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Nonspecific low back pain

Low back pain (LBP) is tension soreness and or stiffness in the back, between the bottom of the ribcage and top of the leg, that can be triggered by physical factors (e.g., lifting awkwardly) or psychosocial factors (e.g., being fatigued or tired), or by a combination of the two (e.g., being distracted while lifting). It can often get worse with movement of back, coughing, or sneezing.`

Low back pain is one of the most common causes for seeking medical treatment and it is estimated that one in two people will experience low back pain at some point during their lifetimes. LPB is the leading chronic health problem that causes activity limitation and work absence (Kent PMKJ 2005, Chiropractice and Osteopathy), and forcing older workers to retire prematurely. It keeps more people out of the workplace than heart disease, diabetes, hypertension, neoplasm, respiratory disease, and asthma combined. (Schofi Eld DJ, 2008). Also, individuals who have experienced activity limiting LPB often experience reoccurring episodes with estimates ranging between 24–33%. (Stanton T. et al, spine 2008; Wasiak R, spine 2003)

LPB is a symptom rather than a disease. Like other symptoms, such as headache and dizziness, it can have many causes. It is thought that in some cases the cause may be a sprain (an over-stretch) of a ligament or muscle. In other cases the cause may be a minor problem with the disc between two vertebrae, or a minor problem with a small ‘facet’ joint between two vertebrae. There may be other minor problems in the structures and tissues of the lower back that result in pain. (Chris Maher, The Lancet, 2016)
Interestingly sometimes LPB can develop even in the absence of any associated change in radiographic appearance of the spine. Studies have reported that, 32% of asymptomatic subjects had ‘abnormal’ lumbar spines and only 47% of subjects who were experiencing low back pain had an abnormality identified. (Savage et al 1997)

Non-specific low back pain means that the pain is not due to any specific or underlying disease that can be found. It is the most common type of back pain. About 19 in 20 cases of acute (sudden onset) low back pain are classed as ‘non-specific’. (Chris Maher, The Lancet, 2016)

Patients who suffer from chronic low back pain often have impaired quality of life and also suffer from depression. Depressive symptoms can appear because back pain limits patients’ ability to work and engage in their usual social activities because of their disability. (Kristallia Vitoula 2018)
Low back pain is a self limiting condition. Most people with a bout of non-specific low back pain improve quickly, usually within a week or so, even without treatment. Sometimes it takes a bit longer time to recover. Although the pain may go away, the re-occurrence rate of LBP is extremely high and these individuals are likely to experience another episode of LBP within 3-6 months. Re-occurrence is a major problem with the re-occurrence rate being approximately 60%.

The temporal evolution of symptoms divides low back pain into acute (symptoms lasting \ 4 weeks), sub-acute (symptoms lasting 4–12 weeks) or chronic (symptoms lasting at least 3 months). Chronic LBP will affect at least 10% of low back pain sufferers. (Meucci RD 2015)
It is believed that early physical therapy intervention can help reduce the risk of conversion
of patients with acute low back pain to patients with chronic symptoms. A study by Linton
demonstrated that early active physical therapy intervention for patients with the first
episode of acute musculoskeletal pain significantly decreased the incidence of chronic
pain. (Linton SJ, Pain 1993)

Management of LPB:
There is a substantial amount of medical literature supporting specific physical therapy exercises for the treatment of low back pain. While most episodes of low back pain are self limiting and will get better on their own, active exercise plays an important role in helping reduce the patient’s pain and improving subsequent function in patients with low back pain.

Common techniques of physiotherapy include:

MANUAL THERAPY
Thrust and non-thrust mobilization/manipulation is a common intervention utilized for
acute, sub acute, and chronic low back pain. Studies suggest that, for patients with LBP a comprehensive treatment plan including thrust and non-thrust mobilization/manipulation directed at the lumbo-pelvic region is effective at decreasing pain and disability. (Whitman et al 2006)

