Low back pain (LBP) is a broad term encompassing various conditions, with approximately 80% of adults experiencing it at some point in their lives. This type of pain is defined as discomfort located between the bottom of the ribs and the crease of the buttocks.
Maintaining high physical fitness, particularly in terms of back muscle endurance, is linked to a reduced risk of developing back pain. A common and detrimental belief is that exercise should be avoided when experiencing LBP. Many patients fear that physical activity might worsen their pain, leading them to avoid exercise and rely more on medications.
However, engaging in physical activity to improve both aerobic capacity and muscular strength, especially in the lumbar extensor muscles, is crucial for individuals with chronic LBP. It helps them manage daily activities more effectively.
Fitness:
Physical fitness encompasses a range of attributes that individuals possess or can develop. It is commonly defined as the capacity to perform daily activities with energy and alertness, without excessive fatigue, and with enough vitality to enjoy leisure activities and handle unexpected challenges.
Fitness is determined by how well a person meets various health-related components, including:
Cardiorespiratory Endurance: This is often measured by VO2 max relative to body weight.
Muscular Endurance: There is currently no universally accepted standard measurement for muscular endurance.
Muscular Strength: Several methods exist for assessing muscular strength. The Biering-Sorenson Test is a straightforward way to measure back strength, while Isokinetic Dynamometry is considered a gold standard but is costly.
Body Composition: The Four-Compartment Model, which typically measures body mass, total body volume, total body water, and bone mineral content, is regarded as the gold standard.
Flexibility: Advanced systems such as the Vicon Motion Tracking System are considered optimal for measuring flexibility.:
Cardiorespiratory Endurance:
Cardiorespiratory endurance reflects the efficiency of the body in delivering fuel during physical activities through the circulatory and respiratory systems.
Aerobic exercises that enhance cardiorespiratory endurance involve activities that elevate the heart rate over an extended period. Examples include swimming, brisk walking, jogging, and cycling.
Relevance to Low Back Pain (LBP):
Engaging in aerobic exercise boosts blood flow and nutrient delivery to soft tissues, including those in the back, which can accelerate the healing process. Additionally, 30 minutes of aerobic activity increases endorphin production, which provides natural pain relief and can help alleviate pain levels, potentially reducing the need for medication.
Low levels of aerobic fitness are linked to chronic low back pain (CLBP). Research indicates that maximum oxygen consumption (VO2max) is significantly lower by 10 mL/kg in men and 5.6 mL/kg in women with CLBP compared to their counterparts without the condition.
Muscular Endurance:
Fitness also encompasses muscular endurance, which is the ability of a muscle to sustain exertion over an extended period without fatigue.
Individuals with low back pain typically have lower endurance in their lumbar extensor muscles compared to those without back pain. This can be assessed using tests such as the Biering-Sorenson Test. Additionally, abdominal muscular endurance is notably reduced in people with low back pain compared to healthy individuals.
Reduced lumbar endurance can lead to difficulties in sensing the position of the lumbar spine. People with chronic low back pain often experience challenges in controlling lumbar spine position after engaging in fatiguing activities, which contributes to lumbar instability.
Furthermore, individuals with low back pain tend to have a higher proportion of fast-twitch type I glycolytic fibers, which contract rapidly but are more prone to fatigue. This makes them more vulnerable to back injuries. In contrast, those without back pain generally have a higher percentage of slow-twitch fibers, which are more suited for endurance activities, allowing for prolonged muscle activity without quick onset of fatigue. These fibers are crucial for core muscles and endurance tasks.
Strength and Low Back Pain:
The core comprises the muscles of the trunk and hips that encase the spine, abdominal organs, and hips. These core muscles play a crucial role in balancing loads within the spine, pelvis, and kinetic chain. Strengthening the core is widely supported for the treatment and prevention of low back pain and other musculoskeletal issues. Weakness in core strength can contribute to lumbar instability.
According to NICE guidelines, muscle strengthening exercises are recommended for the early management of persistent non-specific low back pain.
