Lower back pain core stability

Low back pain: Balancing mobility and stability

The title image of this post is an artists’ rendition of Philippe Petit’s 1974 high-wire walk between the previous Twin Towers of New York’s World Trade Center. Petit wrote a book: “To Reach the Clouds”, which was later release in paperback under the title “Man on Wire”.

The relevance of this image to this post cannot be understated. Petit’s unrivaled feat of balance and stability is an undisputed display that stability comes from control of movement, not the prevention of it. Philippe Petit would never have achieved his walk between the towers if he had been rigid. Faced with upwinds, crosswinds and a moving wire he had to use a dynamic approach to balance. He was so well poised that he was even able to lie down on the wire at the half way point. To watch his amazing achievement, and the beautiful dance on the wire you can watch it on the 2008 film Man on Wire.

Paul Hodges on balancing mobility and stability:

Paul Hodges is a Professor at the University of Queensland with over 520 research items listed on Researchgate.  He is well respected with over twenty-three thousand citations. His main area of focus is listed as “Neuromotor control of movement and stability, and changes in this system with pain”.

Current themes that Professor Hodges is working on:

  • Physiology and pathophysiology of movement control mechanisms.
  • Integration of neuroscience and biomechanics to investigate the nervous system control of joint stability and movement.
  • Effect of conflicting task demands control on spinal control.
  • Biomechanical effect of contraction of the intrinsic spinal muscles on stability of the spine.
  • The effect of pain on motor control and possible mechanisms.
  • Mechanism of efficacy of therapeutic exercise.

Paul Hodges was recently interviewed by Dr Karim Kahn of the British Journal of Sports Medicine for a BJSM Google hangout: Paul Hodges on BJSM

The summary of this interview:

According to Paul Hodges there are three major misconceptions with regards to “core stability”:
1) Misconception: It is all about stiffness
2) Misconception: It is all about one muscle (or a select handful of muscles)
3) Misconception: There is a one size fits all approach to fixing back pain

Reality 1: It is about dynamic control.

Different tasks place different demands on the body. Some movements require more stiffness/bracing while others require more fluidity. The dynamic control for weight lifting for example is different to the dynamic control of running. Weight lifting may require more stiffness, while the same level of stiffness applied to running would be detrimental to performance, and may lead to injury.

Dynamic control is therefore the control of movement relative to task, rather than the prevention of it.  Too many pseudo-core routines are designed around rigidity, stiffness and the prevention of movement. A plank is a prime example. Thousands, if not millions, of planks are performed annually with the belief that they are core-centric. However, a plank is not a core stability exercise, it is a pain tolerance exercise. Planks are terminated after a set time limit or due to pain in the shoulders/lower back.  They are not terminated due to core fatigue or loss of stability.

Reality 2: The body is a complex system of neuro-muscular-skeletal interactions.

There is more to the body than just one muscle or a select group of muscles. A number of paradigms promote the training / re-training of the Transversus Abdominus, which has been shown to be an important muscle for stability of the torso. It is hypothesised that the Transversus Abdominus achieves this by increasing its thickness and consequently the intra-abdominal pressure. However, it is one muscle. It is a local stabiliser, that is believed to fatigue quickly, and does not produce movement. It is therefore part of the puzzle, not the only piece. Countless patient hours are devoted to this muscle (along with Multifidus) using motor control exercises (precise movements aimed at “isolating” the muscles) at the expense of general exercise (cardio / weights / flexibility).

Reality 3: There is no one size fits all.

No two patients are the same. Some back cases may have similar signs and symptoms  but the human being experiencing the back pain is unique and needs to have a unique case management. Too often the approach is a one size fits all. In a best case scenario a patient should be given a bespoke exercise programme tailor made to their individual injury needs, goals and lifestyle.

The problem with the term “core”:

We have a problem in the rehabilitation/fitness industry: an obsession with the term “core”. The word core is reductionist in itself. It should be core + stability = core stability. In actual fact it is the stability component that should get the emphasis, not just the core.  Stability of the body is not derived from one particular system or isolated area of the anatomy. Nothing in the human body works in isolation. It is a “symphony” of Newtons 3rd law: action and reaction.