EXERCISES THERAPY
Gentle exercise for mobility and stretching (especially the muscles of the legs and back) can help decrease the severity, duration and recurrence of low back pain. Exercises may vary in intensity, frequency, and duration. Exercise therapy when used in isolation or with additional interventions is effective at decreasing pain and disability related to nonspecific LBP. (Macedo et al Phys Ther 2009) In various researches exercise therapy was found to be effective in decreasing pain in the chronic population, graded activity improved absenteeism in the sub acute population. (Hayden JA 2005, Cavanaugh JM 1995, Aure OF 2006)

DIRECTIONAL PREFERENCE EXERCISES
Flexion based exercises have long been utilized to potentially relieving mechanical compression of the lumbar nerve roots and improving spinal flexibility. (Backstom et al, Manual Therapy 2011)
Some other studies also suggest that spinal extension exercises (McKenzie therapy) is more effective than comparison treatments like NSAIDS, educational booklet, etc. (Clare, et al, Aust J Physiother 2004)
Nerve mobilization: patients treated with end range nerve mobilization procedures (like passive slump) demonstrated marked reductions in pain. (George JOSPT 2002 and Cleland et al Manual Therapy 2004)
Flexion exercises in combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking have shown significant reduction in pain and disability in older patients with chronic low back pain with radiating symptoms. (Anthony Delitto , Steven Z George JOSPT 2012)

PATIENT EDUCATION AND COUNSELING
Education and counselling about causes of back pain, prognosis, appropriate use of imaging studies and specialists, and activities for promoting recovery and preventing recurrences have been traditional used for patients with acute, sub-acute, and chronic low back pain.

PROGRESSIVE ENDURANCE EXERCISE AND FITNESS ACTIVITIES
Presently, most national guidelines for patients with chronic low back pain endorse progressive aerobic exercise with moderate to high recommendations. (Airaksinen O Et al, EUR Spine J 2006, Bekkering GE physiotherapy 2003, Chau R 2007, Mercer MK 2006, Pillastrini P. Spine 2011, Savigny P, 2009)
High intensity exercise has also been demonstrated to have a positive effect on patients with chronic low back pain. (Staal JB JOR 2005, Smith C 2010, Rainville, Spine 2002, Murtezani A 2011, Cohen I Spots Med 2002)

Modern approach for treating Chronic Low Back Pain
Chronic low back pain is no longer considered a purely structural, anatomical or biomechanical disorder of the lumbar spine. Instead, there is strong evidence that chronic low back pain is associated with a complex interaction of factors across the biopsychosocial spectrum. These not only involve structural or biomechanical factors, but also cognitive (e.g., unhelpful beliefs, catastrophising, maladaptive coping strategies, low self-efficacy), psychological (e.g., fear, anxiety, depression) and social (e.g., work and family issues) factors (Vibe Fersum , O’sullivan, Eur J Pain 2013).

How it works:
•Negative thoughts (e.g., “My back pain is uncontrollable” introduce Negative feelings (e.g., depression, anger) and bring maladaptive health behaviours (e.g., skipping treatment sessions) thereby reinforcing negative cycle.

If one negative thought can be changed or better understood, then it can break down this negative cycle. This can be addressed through education and Cognitive Behavioural Therapy (CBT)
CBT aims to shift attention from incorrect and erratic thoughts and fears to adaptive thought patterns. It modifies the overall pain experience, help restore functioning and improve the quality of life of patients who suffer from chronic pain.
There is a great evidence to support the effectiveness of various cognitive behavioural interventions for reducing pain intensity and improving a patient’s coping skills. They help the patient let go the struggle against pain and move toward achieving their most valued life goal. Medical management is also more effective if cognitive, psychological and social factors are addressed. (Mark Jensen PHD, Mansell G 2013, Smeets 2006).

At Ability Physiotherapy and Sports Injury Clinic, we choose the best approach for your low back pain and help you return to activity at the earliest.

Why To Warm Up Before Exercise

A muscle is like a car. If you want it to run well early in the morning, you have to warm it up – Florence Griffith Joyner (Olympic 100 meter world record)

Any exercise or physical activity starts with a good warm up. When a person starts doing any physical activity they try to attain their goal and improve it. To reach the goal they need to exceed from their limit level and to reach out to the next level. Human body needs a preparation which can be a preferred form of exercise which prepares the muscle joints and bones for a large amount of exercises.

