ARTHRITIS AND DEGENERATIVE CHANGES
The most common form of arthritis is degenerative in nature and often referred to as osteoarthritis. Degenerative changes involving the joints are commonly termed degenerative joint disease, whereas degenerative disc disease involves dehydration and degenerative changes of the intervertebral disc (4). These degenerative changes are frequently accompanied by a decrease in lubrication of the articular surfaces with synovial fluid and a stiffening of the joint capsule. Deleterious forces distributed through the facet joints in the lumbar spine can advance the degenerative process and occurs most often during movements that tend to compress the joints such as extension or rotation (13). Individuals with either of these conditions will likely describe morning stiffness that eases with activity or movement. These individuals should spend additional time warming up before exercise and in advanced cases may consider alternate exercise environments such as a pool. As arthritis and degenerative changes advance, one is likely to develop symptoms associated with spinal stenosis.
Spinal stenosis is a general term, which describes a compromise or narrowing of key spaces within the spine (39). Two key areas commonly affected by spinal stenosis include the central canal and the lateral (intervertebral) foramen (Figure 2). The central canal is the space where the spinal cord and the cauda equina are located within the protective margins of the vertebrae. Narrowing of the central canal can occur because of various reasons, including degenerative changes or disc pathology (27). Lateral foraminal stenosis occurs when the space between 2 vertebrae, where the lumbar nerve roots exit, becomes narrowed. This may be because of a decrease in disc height or formation of bone spurs in the lateral foramen. Regardless of whether the stenosis is central or lateral foraminal, patients often describe an exacerbation of symptoms with extension-biased activities, which include standing or walking for prolonged periods of time and arching the spine (39).
Spondylolytic conditions that may contribute to LBP include spondylolysis and spondylolisthesis. Spondylolysis is a defect in the pars interarticularis most commonly associated with a stress fracture, whereas spondylolisthesis suggests an anterior or posterior displacement of the vertebrae (32). The strength and conditioning professionals should be cautious with those individuals who report a history of activities requiring competitive sport participation and repeated backward extension or loading because they tend to have a predilection for a spondylolytic disorder. Repeated extension in individuals with a spondylolysis may exacerbate the condition and further disrupt the anatomy. These individuals will generally benefit from maintaining a neutral spine and avoiding excessive flexion or extension. Readers are encouraged to review the article by Nau et al. (32) for a detailed discussion of exercise selection appropriate for individuals with a spondylolysis or spondylolisthesis.
Repeated movement in different directions and sustained positioning can influence symptoms associated with LBP (22). Some movement patterns may exacerbate symptoms, whereas others may help ease symptoms and prepare an individual for exercise (19). If an individual notices a decrease in symptoms, it is suggested that they would have a "preference" for this direction. Symptoms that increase with movement and move down the leg would be referred to as "peripheralization" and should be avoided because this can signify worsening of one's condition (24). A recent systematic review evaluated the efficacy of directional preference in management of LBP. Surkitt et al. (40) evaluated 6 different randomized controlled trials and found evidence that suggested that those with a directional preference demonstrated significantly better outcomes when compared with alternate forms of intervention. A case series by Long et al. (24) described poor outcomes for those individuals with LBP who received treatment not consistent with their direction of preference. Once treatment parameters changed to match the patient's direction of preference, symptoms began to improve.
Another large-scale, randomized controlled trial evaluated 312 patients with reports of acute, subacute, and chronic LBP who participated in a standardized assessment evaluating their direction of preference (23). They found that those individuals treated with a match to their direction of preference demonstrated a significant improvement in symptoms (p < 0.001) when compared with those in unmatched groups. Although subjects included in the aforementioned studies were patients seeking treatment for LBP, the concept of directional preference is not limited to the patient population. The purpose of this article is not to "treat" LBP but to use a similar framework to decide how specific movements may be adapted or otherwise modified to make participation in a conditioning program more comfortable. There are 2 primary directions to consider for most individuals, which include extension and flexion (10). Others may simply prefer a neutral spine (between flexion and extension) position. The 2 patterns of directional preference and neutral spine positioning are discussed below.
