Exercise for back pain seems to be reasonably positive for an issue that is fairly problematic across healthcare as a whole. A recent systematic review including a meta analysis found beneficial effects for pretty much all exercise types *Click Here* Some exercise types such as Pilates have been touted as superior but this does not seem to be the case according to a recent Cochrane review *Click Here*
I wanted to focus on two pieces of research into lower back pain that got me thinking about the way we focus on back pain and therapeutic exercise in general. Both seem to have flown a little under the radar but in my humble opinion have profound implications for how we view therapeutic exercise.
Firstly we have a systematic review from 2012.
“Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review”
This paper looked at exercise therapy trials for cLBP. They wittled down 1217 studies from the initial search to 13 RCT’s (randomized controlled trials) and 5 non RCTs that met the inclusion criteria.
The aim of the review was to find out if the evidence contained within these trials supported the change in pain of the subjects with the targeted aspects of physical function after exercise therapy. The aspects of physical function were mobility, trunk extension and trunk flexion strength and back muscle endurance.
The point from the researchers perspective was that studies report if an exercise intervention for cLBP has an affect on key out come variables such as pain or disability but not if the outcome is actually tied into the targeted aspects of the exercise program.
10 studies explored the relationship of changes in pain and sagittal (flexion and extension) mobility. 7 found not correlation but did not provide supporting data and 3 found no correlation with data. The authors performed a meta analysis of this data and found total correlation was very low between changes in mobility and changes in pain.
9 studies and 5 studies respectively explored trunk extension and flexion strength. A meta analysis of the available data showed no significant correlation between changes in pain and strength.
Muscular endurance was explored in 7 studies none showing a correlation but without reporting specific correlation coefficients.
The correlations between disability and strength and mobility were also pretty underwhelming.
The authors stating:
“We conclude that the available literature does not appear to support a convincing association between changes in clinical outcome and changes in physical function after exercise therapy for cLBP”
“The findings do not support the notion that the treatment effects of exercise therapy in cLBP are directly attributable to changes in the musculoskeletal system. Future research aimed at increasing the effectiveness of exercise therapy in cLBP should explore the coincidental factors influencing symptom improvement”
So people can get better from exercise, we know that moving works but it may not mean that they are weak or inflexible and this is the cause of their back pain or working on this cause is the remedy to their problems. The authors here feel that the effects of exercise maybe more down to ‘central’ rather than ‘local’ changes such as psychological, cognitive or neurophysiological adaptations.
These would include changes in movement patterns and sensory input, alterations in cortical representations or body ‘schema’ and positive therapist/patient interactions. It could also involve decrease in fear avoidances and catastrophising behaviours.
I don’t think we can discount basic physiological processes associated with moving such as increases in blood flow and the effects of simply moving more on people’s general systemic health or increasing someones 'zone of homeostasis' to activity which could be on a local cellular level or more CNS based.
Another potential issue is how does telling people they need to ‘strengthen’ affect their perception of their capabilities? For many it could imply they are weak to begin and therefore at increased risk which may or may not be true but is often under quantified instead being assumed.
As I have discussed before many therapeutic exercises do little to strengthen but do involve moving more! *Click Here*
I think this paper questions how we view exercise and the potential mechanisms behind why exercise works.
Secondly a short paper on goal setting.
This paper identified 27 unique goals from 20 participants with goals relating to physical activity being by far and away (49.2 %) the most common. The second common goal was work place related at 14.29%. I do feel this paper would have been strengthened significantly by the inclusion of some examples of what these goals were so we could get an idea of the functional activities that people found important. I suspect they would be related to things such as tying their shoe laces and picking their kids up. These are important relevant and meaningful goals that are perhaps under explored in relation to more clinical variables such as strength and range of motion (ROM). Although they may include aspects of physical performance they often are not resolved simply by working solely on these components in isolation without relevance.
The results of the study found that NONE of the patient goals were aligned with common measures used by physiotherapists. The traditional measures were pain, strength and ROM. The argument here would be that these traditional measures would go towards enabling patients to be able to achieve their goals but again this maybe an assumption. If you feel someone has achieved your success measures then their success measures maybe less relevant.
The authors state:
“Clinical outcome measures may not be providing accurate information about the success of treatments that are meaningful to the patient. Clinicians should consider a collaborative approach with cLBP patients to determine treatment interventions that are driven by patient preference”
It maybe simple to help someone experience less pain, an example would be telling someone to avoid bending over if they experience back pain doing so.
One perspective of success is no pain from bending over – Goal achieved. Another perspective would be being able to bend down to do my shoe laces again– Goal not achieved. A reduced measure of pain does not simply imply success in the eyes of another party. Maybe people would even be willing to put up with a larger amount of discomfort coupled with a greater functionality rather than no pain and a sense of disability?
Both of these papers I think challenge a traditional view of therapeutic exercise and the mechanisms behind positive outcomes. The more we understand about the mechanisms the better we can design the exercise parameters. The use of strength or ROM measures do not align with peoples goals nor is recovery dependent on these measures changing.
Perhaps success cannot always be quantified with traditional measures and ultimately the success of an outcome lies not in these measures but the perception of those that the therapeutic exercise is being applied to. I am going to go out on a limb and say these results could apply to other parts of our anatomy also!
In my opinion dosage, relevance (even if it is perceived) and enjoyment maybe the key factors in moving for those with cLBP. I would love to see those variables explored more.