 

Corexia

“Corexia”:

Medical professionals, trainers and the media have created a nervous condition involving a misinformed belief system that there is a catastrophic lack of spinal stability, and the only remedy is to “fix” the “core”. This paranoia can be conceptualised as a Corexia-nervousa or Core-dysmorphic-disorder .  Even though most patients have limited concept of what the core is anatomically, they know that they have to have one. It is like a magical unicorn, or pot of gold at the end of a rainbow.

We have created a generation of patients that believe that the centre of their back pain problem is due only to the lack of “core”. Their misconstrued philosophy is that the more core they do the better they will be. Unfortunately, there is never enough core in their minds. And if you do not give them core, the patient believes that their back will be left vulnerable. The tragedy of this scenario is that the seed of this misinformation is often planted by a medical professional. The spine is hugely resilient. It is not a dry twig waiting to snap at a moment’s notice.

Evidence against the “Corexia” / lack-of-core paradigm exists, but patients and practitioners choose to ignore it.  If you listen to Dr Fiona Wilson on the following soundcloud interview (Treating low back pain in sport: Dr Fiona Wilson. ) you will hear how some patient population groups have a direct correlation between amount of time spent on core, and back pain. What on earth does that mean?: it means that the more core training that this particular patient group performed the more likely they were to experience back pain. This can be attributed to both volume but also the type of exercise included in a core routine. Clearly we are getting it wrong! Lack of “core” is not the problem.

Advancing with the times:

If you are shoved into a generic Pilates class or force-fed the same tired dogma of “core” it is time for a change.  It is important to read wider than just the echo chamber of core and Pilates posts in your local magazine or Facebook feed. If you need bespoke exercise advice, seek out a Biokineticist / Physiotherapist with special interest in low back rehabilitation, but do not settle for mediocrity. Science has evolved and the Biokineticist / Physiotherapist that claims to be current and up to date with best practice needs to give you way more than just core. Like Phillipe Petit on his wire, you need a dynamic approach to your movement.


References:
Paul Hodges BJSM interview with Karim Khan: https://www.youtube.com/watch?v=hplw6Lg95SY
Main image: http://www.perezosos.mx
Image: PsyPost

Treating the patient

If you are injured and want to use exercise as a modality it is important that you realise that the exercise does not treat pain directly.

Exercise may alleviate discomfort and improve functional ability.  But it does not “treat” the pain. Likewise, when you seek the advice of a Biokineticist or exercise specialist they should not have the goal of trying to “treat” your pain. They need to treat you. The patient. Not the pain. In the process of the exercise journey the pain may diminish. This is more often than not (depending on the condition) due to the exercises addressing the causative factors rather than just the symptoms/consequences of your particular injury.

Biokinetics Cape Town

 

Often practitioners and patients alike get stuck “looking down the microscope”. They are so focused on pain that they miss the factors that contribute to the pain.  Pain viewed from a “catastrophic model” perspective puts pain in the centre of attention. Something is wrong. There is a crisis, and the symptoms of that crisis need to be addressed immediately. And at a localised level. But you and your injury are more than just pain. Pain is complicated. It is multi-factorial. There are physical factors, biological factors, social factors, psychological factors, and even environmental/lifestyle factors.  For this reason the treatment approach should be multi-factorial. Causation rather than catastrophe.

Your treatment team needs to keep this in mind and work as a unit rather than as individuals. Each team member has a role to play in the management of your injury. Doctors / Physiotherapists / Biokineticists / Osteopaths / Chiropractors need to work in unison to meet your treatment goals.

Biokinetics Neil Hopkins

Voltaire was a philosopher in the 1700’s. He apparently wrote the following phrase: “Doctors/Physicians are like wizards/magicians, they enact trickery while the body effects the cure”. Given the right environment, and treatment approach, your body does the healing work. The therapists that you work with are privileged enough to be along for the ride. They may be highly educated/skilled, but your recovery is your responsibility and your achievement.

