Exercise to Optimize Outcome in Low Back Pain

Scientific Evidence
How to accomplish this is less clear, with conflicting scientific literature. Cady et al found that firefighters with lower levels of physical fitness had greater episodes of low back pain. Unfortunately, those with the lower levels of fitness were also older. In addition, prior episodes of LBP were not discussed.

A follow up study found that firefighters that were less "fit" were more costly to treat, suggesting the benefit of aerobic fitness. Improvement in aerobic fitness can improve blood flow and oxygenation to all tissues including the muscles, bones and ligaments of the spine.

Aerobic exercise may also decrease the psychological impact of low back pain by improving mood, decreasing depression, and increasing pain tolerance. On the theoretical side, aerobic exercise may help to improve the body's ability to break down scar tissue via tissue plasminogen activator. Improvement of aerobic fitness is a reasonable goal, in conjunction with an active exercise program that emphasizes restoration of normal lumbosacral motion, trunk strengthening, and instruction in proper body mechanics. A program of aerobic exercise alone would be overly simplistic, unlikely to benefit most patients and potentially pain provoking.

Deconditioning should be avoided at the onset by limiting bed rest and immobilization. Those patients who are significantly deconditioned should be instructed in the basics of aerobic exercise which includes a proper warm-up, cool down, and an assessment of target exercise intensity by heart rate or rating of perceived exertion (RPE).

Strengthening
Conflicting literature exists on the efficacy of strengthening exercises in the treatment of acute low back pain. Some of this is due to poor study design, difficulty in randomization, and the lack of specific diagnosis in most studies.

There has also been debate over the merits of flexion versus extension exercises for the treatment of various low back conditions. Some studies have shown that flexion exercises are helpful in patients with posterior element dysfunction, such as spondylolysis and spondylolisthesis. Others have demonstrated the efficacy of an extension-biased program in patients with discogenic low back pain. Unidirectional exercises by themselves are essentially too simplistic to address the multitude of pathophysiologic changes occurring with acute and recurrent low back pain episodes.

McKenzie Method
The McKenzie exercise approach to disc pathology does not commit to either flexion or extension activities, but rather to pain centralization. The McKenzie program is initiated only after a comprehensive assessment in which those positions that centralize pain are discovered. These are eventually incorporated into the comprehensive program. The overall goal of this comprehensive exercise program is to reduce pain, develop the muscular support of their trunk and spine, and to diminish stress to the intervertebral disc and other static stabilizers of the spine.

Therapy sessions should be actively directed and limited to a number that ensures that the patient has a conceptual understanding of the entire program, demonstrates good technique in performing the exercises, and can perform them independently on a home basis. In addition, activity specific training should be incorporated so that patients are instructed to maintain a neutral spine and dynamic muscle support of their spine in all activities of daily living, work, and recreation. Those not improving within six sessions should be re-evaluated and communication with the treating therapist should be initiated. The success of these comprehensive programs has now been well documented.