A Personal Trainer’s Evidence-Based Guide to Lower Back Pain by Ben Cormack
Although there are mountains of research into back pain there has been neither a simple cure nor cause present itself, despite what you may read on social media and the Internet in general! The strength or ‘correct’ firing of a particular muscle or the right level of stability, mobility or alignment at a joint is clung on to by many in the world of fitness, but there is no real evidence to back up the mountains of mechanically based theory. In fact, there is a lot of evidence to the contrary.
The medical world has been stumped by this problem for ages hence all the research and diagnosis such as ‘non-specific back pain’. It is becoming more apparent that this is an issue that goes well beyond mechanics and simple binary thinking. Research by Bardin (2017) found that a specific pathology (fracture, malignancy, infection) accounted for under 1% of back pain and between 5-10% was radicular (nerve or nerve root related) in nature. The rest of it, 90%, is termed unspecific. This simply means we have no real idea where the pain is coming from and added to what we know about the complexity of pain means it is currently a very unclear picture.
The number of factors that may play a role in back pain are many, as we can see from the graphic below. They may all need to be taken into consideration in varying degrees based on the individual.
What does this mean for the personal trainer?
The first thing a trainer can move away from is trying to find or treat a cause. Common gym-based diagnosis’s such as “you lack core ‘stability” or “your posture is bad” are simply not supported by the available evidence we have at this point.
Here are some examples of common ‘problems’ not really supported by the evidence base.
Smith et al (2014) using a systematic review of 29 papers found that core stability exercises were no more effective than any other form of exercise and that because of the strong level of research this conclusion was unlikely to change. This is in contrast to much of the advice given in many quarters about the ‘best’ exercise for back pain.
Lots of research, including Tsang’s recent 2017 study, shows that people with lower back pain actually have increased ‘core stability’ and this makes their movement more rigid, stiffer and less variable. Perhaps a key is not to focus on their stability by switching on their ‘core’ but instead making people more relaxed and trying to switch muscles ‘off’ might be beneficial.
Heino (1990) found that tight hip flexors had no relation to lumbar curvature, a common myth, and another large systematic review (Christensen 2008), using 54 papers, found that spinal curves, in general, were also unrelated to back pain. Murrie et al (2003) also found that lumbar lordosis and back pain were unrelated in their study. Nourbakhsh et al (2002) found that structural factors such as the size of the lumbar lordosis, pelvic tilt, leg length discrepancy, and the length of abdominal, hamstring, and iliopsoas muscles were not associated with the occurrence of LBP.
This might be quite different to the information that is currently available to the personal trainer but is based on the best available current evidence. If somebody proposes a ‘fix’ for back pain then they must produce some decent evidence that their cure has been implicated with factors involved in back pain, or has had an effect on back pain. Always remember extraordinary claims require extraordinary evidence!
A theory is just a theory until it is supported with some evidence. The fitness world has long been dominated by theory often lagging well behind the available evidence, or just simply not requiring people to provide any.
The problem with misinformation is it also drives our next problem, this being what trainers are telling their clients. A poorly thought out ‘diagnosis’ regurgitated from an internet guru might just do a little more damage than you think.
Words affect people deeply. The beliefs that people hold about their backs can influence how people perceive their ability to perform certain movements and may actually make their problems worse not better. Telling people they may lack core stability, as an example, may imply more to someone than is actually intended. Darlow’s (2011) research into the use of the language used around back pain and how it is perceived, explored the term ‘instability’, among many others.
The term instability was actually perceived as “the back could go at any time” or “Something’s a bit loose … It’s liable to pop out”.
How would that affect your movement or function if you felt this way about your back? Increased muscular co-contraction and reduced relaxation are already associated with back pain so using these types of terms may actually INCREASE the pain, turning up the pain dial rather than helping turn it down.
Much as words can hurt, they can also help. One of the leaders in the field of pain education Adriaan Louw looked at how helping people understand more about how pain works can have a positive influence.
His group’s systematic review “The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain” came to this conclusion.
“For chronic MSK pain disorders, there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance”
So, how can you help?
