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© National Strength & Conditioning Association

SPECIAL POPULATIONS Volume 25, Number 6, page 56–59

Strength Training
and Low Back Pain
Thomas E. Dreisinger, PhD
Progressive Spine Care & Rehabilitation
Columbia, Missouri Tom LaFontaine
Column Editor

BACK PAIN IS AN INSIDIOUS AND symptoms. Indeed, one might tion. McKenzie (5), a physical
common occurrence in American present the same symptoms to a therapist from New Zealand, de-
society. Seven out of 10 adults in family practice physician, physi- veloped a unique method of me-
this country will suffer low back atrist, orthopedist, physical chanical diagnosis and therapy.
and/or neck pain during their therapist, and chiropractor and It is considered the most valid
lives (8). At any given time, be given a dif ferent diagnosis and reproducible assessment in
15–20% of Americans may be from each of them. This adds to determining how significant the
suffering from some amount of the overall confusion about the mechanical component of back
low back pain (LBP; 8). Symp- best way to treat this common pain is. The hallmark of this
toms may manifest themselves malady. The good news, howev- method is the ability, on physical
as pain, numbness, or tingling er, is that successfully treating examination, to cause the symp-
in the leg, buttock, or central LBP does not necessarily require toms to “move” either distally
back. LBP can range from a knowing exactly what the specif- (farther away) or proximally (clos-
minor irritation to being com- ic “pain generator” is. er to) the center of the low back
pletely debilitating. Besides the With few specific exceptions, (5). If the symptoms can be
human suffering, costs for LBP the majority of LBP can be clas- moved one way or the other, the
are also quite high, estimated to sified as “mechanical” (5). Me- potential for a positive clinical
be in the neighborhood of 56 bil- chanical LBP refers to symptoms outcome for the patient is greatly
lion dollars per year (2). Al- that are intermittent in nature enhanced. The movement of
though it is not as serious a con- and wax and wane in intensity. symptoms in a patient is termed
dition as vascular diseases or This means that there may be “directional preference” (symp-
cancer, it is the most common times of the day or positions toms migrating distal are termed
cause of disability in the United (e.g., sitting, lying, standing, “peripherilization,” whereas prox-
States for people under the age walking, etc.) when the symp- imal migrating symptoms are
of 45, and second to the com- toms are better or worse. The considered “centralization”). The
mon cold as the most frequent clinical implication of this is that outcome of the mechanical as-
reason for visiting the doctor (3). the precise source of the symp- sessment guides the subsequent
Unlike other orthopedic in- toms is less important than the active rehabilitation.
juries (e.g., rotator cuff tear or ability to treat them. Active programs have been
anterior cruciate ligament in- For this reason, a good me- recognized as important interven-
jury), health care practitioners chanical assessment of the low tions and treatment for people
are often unable to determine back is essential as part of the with back pain. The Agency of
the exact cause of back pain history and physical examina- Health Care Policy and Research

56 Strength and Conditioning Journal December 2003


(AHCPR), when reviewing back Strength training of patients (4). Finally, strengthening of the
pain problems in this country, with back pain is very important lumbar spine has been shown to
stated that physical activity is a for a successful rehabilitation reduce the need for surgery, de-
key element in treatment (1). Al- plan. It is interesting to note, how- crease reuse of the health care
though the AHCPR did not provide ever, that there is a hesitance system, and consequently great-
specific exercise guidelines, it among many rehabilitation spe- ly reduce health care costs for
strongly encouraged active exer- cialists to strengthen the lumbar back care (6).
cise programs. This has led to a spine during rehabilitation. No Another value of strength
de-emphasis of the use of passive one would argue the need to training in the clinical setting is
modalities and an increased em- strengthen the quadriceps follow- that it provides immediate feed-
phasis on and growing promi- ing an anterior cruciate ligament back to the patient. Often pa-
nence toward aggressive and early injury. Passive and active motion tients are given lifting restric-
activation of patients with injuries is critical to prevent adhesions tions (e.g., 15–20 lb), which are
to the lumbar spine. This kind of from developing and to keep the very subjective. This may be a
rehabilitation uses quantitative vastus medialis from withering disservice to patients because it
equipment such as treadmills, away. It would almost be consid- creates an artificial limitation to
stationary bicycles, weight train- ered malpractice in the knee not to their activities of daily living. It
ing machines, and back assess- do active rehabilitation even in the also engenders fear, in that near-
ment devices as part of the clinical face of patient pain. What makes ly everything they consider lifting
armamentarium. This permits ob- the lumbar spine any different? will be perceived as potentially
jective measurement to monitor Nothing! dangerous. Once patients per-
the progress a patient makes dur- Why is strength training im- ceive this imposed limitation as a
ing clinical treatment. portant in the spine? Repair of in- danger, they will find themselves
Part of the increased interest jury to soft tissue is really an in a downward cycle of decondi-
and awareness in the impor- issue of cellular nutrition. The tioning and further loss of con-
tance of exercise has also come better the supply of nutrients to trol in their lives. Strength train-
about because of the drive to- the area of injury, the better op- ing is a marvelous tonic for this
ward accountability in medical portunity for that tissue to be- debilitating mental thought
practice. The language support- come healthy. Because blood flow process. Allowing patients to see,
ing evidence-based/outcomes- is in parallel and not in series, re- feel, and per for m safe move-
driven medicine, which is ap- gional blood flow is a function of ments with specific weights pro-
pearing more and more in the the “need” expressed by the exer- vides them with important kines-
literature, reflects this. Giving cising muscle. Strengthening the thetic feedback. This feedback
patients medication and sending extensors of the low back encour- tells patients objectively what
them down for “a little PT” is be- ages blood flow to the area or in- they can actually lift safely.
coming less acceptable in the jury, and consequently enhances Other benefits that occur from
management of LBP. Rehabilita- the opportunity for healing to strength training are the reduced
tion specialists are being asked take place. Blood flow may be oc- risk of injury and increased sense
for defensible rationales for pre- cluded during the actual exer- of well-being that comes from this
scribed treatment plans. cise, but immediately following activity. In unpublished data from
The introduction of the field of the activity fresh blood and nutri- 2 major airlines, low back injury
exercise science has helped move ents flood the exercised muscle. costs were reduced by over 70%
the objective management of LBP From a clinical standpoint, following a systematic strength
patients forward. Clinical exercise aggressive strength training of training program focusing on the
physiologists (CEP), working with the lumbar spine has been shown lumbar extensor muscles. With
physicians and physical thera- to overcome structural weak- these principles in mind, let us
pists, have brought a more quan- nesses in patients with LBP (7). It take a look at a specific outcomes-
titative thought process to this has been shown to “lay down based conservative care (i.e., non-
arena. The CEP’s ability to mea- bone” in the lumbar spine follow- operative) spine center, Progressive
sure human performance has ing a training regimen (4). It has Spine Care and Rehabilitation. The
aided in the process of moving also been used as a successful program focuses on testing and
conservative spinal care forward strategy in the reduction of pain training the muscles of the low
in a more objective manner. and increased physical function back and peripheral joints, which

