting 20–30 minutes on at least 2–3 d/wk are appropriate for older individuals (1,3) and have been well tolerated in persons with CNSLBP (4,12). Exercise professionals should modify exercise selection, intensity, and volume if clients experience increased pain or fatigue and communicate with and refer their clients back to their physician and/or health care provider. Table 1 summarizes ACSM PA/exercise guidelines for apparently healthy individuals. There are some special exercise considerations (Table 2) for clients with CNSLBP that exercise professionals should be aware of.
Persons with CNSLBP derive the same physical health and quality of life benefits from individualized exercise programs as apparently healthy participants without CNSLBP. Comprehensive, individualized, progressive exercise programs consisting of AT, RT, flexibility, and neuromotor training have been proven effective in enhancing physical activity tolerance and function and well tolerated in persons with CNSLBP. Exercise professionals should perform within their scope of practice by obtaining medical clearance from their clients, monitoring clients for signs of overexertion, communicating regularly with their client's physician or health care provider and by working with clients who have been discharged from formal physical therapy and rehabilitation.
1. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription (8th ed). Philadelphia, PA: Lippincott Williams & Wilkins, 2010. pp. 18–29, 152–182.
2. American College of Sports Medicine. Position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc 41: 687–708, 2009.
3. American College of Sports Medicine. Position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc 43: 334–359, 2011.
4. Descarreaux M, Normand MC, Laurencelle L, Dugas C. Evaluation of a specific home exercise program for low back pain. J Manipulative Physiol Ther 25: 497–503, 2002.
5. Duque IL, Para JH, Duvallet A. A new non exercise-based V02max prediction equation for patients with chronic low back pain. J Occup Rehabil 19: 293–299, 2009.
6. Duque IL, Para JH, Duvallet A. Maximal aerobic power in patients with chronic low back pain: A comparison with healthy adults. Eur Spine J 20: 87–93, 2011.
7. Henchoz Y, Kai-Lik So A. Exercise and nonspecific low back pain: A literature review. Joint Bone Spine 75: 533–539, 2008.
8. Jackson J, Shepherd T, Kell R. The influence of periodized resistance training on recreationally active males with chronic nonspecific low back pain. J Strength Cond Res 25: 242–251, 2011.
9. Kell R, Asmundson G. A comparison of two forms of periodized exercise rehabilitation programs in the management of chronic nonspecific low back pain. J Strength Cond Res 23: 513–523, 2009.
10. Kell R, Risi A, Barden J. The response of persons with chronic nonspecific low back pain to three different volumes of periodized musculoskeletal rehabilitation. J Strength Cond Res 25: 1052–1064, 2011.
11. Koes BW, Van Tulder NW, Thomas SS. Diagnosis and treatment of low back pain. BMJ 332: 1430–1434, 2006.
12. Maul I, Laubli T, Oliveri M, Kroeger H. Long-term effects of supervised physical training in secondary prevention of low back pain. Eur Spine J 14: 599–611, 2005.
13. McGill SM. Low-Back Disorders: Evidence Based Prevention and Rehabilitation (2nd ed.). Champaign, IL: Human Kinetics Publishers, 2007.
14. McGill SM. Ultimate Back Fitness and Performance (4th ed.). Waterloo, Canada: Back Fit Pro Inc, 2009. Available at: www.backfitpro.com/
. Accessed: August 14, 2012.
15. Perkins J, Zipple JT. Non-specific low-back pain. In: Clinical Exercise Physiology (2nd ed). Ehrman JK, Gordon PM, Visich PS, Keteyian SJ, eds. Champaign, IL: Human Kinetics, 2009. pp. 497–520.
16. Robertson RJ, Goss FL, Rutkowski J, Lenz B, Dixon C, Timmer J, Frazee K, Dube J, Andreacci J. Concurrent validation of the OMNI perceived exertion scale for resistance exercise. Med Sci Sports Exerc 35: 334–341, 2003.
17. Simmonds MJ, Derghazarian T. Lower back pain syndrome. In: ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities (3rd ed). Durstine JL, Moore GE, Painter PL, Roberts SO, eds. Champaign, IL: Human Kinetics, 2009. pp. 266–269.
18. Smeets RJ, Wittink H, Hidding A, Knotterus JA. Do patients with chronic low back pain have a lower level of aerobic fitness than healthy controls?: Are pain, disability, fear of injury, working status or level of leisure time activity associated with the difference in aerobic fitness level? Spine (Phila Pa 1976) 31: 90–97 discussion 98, 2006.
19. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. Washington, DC; 2008. Publication Number V0036. Available at:http://www.health.gov/paguidelines/pdf/paguide.pdf
. Accessed: August 14, 2012.
20. Vlayen JW, Linton SJ. Fear avoidance and its consequences in chronic musculoskeletal pain. A state of the art. Pain 85: 317–322, 2006.