If you are injured and think that you could benefit from seeing a Biokineticist, speak to your Specialist / Doctor / Physiotherapist / Osteopath / Chiropractor, to see if you are a suitable candidate for Biokinetics exercise rehabilitation. Otherwise feel free to visit your local Biokineticist. If your injury is too acute, or in need of more physical therapy the Biokineticist will refer you to a Specialist / Doctor / Physiotherapist / Osteopath / Chiropractor for appropriate management and care.


 

References:

Microscope image: Techtimes
Pain image: PBS Newshour
Voltaire image: Amazing people

Biokineticist Cape Town

Should I see a Biokineticist?

There is often confusion about the role of a Biokineticist.

Ask any Biokineticist, it is their biggest frustration. People don’t know who they are, or what they do.

Granted, there are a lot of similarities to Physiotherapy and personal training, the two disciplines that are most frequently referred to when you mention Biokinetics. But they are not Physiotherapists, nor are they personal trainers. But they do fill the void between the two. The reality is that you can actually be seen by all three, at the same time (no, not the same consultation, but the same time period). Conjunctive care is possible provided that there is no distinct overlap of services. The best management of your injury/condition is a patient-centric approach, not an egocentric approach. Your needs have to be taken into account and for that to happen medical professionals and trainers need to play as a team, not as individuals.

Image 1) Team play: Below is an info-graphic of a hypothetical treatment team scenario.

Cape Town Biokinetics

So when can a Biokineticist help you?

The answer in terms of “time” on a timeline is quite contentious, particularly with the scope of Physiotherapy (Scope: Physiotherapy) and Biokinetics (Scope: Biokinetics) being discussed at the HPCSA (Health Professions Council of South Africa). The time frame also depends on the injury/condition.

Certain skills/services are not within the scope of Biokinetics and most likely never will be. As a rule of thumb the Biokineticist you see should provide you with exercises. Their primary role is exercise rehabilitation. In the scope of practice document reference is made to the role of the Biokineticist commencing when exercise is the primary modality of care. ie: when 51% of your session with a primary care giver becomes exercise you can start to consider seeing a Biokineticist.

When it comes to rehabilitation you as the consumer have the power to choose who you wish to see. However, it is important to know what is in scope and what is not. If you choose to see a personal trainer for injury rehabilitation and something goes wrong their liability cover may not come into effect as they are not qualified or insured for exercise rehabilitation. The same applies to Biokinetics, if you are seeing a Biokineticist and they are treating you out of their scope you may not be covered.

Image 2) Biokinetics? Below is a guide of how a Biokineticist can help you (please note that not all Biokinetics practices are the same)

Biokineticist Cape Town

Orthopaedic / Injury rehabilitation:

The branch of medicine that deals with the prevention or correction of injuries or disorders of the skeletal system and associated muscles, joints, and ligaments is called orthopaedics. You can see a Biokineticist for an orthopaedic injury, depending on the nature and severity of your injury.  You may require to have clearance from a Doctor/Physio/Chiro/Osteo before commencing your exercise rehabilitation. Each injury needs to be assessed on a case by case basis. If the injury is too acute the Biokineticist must refer you on/back to a Doctor/Physio/Chiro/Osteo.

In terms of a treatment timeline you can see the Biokineticist for the initial consultation and programme and then decide on weekly training based on the nature/severity of your injury, as well as your compliance to exercise rehabilitation. It may be necessary to see the Biokineticist more frequently in the early stages of rehabilitation and then slowly wean off into independence. Please note that it is not implicit that you see the Biokineticist weekly. You can visit them sporadically provided that you are compliant with your exercise rehabilitation programme.

Chronic disease risk reduction and reversal:

The treatment timeline for chronic diseases will be different to orthopaedic injuries. Due to the nature of the illness/disease you may require ongoing guidance. This does not imply weekly sessions and a huge financial burden. You can see a Biokineticist sporadically or join a group class. However it is important to stress that just going for the initial consultation will not be sufficient. Once off sessions are not beneficial as you will need guidance and someone to monitor your progress.

High performance and general conditioning:

Athletes who are injured, have been injured in the past, or who just need planning/guidance can see a Biokineticist. A Biokineticist can assist with a structured exercise programme and plan, no matter what level of competition or the nature of your sport. The Biokineticist can address the athletes needs with supervised sessions or comprehensive exercise programmes. The Biokineticist is not your coach and will never replace the role of your coach. They are there to mentor and guide you as part of the training team.