Good warm up is essential to limit the chances of injury which helps to maintain the self confidence and interest in physical activity.
Warm up is nothing but a low-level activity in which a human body prepares itself for the further exercising and stretching as well as weight lifting. A warm up should be completed prior to stretching and more strenuous exercises.

Reasons to warm up-
• Warm up increases movement of blood through tissues making muscle more flexible.
• Delivers the oxygen and nutrient to your muscle.
• Prepare the muscle for stretching and prepare your heart for increased activity by preventing a rapid increase in blood pressure.
• Prepare the body for high intensity exercise by increasing body temperature, metabolism and blood circulation so that more oxygen is more available to increase muscle activity.
• Increased temperature helps to increase the rate of energy production contraction and relax time or improve with higher muscle temperature.
• Warm up can help to reduce muscle soreness post exercise.
• Warm up prepares the nervous system by mimicking sport specific movements.

A perfect Warm up routine consists of-
• General warm up
• Stretching
• Sport Specific warm up

General warm up
By warming up before exercise you increase blood flow to muscle and other soft tissue which is an important factor in avoiding damage to the ligament muscle joint and tendons. General form of warm up should include 5 to 10 minutes of light cardiovascular activity such as fast walking or slow jogging to increase your heart rate gradually, promote blood flow to your muscle and supply them with more oxygen.

Stretching
Stretching can be of two types dynamic and static. Dynamic stretching is ideal prior to exercise to prepare the joint for movement and muscle for optimal activation where as static sustained stretches are designed to hold a position for a joint and muscle that is minimally challenging. Stretches can be effective to improve overall flexibility, which can allow you to move more freely and effectively.

Sports specific warm up
By doing sports specific warm up you properly prepare your muscle and increases your mobility. It stimulates competition action and intensity in order to start the competition in the highest level.
For example before start running take a slow jog, a gentle cycle for a spin class or a slow swim before building up speed in a pool.

Warm up varies with sports and activity for eg. a 100m sprint needs 20 minutes of warm up. The sprint time was significantly better when performing after a specific warm up as compared to a general warm up. The rate of the perceived exertion was significantly lower during the specific short warm up. Research has also shown that warm up has a positive effect on the swimmers performance especially for distance greater than 200 m. We recommend that swimmer warm-up for a relatively moderate distance (between 1,000 and 1,500 m) with a proper intensity (a brief approach to race pace velocity) and recovery time sufficient to prevent the early onset of fatigue and to allows the Restoration of energy reserves (8 -20 minutes), Neiva HP et all.

Few of the sports and the joint to be focused while doing their Warm ups are mentioned herein:-
Tennis and Badminton
Shoulder hip and knee injuries are very common among tennis and badminton player. These sports include the movement of high step up, multi direction lunges, and multidirectional arm range of motion for service and multiple shots e.g. forehand/backhand etc.

A small set of specific warming which can be done by a tennis and badminton players will be a
• Lunge walk.
• Buttock kicks.
• Jumping high from side to side
• Rotating your torso from side to side.

In a research study by Maloney SJ, Turner AN et al it was shown that warm up may improve power performance in a badminton player. Examination shows the effect of dynamic warm up on change of direction speed (CODS). Vertical jump and CODS were tested post warm up. In conclusion the study demonstrated that post warm up CODS, was significantly faster. In addition peak CODS test performance was faster then the control condition.

Running/jogging
Knee ankle and foot injuries are common amongst runner. In addition to your cardiovascular warm up you should also add
• Lunge walk
• Buttock kick
• Controlled leg swings
• Fast feet.
• Stretching for calf, hamstrings and quadriceps.

Cycling
Knee and low back problems are common among cyclist. Before you start biking, do try the following:-
• The spot jump from side to side
• lunge forward and back
• Both knee to chest lying on the floor.
• Slow paddling movement with your legs.

In a research study, Abad CC, Prado ML et all have proved the general and specific warm up improves the performance maximum 1RM compared with specific warm up in trained individual.

At Ability Physiotherapy and Sports Injury Clinic, we can help you with a suitable warm up prescription and advice which will help you stay injury free.