EXTENSION DIRECTIONAL PREFERENCE
Individuals with a preference for extension-biased movements will report a reduction in symptoms during activities such as standing or walking. In some cases, an individual's LBP may improve while the leg worsens; therefore, careful attention to pain patterns and location is essential when working with this population. It is essential to note that any exercise that causes pain to travel into the thigh, leg, or foot (peripheralization) would be contraindicated irrespective of improvement in LBP.
There are several extension-biased movements that may be performed by individuals with a directional preference for extension. Consider incorporating these movements before or after a bout of exercise. Additionally, extension movements may be incorporated into one's routine as a preventative tool after flexion-biased exercises.
Extension can be performed in standing with the individual's hands placed posterior to their hips and feet approximately shoulder width apart (Figure 3). Ask the individual to gently extend backward for a trial of 3–6 repetitions with a brief hold at end range to determine how symptoms are influenced. If symptoms are eased, consider incorporating 10–15 repetitions before exercise and particularly after those exercises that place an individual in a forward bent position such as abdominal strengthening and seated rows. It is important to note that discomfort and or peripheralization should be avoided at all times.
Another option is a prone press-up that may reduce loading on the spine during movement when compared with standing (6). Ask the individual to lie prone with their hands placed at approximately shoulder level. While keeping their hips resting on the floor, they gently push up with their hands extending through the lumbar region (Figure 4). The individual should extend backward for a trial of 3–6 repetitions with a brief hold at end range to determine how symptoms are influenced. If symptoms are eased, consider incorporating 10–15 repetitions before or after exercise. As stated previously, discontinue this exercise or any exercise that peripheralizes the client's symptoms.
The prone swimmer is an exercise that requires dynamic control of the spine while in an extended position. To perform this exercise, ask the individual to lie prone with arms positioned overhead and legs extended. Begin by lifting the opposite leg and arm and alternating back and forth. To increase the dynamic aspect of the exercise, ask him or her to alternate movement of the arms and legs (Figure 5). Attempt a trial of 3–6 repetitions with a brief hold to evaluate the influence on symptoms. If symptoms decrease, consider incorporating 10–15 repetitions before or after exercise.
This is another exercise that requires dynamic control in an extended position. The individual lies prone with arms placed by their side and palms facing up. He or she should slowly extend their back, lifting the sternum from the floor while sliding their hands down the side of their leg. Be sure they keep his or her head in neutral and avoid extending the cervical spine (Figure 6). Again, attempt a trial of 3–6 repetitions with a brief hold to be confident symptoms will not be provoked. If the symptoms improve, consider 10–15 repetitions before or after exercise.
CARDIORESPIRATORY EXERCISE FOR EXTENSION DIRECTIONAL PREFERENCE
There are several ways to consider incorporating cardiorespiratory exercise for those with a directional preference for extension. Use of a treadmill may provide adequate cardiorespiratory challenge; however, inclines should be avoided because this may place the spine in a more flexed position. If balance is an issue, the client's hands should remain on the support rails and excessive inclines avoided. Stationary bikes may be useful; however, the individual must maintain an upright posture and maintain a proper lordosis during exercise sessions.
FLEXION DIRECTIONAL PREFERENCE
Unlike individuals with discogenic pathology who experience symptom worsening with flexion, those with degenerative changes such as spinal stenosis may have a preference for flexion-biased movements. These individuals will complain of symptoms with prolonged standing or walking (27). A reduction of symptoms will generally occur during activities such as sitting or bending forward. If this is the case, warm-up activities may include repeated flexion. Flexion may be contraindicated for individuals with certain comorbidities such as osteoporotic compression fractures and certain hip replacement surgeries (see hip arthroplasty article in this issue for further information on precautions); thus, it is essential that strength and conditioning professionals recognize their client's medical history. The following are representative examples of exercises for those with a directional preference of flexion.
KNEES TO CHEST
Start in the supine position with hips and knees flexed and feet flat on the floor. Then ask the individual to grasp one knee and then the other pulling both knees toward their chest (Figure 7). Attempt 3–6 repetitions with a brief hold at end range to evaluate the influence on symptoms. If symptoms are eased, the individual can incorporate 10–15 repetitions before or after exercise. This exercise is useful before or after a prolonged bout of extension activity such as walking or standing.
