Lower Back Pain

Lower Back Pain Management

John is a qualified Level 4 Lower Back Pain Management specialist instructor. You may therefore ask John to help you with a programme of exercise as part of a referral from your GP/consultant. You may also approach John independently for help (self-referral).

Low Back Pain Defined

Low back pain (LBP) is pain, muscle tension or stiffness localised below the ribs and above the waist. Your pain may or may not be accompanied by leg pain (sciatica).

Back pain may be clearly due to an accident, injury, trauma or disease. However, in around 95% of back pain sufferers there is no specific problem, injury or disease. It is therefore not clear what is causing the pain. This type of back pain is known as non-specific low back pain.

The Incidence of Low Back Pain

Of this group 75% will have a significantly reduced amount of pain or be pain free and back to normal function within 4 weeks. Most of the remaining 25% take another 2 weeks or so to fully recover and be pain free.

However, a small percentage of this group do not recover within these time frames and go on to develop chronic LBP (cLBP) and related disability. Few people with chronic, long-term pain (ongoing for over 12 months) return to normal activities. Consequently, the bulk of healthcare and social costs associated with LBP relate to this patient group.

Estimates suggest that 4 out of 5 (80%) adults will suffer back pain at some point in their life (Maniadakis and Gray, 2000). Furthermore, at any given time, up to 33% of the UK adult population will be suffering from low back pain (Dionne, 1999).

Low back pain is the most common reason people seek medical advice from their GPs. Among the factors that are linked with higher incidence of LBP are:

  • having children
  • heavy manual labour
  • highly stressful jobs
  • lifestyle e.g. smoking

The Cost of Low Back Pain

In the UK, we lost 3.7 million working days through sick leave as a result of back pain in 2005-2006. It is thought to cost UK businesses over £5 billion annually.

Treating all types of back pain costs the NHS more than £1 billion per year with a further £565 million in private medical care.

The Role of the Low Back Pain Management Specialist Instructor

Even as a specialist Low Back Pain Management personal trainer, John does not offer to diagnose the cause of LBP. When you present with symptoms, however, John will be able to gather relevant information and understand the nature of the symptoms. john can then give suitable advice, design a programme of exercise, and make appropriate referrals if necessary.

Government Policy and National Guidelines for the Management of LBP

NICE guideline [NG59] (May 2009)

  • covers assessing and managing low back pain in people aged 16 and over
  • outlines physical, psychological, pharmacological and surgical treatments
  • aims to improve quality of life by promoting the most effective care for LBP

Figure 1: NICE NG59 Managing low back pain and sciatica flowchart

Figure 1 shows that exercise is an integral part of the care pathway for low back pain. Indeed, as the NICE guideline notes explain, exercise can be considered as a management strategy independent of other treatments.

Manual therapy and psychological therapy packages are also to be considered, “but only as part of a treatment package including exercise.”

Consequently, this puts the exercise professional with a Level 4 specialist qualification in the unique position of being able to accept a referral without the referring GP needing to first liaise with, for example, a massage therapist (manual therapy) or CBT practitioner (psychological therapy).

On the other hand, these practitioners would need to work with an exercise specialist before planning treatment.

Having a L4 specialist qualification allows John to deliver a client-centred programme as stipulated by the NICE guidelines, which state the requirement to “Take people’s specific needs, preferences and capabilities into account when choosing the type of exercise.”

RCGP Guideleines

The Royal College of General Practitioners (RCGP) produced guidelines adopted by NICE for the early management of persistent nonspecific low back pain in 2009. Some of their ‘key priorities’ were to:

  • Have a high impact on patients’ outcomes in particular pain, disability or psychological distress
  • Provide people with advice and information to promote self-management of their low back pain
  • Offer a structured exercise programme tailored to the person, to include aerobic activity, movement instruction, muscle strengthening, postural control, and stretching

Advice to continue with normal activity and be physically active is well supported by evidence to aid rapid recovery. Additionally, by avoiding unnecessary investigations the cost of care and the anxiety to the patient are reduced.

Pain killers have a role to play, but this is to enable a return to normal physical activity sooner and promote a faster recovery. Reliance on drugs may lead to patients thinking the physical activity or other physical therapies are not necessary or important.

Key Benefits of Exercise

Exercise for the management and prevention of low back pain:

  • Can be used with, or as an alternative to, medication
  • Improves mobility, body awareness, back strength and muscular endurance
  • Allows self management and therefore personal control of the condition
  • Improves low mood or mild to moderate depression resulting from LBP
  • Enhances self confidence and self esteem, despite LBP
  • Can result in better general health
  • Can decrease pain
  • Aids a return to function and work
  • May help prevent recurrence
  • Can be done at home
  • Improves posture and alignment
Return to Work

There is strong evidence that occupational outcomes for most people with most musculoskeletal disorders are improved by (increasing) activity, including early return to (some) work.

Traditionally LBP was treated with rest and immobilisation. It is nowadays viewed as a self-limiting condition that may not be cured but should be managed with:

  • appropriate pain medication
  • minimal rest
  • active self-management through exercise and education
  • an early return to work and normal activity
  • appropriate referral for any psychological issues that may become apparent
Self Referral

A client might refer themselves to a fitness professional, such as John, that they know deals with LBP issues. They may or may not have a diagnosis. During the initial consultation will highlight the LBP problem.