THANKYOU

CARDIO Vs WEIGHT TRAINING Vs YOGA

Determining what you are looking to achieve from your exercise drastically changes the exercises that would work best for you. A workout routine for someone who is looking to lose weight is very different from one for someone who wants to gain muscle. Knowing what your goals are, is the best way to determine your workout routine.
Some common variants of fitness regimes are Cardiovascular training, Resistance training and Yoga.

CARDIO
These help you burn more calories and are usually of lower intensity and sustained effort, however can also be shorter bouts of high intensity in some methods.
Cardio exercise uses large muscle movement over a sustained period of time keeping your heart rate to at least 50% of its maximum level.
Cardio exercise is any exercise that raises your heart rate.Movement makes the muscles stronger and stronger muscles make for a more efficient and healthy body.

Some of the Best Cardio Workouts Are:

Walking – This is the easiest and safest way to start getting in your cardio.

Elliptical – Minimal impact on the knees and hips but calorie burning is still high. When you increase the incline you will activate more muscles.

Running – This one is easy to understand. Just remember if you train like a distance runner you will look like a distance runner. If you train like a sprinter you will develop a sprinters body. Steady running burns calories but sprints take it to the next level.

High Intensity Interval Training – Short intervals at maximum intensity followed by short periods of rest. Best all around workout that burns fat and calories commonly known by the Tabata method.

Bike Riding or Cycling – Cycling uses large muscle groups in the legs and helps elevate your heart rate. This one is great you and you can do it indoors or outdoors.

Stair Climber – Uses more muscles than walking.

Jumping Rope – Cheap, easy and burns tons of calories. If you remember doing this for hours as a kid you will be surprised at how exhausted you will get now.

Swimming – This is a total body workout as long as you are not just floating – even treading water burns calories. Swimming laps would be best and change up the strokes you use so that you work all different kinds of muscles and the continuous pace works your heart and lungs.

Rowing – Works both the upper and lower body and is low stress on joints and ligaments.

Circuit Training – When you work out at a high intensity the blood starts to pump a lot harder and that challenges the elasticity of the arterial wall.

WEIGHT TRAINING
Resistance, or strength, training increases muscular fitness, which includes both muscular strength and muscular endurance. Muscle strength is the ability of the muscle to exert force, whereas muscle endurance is the ability of the muscle to continue to perform without fatigue. This form of training includes exercises performed using weights, weight machines, resistance bands, or one’s own body weight as resistance (e.g., pushups and squats). Regular resistance training can increase muscular strength, muscular endurance, and functional capacity .

YOGA–
Yoga relies on your own your entire body for strengthening . The way resistance classes use weights and other equipments , in yoga through different poses,your full body becomes toned and stronger by using your entire body weight as “weights”. Yoga is closely intertwined with breathing methods and poses that involve multiple joints to participate simultaneously.

Core components of yoga involve poses called asanas which work on many systems of our body. Yoga’s health benefits include increased fitness, stress reduction, weight loss and management of chronic conditions, such as pain, anxiety, depression and sleep problems.
1 .Better Body Image –
Focussing inward during yoga helps you to be more satisfied with your body and less critical of it.

2.Heart benefits–
Yoga can help lower blood pressure , cholesterol and blood sugar,all of which are good for heart abd blood vessels.

3.Overall fitness-
Practicing yoga a couple times a week increases muscle strength and flexibility ,boosts endurance and tunes up heart ,lungs and vessels.

4.Mindful eating -Being more aware of how body feels carrier over to mealtimes.

5.Weight control- Mindfulness developed through yoga makes you more sensitive to cues of hunger and fullness, which help you develop a more positive relationship with food.

Whichever form of exercises you chose , at Ability we can guide you in progressions and tips to stay injury free helping you take your fitness journey ahead.

References:-

1.Akhtar P, Yardi S, Akhtar M. Effects of yoga on functional capacity and well-being. Int J Yoga. 2013;6:76–9. [PMC free article] [PubMed]
2. Ross A, Thomas S. The health benefits of yoga and exercise: A review of comparison studies. J Altern Complement Med. 2010;16:3–12. [PubMed]