Movement helps. Simple. Not just the movement itself but people’s perception of how much they can move and their confidence levels to do so. A great relationship with your client can help them overcome their reticence of activity rather than inducing further problems with spurious information. Pain and fear of pain or “throwing the back out” influences peoples activity level but what better way to increase activity levels than under the watchful eye of a qualified trainer who understands the current evidence base?
Exercise seems to be beneficial in whatever format it is delivered. Searle (2015) found beneficial effects for strength/resistance and coordination/stabilisation exercise programs and Steffens (2016) research suggested that exercise was the most effective way we have of preventing back pain.
Think about people’s exercise preferences more than trying to find the ‘best’ exercises, Shnayaderman (2013) found no difference in the effectiveness for pain between an aerobic walking program and a specific strengthening program. If someone enjoys it they are more likely to do it and therefore gain a beneficial effect.
In fact, as all types of exercise seem to offer benefits, trainers are uniquely placed to offer help in nearly all of the areas, bar pathology and diagnosis, which are both tricky and contentious subjects for even the most highly qualified. Yang (2016) found that physical activity, smoking and obesity were all linked to back pain and these lifestyle factors are all things personal trainers can have a direct impact on and within their scope of practice too.
Finding the right level of activity for your client with back pain is vital. This has been termed ‘graded exposure’ and may mean that just simply moving rather than ‘training’, as regular gym-goers or professionals might see it, is a real positive for some. We may not need to focus on specific lifts or increasing strength for specific muscles.
Sometimes people display specific movement issues such as a fear of flexing or pain when flexing as an example. It is important not to see these movements as problematic but instead try to reintroduce them. Explaining to someone that they will ‘blow out’ their disc if they squat wrong is really not helpful if we appreciate how words can hurt and is probably just not true! People squat with horrendous form on a daily basis and the vast majority never ‘blow out’ a disc.
Instead how to get people back to being happy to move in an unrestricted manner should be the main aim. Slowly introducing positions that have been previously problematic with the minimal amount of discomfort is paramount to increasing functional capacity.
- A specific diagnosis is hard to come by and unlikely to be tied to a single factor
- Movement helps
- Think variety rather than a specific movement, exercise or muscle
- Find exercises that people will enjoy and do
- Use graded exposure & slow progressive loading
- Introduce relaxation rather than stabilisation and stiffness
- Remember words can both hurt and help
Ben Cormack owns and runs Cor-Kinetic. He is a musculoskeletal therapist with a clinical background in sports therapy, rehabilitation, pain science & exercise stretching back 15 years. He specialises in a movement & exercise based approach with a strong education component and patient centred focus. Ben is a popular international presenter who has delivered conferences presentations and courses all over the world.
- Bardin et al. Diagnostic triage for low back pain: a practical approach for primary care Med J Aust 206(6):268-273. 2017
- Christensen, ST, and Hartvigsen, J. Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health.
- Darlow, B, Dean, S, Perry, M, Mathieson, F, Baxter, GD, and Dowell, A. 100 Easy to harm, hard to heal: Patient views about the back. Spine 40(11): 842-850, 2015
- Heino et al. Relationship between hip extension, range of motion and postural alignment. JOSPT. 1990
- Murrie, VL, et al. Lumbar lordosis: Study of patients with and without low back pain. Clinical Anatomy 16(2): 144-147, 2003
- Nourbakhsh, MR, and Arab, AM. Relationship between mechanical factors and incidence of low back pain. Journal of Orthopaedic and Sports Physical Therapy 32(9): 447-460, 2002
- Louw et al. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. (12):2041-5
- Steffens et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med.;176(2):199-208 2016
- Shnayderman et al. An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial Clin Rehabil. 27(3):207-14. 2013
- Searle et al. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil.29(12):1155-67. 2015
- Tsang et al. The effects of bending speed on the lumbo-pelvic kinematics and movement pattern during forward bending in people with and without low back pain. BMC Musculoskeletal Disorders:157 2017
- Smith et al. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskeletal Disorders. 2014
- Yang et al. Behavior-related Factors Associated with Low Back Pain in the US Adult Population. 2016