SEATED FORWARD BENDING
Ask the individual to sit at the edge of a chair with feet and knees spread. They should straighten their arms and slowly lean forward as if reaching down and back between the legs of the chair (Figure 8). Attempt 3–6 repetitions with a brief hold at end range to evaluate the influence of this motion on symptoms. If symptoms are eased, consider 10–15 repetitions before or after training.
Training of the abdominal musculature may be performed in individuals with LBP; however, caution must be exercised in those who experience pain with flexion (1). Ask the individual to lie on their back with hips and knees flexed and feet flat on the floor. With arms extended by their side, he or she should tuck their chin and slowly curl up, lifting the shoulder blades off the ground (Figure 9). Attempt a trial of 3–6 movements with a brief hold, and if no increase in symptoms occurs, consider a set of 10–15 repetitions before or after exercise.
CARDIORESPIRATORY EXERCISE FOR FLEXION DIRECTIONAL PREFERENCE
The treadmill can be a good way to provide cardiorespiratory exercise for individuals with a directional preference for flexion. However, walking tends to be an extension-biased activity, and those with a preference for flexion would have difficulty tolerating long bouts of time on a treadmill. To avoid excessive extension movements, consider elevating the incline of the treadmill. This will shift the center of mass forward unloading the posterior aspect of the spine and ease pressure on the lower back. Again, if there are any deficits in balance, the client's hands should remain on the support rails and excessive inclines avoided (16). A recumbent bike is most often recommended for this population because it tends to flex the spine and avoid provocative positions.
NEUTRAL POSITIONING PREFERENCE
Finally, some individuals may have preference for a more neutral-biased position. These individuals will report a reduction in symptoms when their pelvis is aligned neutrally (somewhere between flexion and extension). If this is the case, warm-up activities may include abdominal bracing in the neutral pelvic position. To obtain a neutral position, tilt the pelvis anterior and posterior and then find a comfortable middle position while maintaining a slight lordosis. This helps to maintain the natural secondary curve of the spine and is the position of least stress that helps to increase activity of the stabilization musculature (31). This position is particularly helpful for those with instability or weakness of the core musculature. Conditions associated with a preference for neutral include spondylolytic conditions or arthritic and degenerative conditions. The goal with these conditions is to place as little force through the spinal column as possible.
Abdominal bracing is a technique to increase stability across the midsection during activities (31). This is particularly important while a person lifts objects, which may place stress through the spine. Before bracing, it is important that the individual is in a relatively neutral pelvic position. Once in a comfortable neutral position, engage the abdominal and oblique muscles as if bracing for a punch to the midsection while squeezing the gluteal muscles slightly (Figure 10). Abdominal bracing should be a prelude to any stressful lifting, bending, or squatting exercise and should be maintained throughout the performance of any such exercise (5).
GROOVING MOVEMENT PATTERNS
Grooving movement patterns is a term that has been used to describe the process of learning movement control (29). There are 2 primary movement patterns that should be "grooved." The first pattern is control of pelvic orientation. The intent is for the individual to obtain a neutral pelvic position and challenge their ability to maintain this position. Although there are several methods to achieve this, "rotary stability planks" have been described as one technique to learn control of the spine and rotation of the hips together (29). To perform this activity, position the individual 2–3 foot lengths away from a wall leaning forward, bearing weight through their elbows (Figure 11A). Provide instruction for the individual to obtain their neutral pelvic position and obtain an abdominal brace. While maintaining an abdominal brace, he or she should rotate on their feet into a side plank position (Figure 11B), return to the start position, and then rotate into a plank position in the opposite direction (Figure 11C). It is important to maintain an abdominal brace the entire time they are performing the exercise. Consider asking the individual to perform 10–15 repetitions with deliberate form.
A second movement pattern is proper lumbopelvic disassociation. Specific movements in the lumbopelvic region tend to occur simultaneously for many individuals with LBP. Namely, as one squats and moves into hip flexion, lumbar flexion tends to follow (25). The process of teaching lumbopelvic disassociation separates these movement patterns and requires an individual to maintain the relatively extended position of lumbar spine while flexing the hips while squatting (26).