The general gym goer can see a Biokineticist if they have not trained in a long time and need guidance to navigate the complexity of the gym environment. The Biokineticist is not stealing from personal trainers, the Biokineticist is there to work along side trainers for guidance and input. You can start with the Biokineticist and progress to the trainer once you have improved your fitness and strength.

If you are a seasoned gym goer and you struggle with the occasional ache and pain you can see a Biokineticist to work on form and technique. The Biokineticist can give you input on injury advice and injury avoidance. They are more like a mentor that you touch base with when the need arises. If you have an acute injury the Biokineticist may refer you on to a Doctor/Physio/Chiro/Osteo.

Fitness assessments:

You can see a Biokineticist for a fitness assessment depending on your medical aid and medical aid rewards scheme. The goal of the fitness assessment is obviously to get points so that you can enjoy the rewards. However, it can be so much more. It is a window into your current health and well being, and a starting point for Biokinetics training. The Biokineticist can use the information from the assessment to assist you with your training goals. Unfortunately this is not part of the fitness assessment itself. It is a stand alone service that will require you to come for a follow up consultation (with cost implications).

Million dollar question:

With so many people offering the “same” service it is hard to decide. It is best to do your homework on your individual condition and whether it responds with exercise. Sometimes ego’s get caught up in the referral process on both sides. But you as the patient have the right to choose who you would like to see. The burden of care rests with the individual therapist/trainer to know when they are out of their depth. Most people will benefit from seeing a Biokineticist, but there are some people who will need additional care before they start. The best thing to do is to ask. Reach out to your local Biokineticist/Doctor/Physio/Chiro/Osteo and see if you are a suitable candidate.

The best advice is to keep well and keep exercising.

 

 


Image acknowledgement: alumni.ctksfc.ac.uk

Exercises for joint replacement

Biokinetics for joint replacement surgery

 

Biokinetics plays an important role pre- and post-surgery.  Your surgeon might refer you to a Biokineticist prior to surgery to improve your physical capacity (which improves surgical outcome and minimises surgical risk) or post-surgery once you have reached a certain level of function / completed your physiotherapy. Therefore a Biokineticist forms part of the medical team that can help guide you through the joint replacement journey.

It is well documented that exercise will yield positive results pre- and post-surgery. From strength and flexibility gains, to maintaining and/or improving cardiovascular fitness.  Below is a very good clip from Dr Mike Evans explaining how to prepare for your surgery, as well as how to recover after it. It is taken from his website Evans Health Lab (http://www.evanshealthlab.com/)

Some take home messages from the clip:

“Minor surgery is surgery that happens to someone else”. This is a humorous anecdote but actually quite appropriate.  Joint replacement surgery is a major life event.  It requires a game plan / strategy. Planning for your surgery, and recovering after it, is an active process rather than a passive one.  The medical team (surgeon / GP / Physiotherapist / Biokineticist) are there to assist and guide you through the process, but the most important thing is that you are involved in the process too. You are a team member. You are at the centre of it.  And as a result you are equally responsible for the outcome. The hard work, and effort that YOU put in will be rewarded.

Dr Mike Evans lists 5 key aspects of joint replacement surgery:
1) Muscle strength and fitness
2) Managing expectations
3) New normal
4) Exercise and lifestyle
5) Attitude

Using Mike’s 5 key aspects in a South African context (Physiotherapy and Biokinetics):

1) Muscle strength and fitness:

As part of your planning for your surgery you can seek the advice from a Biokineticist / Physiotherapist to help in the creation of an exercise routine.  Your exercise routine can be tailor made to suit your needs, and to ensure that you do not experience pain while doing the routine.  It is not necessary to see the Biokineticist on a weekly basis. If you are disciplined enough to exercise on your own you can get a homework programme, which can save you a lot of money.

Your routine can help in building muscle strength, improving flexibility, and increasing exercise tolerance. The gains in strength will help with post-operative walking and recovery.  And even if you cannot train your “injured” / affected side you can train the unaffected side and upper body to make life easier for bed transfers and crutch walking.  The stronger and fitter you are the easier your recovery will be.