The core’s importance lies in its ability to protect the spine from excessive stress and facilitate force transfer between the lower and upper body. A robust and stable core helps prevent injuries and optimizes performance.
To safeguard the back, it’s ideal to maintain a 360-degree stiffness around the spine during activities such as moving, running, jumping, throwing, lifting, and force transfer. This is achieved when the muscles in the hips, torso, and shoulders work in coordination.
For individuals with chronic low back pain, it is especially important to activate both deep abdominal muscles, such as the transversus abdominis, and the multifidus, alongside the superficial muscles.
Body Composition:
The body is made up of water, protein, minerals, and fat. It is possible to maintain the same overall weight while significantly changing the proportions of these components.
One way to assess body composition is through the two-component model, which divides the body into fat and fat-free components. Excess body fat, or storage fat, can heighten the risk of chronic health issues, including lower back pain. Research consistently shows a link between increased fat levels and a higher likelihood of experiencing lower back pain.
A 2003 study found a moderate positive correlation between obesity and lower back pain, although this study used Body Mass Index (BMI), which does not accurately reflect body fat content. Conversely, a 2011 study by Urquhart, which measured body storage fat more directly, confirmed a relationship between obesity and lower back pain.
Increased body weight can alter spinal biomechanics and impose extra strain on spinal structures. For example, obesity may lead to changes in posture, such as increased lumbar lordosis, which can disrupt spinal loading mechanics and exacerbate back pain.
Flexibility:
Flexibility refers to the extent of movement possible around a joint. Having good flexibility is crucial because it helps the kinetic chain function smoothly and can aid in injury prevention. Flexibility varies by joint and is influenced by factors such as the tightness of ligaments and tendons.
Stretching the soft tissues of the trunk and lower limbs, including the back and thigh muscles, as well as the associated ligaments and tendons, can enhance spinal mobility and increase the range of motion, potentially reducing back pain. Stretching exercises can reduce muscle stiffness by altering the viscoelastic properties of muscles, decreasing the formation of actin-myosin cross-bridges, and reducing reflex muscle inhibition.
Improving the range of motion in the spine and related areas facilitates the performance of daily activities such as lifting and bending, which involve both lumbar and hip movements. Tight or shortened back muscles can negatively impact spinal mechanics. Additionally, tight hip flexors and hamstrings can contribute to lumbar hyperlordosis, which may increase the risk of developing lumbar facet syndrome.
Exercises to Decrease Low Back Pain:
Aerobic exercise:
Aerobic exercise enhances blood flow and nutrient delivery to soft tissues, including those in the back, which can speed up the healing process. Low-impact activities raise the heart rate without aggravating back pain.
Exercises such as walking or cycling boost circulation and strengthen the muscles in the legs and back, which can alleviate stiffness and discomfort. Swimming is also an excellent aerobic workout that improves cardiovascular endurance, provides a full-body workout, and enhances both flexibility and muscular endurance.
Stretching and Strengthen Exercise:
Postural exercises have been shown to enhance pain management and functional mobility in individuals with low back pain.
Key exercises include:
Knee to Chest Stretch: Aims to alleviate tension in the lower back and glutes by gently stretching these areas.
Bridges Exercise: Strengthens the glutes, lower back, and core muscles, which supports spinal alignment and stability.
Cat and Cow Stretch: Promotes spinal flexibility and helps reduce lower back stiffness through a dynamic movement.
Seated Lower Back Rotational Stretch: Targets the lower back and hip muscles, improving mobility and reducing stiffness.
Lumbar Rotation: Enhances flexibility and eases pain by allowing gentle movement in the lumbar spine.
For acute low back pain, exercise therapy can be as effective as no treatment or other conservative methods. In the case of chronic low back pain, exercise therapy can provide slight improvements in pain and function, particularly within healthcare settings.
About Authors
Dr. Muhammad Mahmood Ahmad is a Spinal as well as an Orthopedic Surgeon with over 14 years of experience currently practicing at Razia Saeed Hospital, Multan.
