Last week we posted an article discussing some of the research around the clinical guidelines of low back pain.
There are several modalities commonly used that aren’t recommended like Tens, laser therapy, imaging, and corticosteroids, but when we look at what is recommended we have an opportunity to make a real difference for those suffering from back pain.
One of the big things recommended is a biopsychosocial approach along with education. In order to start this kind of approach, patient reassurance is critical in order to help the patient feel safe (as we talked about last week).
In addition to reassurance, supervised exercise is also a crucial part of helping patients deal with their back pain. However, these two go hand in hand as it will quite often take a considerable amount of reassurance to convince a patient that it is okay to move.
One way to help is by looking at what the research says for exercise and low back pain, which you can use as a tool to convince (and reassure) patients this is the best course of action.
Exercise For Low Back Pain
Remember the old days when bed rest was the main prescription for low back pain?
Well, now bed rest is actually discouraged unless the pain is too severe, then only two days of bed rest are chosen. In contrast to this, we now understand that staying active has far better outcomes than the way we used to manage this.
And I know many of you might be saying “exercise is out of my scope of practice” and while this may be true, active and passive range of motion probably is within your scope, so there is no reason you can’t incorporate some of this into your treatments.
I know there is probably some concern over being able to recommend “specific” exercises (or movements) but don’t worry it doesn’t have to be all that complicated…in fact, it shouldn’t be! Supervised movement without the use of expensive equipment is one of the specific recommendations, so you can do this right in your treatment room.
This is especially true in the acute stage, where strengthening, extension, and specific exercises are not recommended. Rather, in this case, we want to use graded exposure to physical activity. Graded exposure is essentially getting a patient to move (gradually) into a feared or painful movement (we’ve had articles about this before which you can read HERE for a more detailed description).
For example, when it comes to acute low back pain, if your patient is scared, or experiencing pain with a certain movement like standing forward flexion, have them change the plane of movement and try flexion again. Try having them sit comfortably in a chair, then lean forward. This is still spinal flexion, it’s just in a more supportive position. When they can move in this position comfortably, point out how capable they are of the movement and reassure them that flexion is safe. You can then gradually work up to standing flexion until this feels safe again.
There are many ways to do this, it just takes a little experimentation on your part.
When it comes to chronic low back pain there is no evidence that one exercise is superior to another.
However, recommendations show that remaining as physically active as possible along with an early return to work is well supported by evidence (probably why some workplaces have a gradual return to work program). While there are no specific exercises highlighted as more effective than others, the exercises that work are simply the ones your patient will do. Find out what’s important to them and encourage them to do it. Whether it is strength training, going for a walk, playing with their kids, or playing hockey, the intent is to build confidence in their bodies as opposed to fixing a problem.
Inevitably the question of dosage comes up and the research shows that too much, or too little exercise with some patients can run the risk of developing persistent pain. This is where it’s important to experiment a little to see what works best for the patient, we don’t want them to overdo it, but also want to avoid not doing enough (one of the reasons bed rest has been eliminated).
Overall since we know a biopsychosocial approach is most effective, encourage things like movement in general, getting back to work, staying connected with the things and the people they enjoy. Just make sure these things are done gradually. If we can address peoples fear of movement by using graded exposure early on, we have a better chance of avoiding prolonged pain and disability. So, don’t stress about ‘specific’ exercises, the overall goal is to get our patients moving and keep them moving. Movement along with some education and reassurance can go a long way in not only improving low back pain but also the patients quality of life.