2) Managing expectations:

Seeing a Physiotherapist, and eventually a Biokineticist, post surgery can help with managing expectations. The Physiotherapist / Biokineticist can act as a mentor to guide you through the changes, and help you to understand what is appropriate post surgery and what is not.  There are always goals to be attained, but never any fixed timelines as such. Each surgery needs to be managed on a case by case basis, as people respond differently to surgery. Your medical team is there to assist you in reaching your goals, and monitor that you are on the road to recovery.

3) New normal:

There is no point in using your new joint to stay the same. Before surgery you may walk with a limp, experience pain, or be limited in your active daily life. Obviously the new joint will be swollen and uncomfortable post surgery, but the medical team is there to help monitor and assist you back to full function. Seeing your orthopaedic surgeon for regular check ups to assess the scar, joint strength and range, as well as gait (walking pattern) is important.  Your surgeon will arrange these milestones with you pre- or post-surgery.  The goal of the Physiotherapist / Biokineticist will be to assist you with the joint range of motion, strength, general fitness and conditioning, as well as gait retraining.

4) Exercise and lifestyle:

You may be required to make a couple of adjustments to your home environment following your surgery.  They can be as simple as removing loose carpets and clutter so that you avoid trip / slip hazards. For more complex cases it is recommended that you seek the help of an Occupational Therapist to assist with the placement of ramps / rails / hoists etc.

Some joints and joint replacements may come with a set of “rules”. The surgeon may wish you to avoid certain movements or joint ranges (at certain times).  These rules will be communicated to the Physiotherapist / Biokineticist prior to your first consultation.  The Physiotherapist / Biokineticist can then explain how to avoid those movements in day to day activities.

Patients may also be required to see an Orthotist to purchase toilet seat raises, crutches, elevated cushions, or other devices that may be needed post surgery.  These may not be necessary but certainly something to consider when budgeting financially for a joint replacement.

In terms of exercise you will progress from in-hospital exercise rehabilitation with the Physiotherapist to out-patient rehabilitation with the Physiotherapist.  Once you have reached certain milestones you will be cleared to exercise with the Biokineticist. It is important to remember that healing can take up to a year.  That is not to say that you have to continue treatment for that long, but certainly you need to keep exercising and keep progressing.  Far too many patients get limited results post surgery because they discontinue too soon. There is the misconception that the hospital exercises and walking will be sufficient. Remember there is a medical team. Your Physiotherapist and Biokineticist are not in competition with each other. They are team-mates and have different roles to play at different stages of your healing.

5) Attitude:

This is essential. Having the right attitude is key. As Dr Mike Evans states: it is a balance of optimism with realism. Your attitude and effort will determine the outcome.

If you are confused and the entire process is overwhelming don’t be afraid to ask for help. The medical team is there to help you.

Is Biokinetics for me?

Ask your Surgeon or Physiotherapist if they feel that you may benefit from seeing an exercise specialist like a Biokineticist.  Otherwise contact your local Biokineticist directly to discuss your case history. If you are not a suitable candidate the Biokineticist will refer you back to your Surgeon / Physiotherapist for more information / treatment.

Now watch the clip and see for yourself: 

(please note Biokinetics is a South African medical profession and is not mentioned directly in the clip)

Acknowledgements:
1) Dr Mike Evans Health Lab – http://www.evanshealthlab.com/ LINK
2) Dr Mike Evans YouTube – https://www.youtube.com/user/DocMikeEvans LINK

Lower back pain rehabilitation

Exercise rehabilitation for lower back pain

Lower back pain will affect most adults at least once in their life time. Some individuals are lucky and only experience an acute bout of back pain. Others are less fortunate and progress into a state of chronic lower back pain. The good news is that a number of chronic lower back pain patients can benefit from a carefully structured exercise programme and lifestyle modification.

Exercise can help in reducing lower back pain and associated functional disability. However, when it comes to determining what the “right” kind of exercise is, it may become difficult to determine fact from fiction with so many opinions available online. There is an overwhelming amount of information on exercise rehabilitation for lower back pain and unfortunately a lot of misinformation. Sifting the truth from post-truth can be tricky.