If necessary, and with the client’s knowledge and written consent, John will approach the client’s GP, consultant or other specialist for further information or confirmation of what the client has reported.

Self referral is becoming more common as a result of NHS waiting lists and often limited input available (e.g. a standard 6 physiotherapy sessions).

Client Assessment

Your initial contact with John will be a consultation based on a questionnaire. This is an information gathering exercise so we can build a picture of:

  • the history of the present condition
  • your personal history
  • any past medical history
  • current medication
  • lifestyle factors
Barriers to Exercise/Behaviour Change

Part of the consultation is to identify possible barriers to behaviour change and exercise, then look at strategies for overcoming these.

Common barriers to exercise include lack of time, fear of injury, cost, access, other commitments, self concept and self efficacy.

We devise and develop completely client-centred, tailored for you to employ should the need arise. It is important to understand that we are assessing your perception of barriers, so these strategies are effective as possible.

Practical Assessment

John, as an objective health and fitness professional, assesses you and records the findings. Therefore, this is often known as the objective assessment.

Dependent upon the consultation, this might include:

  • a static and dynamic postural assessment
  • range of movement assessment
  • basic gait analysis
  • flexibility assessments
  • joint stability
  • muscle testing
  • movement patterns
  • skills tests
  • functional needs
Goal Setting

You will be asked your goals during the initial consultation. However, it is only at this later stage, once the practical assessment has been completed, that we can set goals that are:

  • Specific – something definite and sufficiently detailed
  • Measurable – using a quantifiable scale (e.g. degrees of joint range of movement, or pain score)
  • Achievable/attainable/agreed – client-centred, facilitated by the trainer
  • Realistic – determined by your beliefs, values and attitude
  • Timed – with a definite time frame or target date

We will usually incorporate these factors into a client’s goals, depending on what the practical assessment reveals:

  • Restoring flexibility and mobility
  • Correcting instability
  • Correcting segmental control
  • Improving posture and function

John may prioritise these objectives in varying order, depending on the condition, and existing issues.

For example, if the client is suffering with stiffness from osteoarthritis, the priority would be mobilisation of the spine.

Or, if the issue is hypermobility of the sacroiliac joint post-pregnancy, the initial focus would be stabilisation.

Client-centred goal setting is about you expressing what you feel you need help with:

  • What is the issue as you perceive it and what do you want to do about it?
  • What do you want to change?
  • Which aspects of your lifestyle are you prepared to adjust?

It is important to point out that your pain may not disappear, but that exercise will help you manage your pain.

Exercise Programming

John will tailor your programme to minimise the loading placed on the body, whilst still gradually improving mobility and strength.

John will constantly monitor exercise intensity, movement quality and form/technique, due to the one-to-one nature of the exercise sessions. Because we adapt all activities to your ability, you can be sure your sessions are safe.

Each programme will include all of the following components, in varying degrees depending upon your needs.

Reduce/Eliminate Restrictions

  • Increasing body awareness
  • Educate and establish neutral and core stabilisation
  • Relaxing/releasing tight muscles through stretches, self-myofascial release, massage, etc
  • Improving muscle recruitment, sequential muscle firing and movement patterns

Increase Load/ROM

  • Work with static positions initially and progress to dynamic
  • Increase duration of stretches to assist with increasing ROM
  • Work with more load in a dynamic way, e.g. increase lever length
  • Progress exercises to move through larger ROM with short or long levers
  • Introduce more complex movement patterns

Functional Activities

  • Relate exercises and activities to daily living tasks
  • maintain spine/pelvic stability during these activities
  • Incorporate external resistance, e.g. dumbells, pulleys/cable machine, resistance bands, kettle bells, etc
  • Include cardiovascular activity

Cardiorespiratory training (aerobic exercise)

  • promotes better circulation
  • more efficient blood supply
  • greater concentration of oxygen and nutrients to muscles and other structures of the spine

Muscle strength and endurance

  • enables the muscles, tendons and ligaments to better support and stabilise the spine
  • decreases the amount of pressure on the discs
  • needed to maintain good posture and alignment for extended periods of time
  • allows safe execution of a full range of movement

Flexibility and mobility

  • maintains appropriate range of movement
  • address stiffness resulting from reduced movement due to pain and/or muscle tightness

Motor skills

  • balance influences posture and subsequently which muscles are activated when standing or sitting
  • coordination relates to muscle activation sequences, as well as how limbs move in relation to the trunk and to each other
  • reaction time can also influence muscle activation as pre-determined and often unconscious motor patterns come into play.

Evaluation

We will set an initial programme with a logical and measured approach to managing Low Back Pain, according to the information we have. However, John’s approach is also flexible and he will respond to feedback during each exercise, and after each session.

We schedule more formal reviews into the programme every 4-6 weeks, in order to ensure you are progressing towards your goals. We can then make amendments and goal re-assessments if necessary.

Further information

Please use the form on our Contact page to enquire about the use of exercise for managing chronic lower back pain.