This can be a complicated pattern to teach, particularly in the population with LBP. It is recommended to do this in 3 phases. First, teach breaking of the hip, which is performed by placing the fingertips in the hip crease and flexing the hips while shifting their weight posterior. The individual must maintain a lumbar lordosis while performing this movement (Figure 12A). Once the individual can perform this movement, introduce a small squat with knee flexion while maintaining the lordotic posture (Figure 12B). The final phase encourages deeper squats while preventing the knees from excessive forward movement. Placing a chair in front of the knees will prevent them from moving forward excessively (Figure 12C). Finally, move the chair back 6–8 inches and allow for some forward movement of the knees. This is permitted as long as the knees do not extend beyond the toes and the hips move first. This movement is practiced until the individual can squat to an appropriate depth.
EXERCISE AND TRAINING CONSIDERATIONS
Aerobic conditioning has demonstrated positive results in those individuals with chronic LBP (14,17,20,37). Although resistance training or core stabilization exercise may be beneficial, the evidence suggests that a component of a training program should involve aerobic conditioning. Of particular concern in the population with LBP is the mode of aerobic conditioning as traditional activities such as jogging may exacerbate symptoms. Always consider comfort for those participating in prescribed exercise programs. As mentioned previously, an individual with spinal stenosis may find a recumbent bike more comfortable, whereas another individual with disc-related symptoms might find an elliptical trainer or treadmill less provoking. Consider aerobic training between 60 and 80% of an individual's respective estimated maximal heart rate reserve for a period of 20–60 minutes performed 3–5 times per week (15).
USE OF A BACK BELT
Use of a back belt has mixed support in the literature (36). It is generally not advocated as a preventative measure during weight training and should only be reserved for the heaviest lifts (2). However, in the population with LBP, it is often perceived that additional support is required. Again, although this is not supported in the literature, it is common to see individuals with LBP wear a corset or back belt as a means to alleviate symptoms. Let symptom response guide decision making with the goal of using a back belt as little as possible. If a short bout of back belt support allows an individual to participate in a conditioning program they otherwise would not be able to do, it may be beneficial. However, it must be clearly communicated with the individual that use of a back belt is temporary and the goal is to minimize its use.
Placing load through the lumbopelvic complex while participating in resistance training is common. Whether it is a squat or an overhead press, loads placed through the lumbopelvic complex can be aggravating to symptoms (30). This is particularly the case if an individual is unable to control their pelvic orientation. In a relatively neutral position, the lumbar spine is able to manage its greatest loads because of co-contraction of the abdominal and trunk musculature. However, if an individual were to assume an exaggerated posterior or anterior tilt of the pelvis and subsequently load the spine, symptoms may be exacerbated (29). Therefore, loading activities for those individuals with LBP should be carefully monitored. Weight should never inhibit their ability to maintain control of the lumbopelvic complex. Most importantly, a neutral pelvic position along with a proper abdominal brace should always be maintained during any loading activities (31).
INTEGRATION OF CONCEPTS INTO TRAINING
The strength and conditioning professional is likely to train clients with a current or recent history of self-limiting LBP. Integrating the concepts presented above will improve the ability of an individual suffering from LBP to participate in a training program. It is important to consider that LBP presents differently for each individual. Therefore, it is impossible to develop one program, which will be appropriate for everyone with LBP. Symptoms should always be monitored and considered in relation to the activity at hand. At no point should an individual perform movements or lifting that exacerbates symptoms. These exercises should be modified to accommodate the individual and avoid aggravating the condition.
In conclusion, LBP is one of the most common musculoskeletal conditions reported in industrialized society. The strength and conditioning professional has the ability to design training programs that improve conditioning and avoid exacerbation of symptoms in the population with LBP. It is essential to recognize that characteristics of LBP are unique; thus, all individuals with LBP should be monitored for symptoms and individualized accommodations in training should be made. Anyone with a history of LBP should receive medical clearance before initiating any exercise program, and communication between all relevant professionals involved in the clients' care is advised.
The authors would like to thank Mr. Erik Diaz for acting as a model in the photographs.
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Keywords:© 2013 by the National Strength & Conditioning Association
conditioning; directional preference; disc; lumbago; lumbar; stenosis