That is why it is important to look deeper than just blogs and social media shares. That is where the Cochrane group comes in. They are the scientists who scrutinise scientists and keep the public up to date on relevant topics.

 

Cochrane reviews on exercise and low back pain



What is a Cochrane review?

Cochrane reviews are systematic reviews of primary research in human health care and health policy. Cochrane reviews are internationally recognized as the highest standard in evidence-based health care. They investigate the effects of interventions for prevention, treatment and rehabilitation. They also assess the accuracy of diagnostic tests for some conditions in a specific patient group and setting. Cochrane reviews are published online in the Cochrane Library (LINK).

Who are the Cochrane Back and Neck group?
Cochrane Back and Neck (CBN) [formerly the Cochrane Back Review Group (CBRG)] is one of over 50 international Cochrane review Groups. The CBN coordinates the publication of literature reviews of diagnosis, primary and secondary prevention and treatment of neck and back pain and other spinal disorders, excluding inflammatory diseases and fractures (LINK)

1) Motor control exercise for acute non-specific low back pain. (LINK)

Summary: Motor control exercise (isolating specific muscles such as Transversus Abdominus) showed no benefit over spinal manipulative therapy, other forms of exercise or medical treatment for reducing pain or disability among patients with acute and subacute LBP.

  • Review question: To evaluate the effectiveness of motor control exercise (MCE) (isolating specific muscles such as Transversus Abdominus) for patients with acutenon-specific low back pain (LBP).
  • Background: LBP is a common disorder that is often associated with pain and disability. One common intervention for patients with LBP is exercise therapy, and MCE is widely used for these patients. However, its effectiveness for patients with acute LBP remains unclear.
  • Search date: Evidence is current to April 2015.
  • Study characteristics: The Cochrane Library included in the review three trials evaluating acute or subacute pain in patients with LBP (n = 197 participants). Most participants were middle-aged and were recruited from primary or tertiary care centres. Duration of treatment programmes ranged from four weeks to six weeks.
  • Key results: MCE showed no benefit over spinal manipulative therapy, other forms of exercise or medical treatment for reducing pain or disability among patients with acute and subacute LBP. Whether MCE can prevent recurrences of LBP remains unclear.
  • Quality of the evidence: Results of this review include evidence of very low to moderate quality. The Cochrane back and neck group downgraded all comparisons for imprecision due to small study sample sizes.
2) Motor control exercise for chronic non-specific low-back pain. (LINK)
 
Summary: Little or no difference is observed between Motor control exercise (isolating specific muscles such as Transversus Abdominus) and other forms of exercise. (Given the minimal evidence that MCE is superior to other forms of exercise, the choice of exercise for chronic LBP should probably depend on patient or therapist preferences, therapist training, costs and safety.)
  • Review question: To evaluate the effectiveness of motor control exercise (MCE)(isolating specific muscles such as Transversus Abdominus) in patients with chronic non-specific low back pain (LBP).
  • Background: Motor control exercise is a popular form of exercise that aims to restore co-ordinated and efficient use of the muscles that control and support the spine. Patients are initially guided by a therapist to practise normal use of the muscles during simple tasks. As the patient’s skill increases the exercises are progressed to more complex and functional tasks involving the muscles of the trunk and limbs.
  • Search date: The evidence is current to April 2015.
  • Study characteristics: In total, 2431 participants were enrolled in 29 trials. The study sample sizes ranged from 20 to 323 participants, and most of them were middle-aged people recruited from primary or tertiary care. The duration of the treatment programmes ranged from 20 days to 12 weeks, and the number of treatment sessions ranged from one to five sessions per week. Sixteen trials compared MCE with other types of exercises, seven trials compared MCE with minimal intervention, five trials compared MCE with manual therapy, three trials compared MCE with a combination of exercise and electrophysical agents, and one trial compared MCE with telerehabilitation based on home exercises.
  • Key results and quality of evidence: MCE probably provides better improvements in pain, function and global impression of recovery than minimal intervention at all follow-up periods. MCE may provide slightly better improvements than exercise and electrophysical agents for pain, disability, global impression of recovery and the physical component of quality of life in the short and intermediate term. There is probably little or no difference between MCE and manual therapy for all outcomes and follow-up periods. Little or no difference is observed between MCE and other forms of exercise. Given the minimal evidence that MCE is superior to other forms of exercise, the choice of exercise for chronic LBP should probably depend on patient or therapist preferences, therapist training, costs and safety.
3) Pilates for low back pain. (LINK)
Summary: The overall quality of the evidence in this review ranged from low to moderate. There is some evidence for the effectiveness of Pilates for low back pain, but there is no conclusive evidence that it is superior to other forms of exercise.
 
  • Review question: To determine the effects of the Pilates method for patients with non-specific acute, subacute or chronic low back pain.
  • Background: Low back pain is an important health problem around the world. One of the most common treatments is exercise and in recent years Pilates has been a common option for treating low back pain.
  • Search date: The Cochrane back and neck group conducted searches up to March 2014. They updated the search in June 2015 but these results have not yet been incorporated.
  • Study characteristics: This review included 10 studies and 510 patients. All studies included a similar population of people with non-specific low back pain. The studies only included participants with chronic low back pain. The duration of the treatment programmes in the included trials ranged from 10 days to 90 days. The duration of follow-up varied from four weeks to six months. None of the included studies measured follow-up beyond six months. The sample sizes ranged from 17 to 87 participants.
  • Key results: The included studies demonstrated that Pilates is probably more effective than minimal intervention in the short and intermediate term for pain and disability outcomes, and more effective than minimal intervention for improvement in function and global impression of recovery in the short term. Pilates is probably not more effective than other exercises for pain and disability in the short and intermediate term. For function, other exercises were more effective than Pilates at intermediate-term follow-up, but not at short-term follow-up. Thus, while there is some evidence for the effectiveness of Pilates for low back pain, there is no conclusive evidence that it is superior to other forms of exercise. Minor or no adverse events were reported for the interventions in this review.
  • Quality of evidence: The overall quality of the evidence in this review ranged from low to moderate.

4) Exercises for adolescent idiopathic scoliosis. (LINK)

Summary: No evidence for or against scoliosis specific exercises. The two included studies yielded very low quality evidence that SSEs added to other treatments are more effective than electrical stimulation, traction and posture training for avoiding curve progression, and that SSEs as a standalone treatment yield almost the same results as general physiotherapy.
  • Adolescent idiopathic scoliosis (AIS) is a rare (2% to 3% of the general population) spinal deformity affecting young people aged 10 through the end of the growth period. The deformity may continue into adulthood. AIS is characterised by one or more three-dimensional spinal curves. Disability, cosmetic deformity, pain, activity limitation, quality of life issues, breathing problems and the possibility of the scoliosis remaining with the person into and throughout adulthood are commonly associated with this condition. The cause of AIS is unknown.
  • Treatment for AIS varies according to the degree of severity of the curves. Just the same, exercise is almost always a part of the treatment plan. In milder cases, exercise may be the main treatment, and in more severe cases it may serve as an adjunct. In the UK and the US, physical therapy for scoliosis consists mainly of general strengthening and stretching exercises, along with exercise protocols with which the treating therapist is familiar. There is a corresponding feeling among practitioners in these geographical locations that physical therapy for scoliosis is not effective.
  • Scoliosis specific exercises (SSEs) are individualised exercises aimed at reducing the deformity. SSEs are taught in clinics that specialize in scoliosis. The exercises work by changing the soft tissue that affects the spine. SSEs are also thought to work by altering control of spinal movement. There are no known side effects or risks to using SSEs.
  • The purpose of this review was to evaluate the effectiveness of SSEs in reducing curve progression and postponing or avoiding invasive treatment such as surgery in adolescents with AIS. Two studies involving 154 patients total were included. The review found no evidences for or against SSE. The two included studies yielded very low quality evidence that SSEs added to other treatments are more effective than electrical stimulation, traction and posture training for avoiding curve progression, and that SSEs as a standalone treatment yield almost the same results as general physiotherapy.
  • Possible limitations of this review included the small number of studies that met the inclusion criteria and a high risk of bias, particularly selection bias. More randomised controlled trials are needed in this area, along with a deeper understanding of the types of SSEs useful for the adolescent with AIS.

5) Exercises for prevention of recurrences of low-back pain. (LINK)

Summary: Moderate quality evidence that post-treatment exercises can reduce both the rate and the number of recurrences of back pain. However, the results of exercise treatment studies were conflicting. Limitations of this review include the difference in exercises across studies, thus making it difficult to specify the content of such a programme to prevent back pain recurrences.

  • Back pain is a common disorder that has a tendency to recur. The Cochrane back and neck group conducted this review to see if exercises, either as part of treatment or as a post-treatment programme could reduce back pain recurrences. The Cochrane back and neck group searched for studies that included persons with back pain experience, interventions consisting of only exercises and that measured recurrences of back pain.
  • There were nine studies with 1520 participants. There was moderate quality evidence that post-treatment exercises can reduce both the rate and the number of recurrences of back pain. However, the results of exercise treatment studies were conflicting.
  • Adverse (side) effects of exercising were not mentioned in any of the studies. Limitations of this review include the difference in exercises across studies, thus making it difficult to specify the content of such a programme to prevent back pain recurrences.

6) Exercise therapy for treatment of non-specific low back pain. (LINK)

Summary: Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain. For patients with acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.

  • Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in populations visiting a healthcare provider. In adults with subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. For patients with acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.

Conclusion:

1) Motor control exercise for acute low back pain:

  • Are motor control exercises better than spinal manipulative therapy for acute low back pain? No 
  • Are motor control exercises better than other forms of exercise for acute low back pain? No 
  • Are motor control exercises better than other forms of medical treatment for reducing pain or disability? No 


2) Motor control exercise for chronic low back pain:

  • Are motor control exercises better than other forms of exercise for chronic low back pain? No
  • Does the therapist’s training / qualification / background have an effect on exercises for chronic low back pain? Yes 

3) Pilates for low back pain:

  • Is Pilates effective for treating low back pain? Yes 
  • Is Pilates superior to other forms of exercise in treating low back pain? No 

4) Exercises for adolescent idiopathic scoliosis:

  • Are scoliosis specific exercises effective as a stand alone intervention? Limited evidence 
  • Are scoliosis specific exercises effective as an additive to other interventions? Limited evidence 

5) Exercises for prevention of recurrences of low back pain:

  • Are exercises able to prevent recurrences of low back pain? Limited evidence 

6) Exercise therapy for treatment of low back pain:

  • Is exercise therapy effective at decreasing pain and improving function in adults with chronic low back pain? Yes 
  • Is exercise therapy more effective than no treatment or other conservative treatments for acute low back pain? No
Take home message:

Can exercise help with low back pain?

It depends on the nature and duration of the back pain as well as the type of exercise.

  • Chronic non-specific low back pain can benefit from exercise rehabilitation.
  • Acute low back pain and specific (neurogeneic, discogenic, spondylilosthesis, etc.) conditions may respond better to other modalities initially.

What type of exercise will help with chronic low back pain?

  • There is no consensus on one definitive exercise intervention. Therefore it is wise to steer clear of dogmatic approaches and practitioners that give guarantees on their particular modality. The data above indicates that Pilates and core stability (motor control exercise), which have been heralded as a cure for back pain, are not superior to general exercise.  Movement is good, but using the right kind of exercise at the right time is important. Patients need to find a practitioner that can assess their needs and give them an exercise intervention that is tailor made to their needs, not to dogmatic beliefs.

Is Biokinetics for me?

Ask your Orthopaedic Surgeon (back specialist), GP or Physiotherapist if they feel that you may benefit from seeing an exercise specialist like a Biokineticist. Otherwise contact your local Biokineticist directly to discuss your case history. If you are not a suitable candidate the Biokineticist will refer you back to your Specialist / Physiotherapist for more information / treatment.

Published Cochrane review articles on exercise for low back pain:

Pending Cochrane review articles on exercise for low back pain:
Acknowledgements:

1) Cochrane library. (LINK)
2) Cochrane library: Back and Neck. (LINK)