December 2003 Strength and Conditioning Journal 57


are important for good postural body strengthening, therefore, is ally lift. It increases their sense
support. an integral part of the rehabilita- of well-being by demonstrating
tion. Specific muscle groups gains in strength that are made
■ Progressive Spine Care such as quadriceps, hamstrings, as a result of the rehabilitation
and Rehabilitation: A Model rhomboids, and latissimus dorsi, program. It introduces patients
This program is evidence-based among others, are trained. These to a form of exercise that can en-
and outcomes-driven. This means ancillary muscle groups act to hance the quality of their lives in
that assessment and treatment support good posture, and the short term through success-
protocols are based on published therefore the low back. ful treatment of their LBP. Final-
scientific literature that guides the All objective data are entered ly, strength training acts as an
clinical course of our patients. A either daily by the therapist or encouragement to make perma-
touch-screen computer system electronically directly from the nent lifestyle changes that will
acquires patient demographics, strengthening machine. This per- increase the quality of their
health and work history, as well as mits clinical notes to reflect, on a lives. ▲
outcomes information in the form daily basis, changes that occur
of the SF-36 (quality of life), Os- from baseline measures. ■ References
westry (disability score), and the In addition to progressive 1. Bigos, S.J., R. Bower, G.
Spinal Function Sort (physical functional strength changes in pa- Braen, et al. Acute low back
function). These well-validated tients, the outcomes measures are pain problems in adults. Clini-
and reliable outcomes question- very important to the clinic’s suc- cal Practice Guideline, Quick
naires help determine the success cess. For example, when looking Reference Guide No. 14.
of the rehabilitation program for at quality of life measures, our Rockville, MD: U.S. Depart-
the patient, insurance companies, clinic population has shown a ment of Health and Human
and referring doctors. Real-time 28% and 65% increase in physical Services, Public Health Ser-
data acquisition permits ongoing and general health, respectively, vice, Agency for Health Care
and im mediate access to summa- following early phase rehabilita- Policy and Research, 1994
ry data of the clinical population. tion and at 6 months follow-up. (AHCPR Publication No. 95-
A key part of the approach is Perceived disability decreased by 0643).
strengthening of the extensor mus- 25% at discharge from early phase 2. Cleary, L., et al. Occupational
cles of the lumbar spine. Assess- rehabilitation and 50% by 6 low back disability: Effective
ment of strength and range of months. Finally, perceived physi- strategies for reducing lost work
motion (ROM) begins the rehabili- cal function increased by 38% by time. AAOHN J. 43:87–94.
tation process. Strength is mea- the end of early phase rehabilita- 1995.
sured isometrically in several posi- tion and maintained a 23% gain at 3. Cunningham, L., and J.
tions throughout the measured 6 months follow-up. These data Kelsey. Epidemiology of mus-
ROM. Once maximal strength is demonstrate the empowerment culoskeletal impairments and
known, it is a simple matter to pro- that comes when patients learn associated disability. Am. J.
vide a safe dynamic strength pre- what they can and cannot safely Pub. Health. 74:574–579.
scription within an appropriate do in their lives. This is the ulti- 1984.
ROM. Objectively testing strength mate purpose of a rehabilitation 4. Graves, J.E., J. Mayer, T.E.
and range of motion is critical be- program—enhancement of the pa- Dreisinger, and V. Mooney. Re-
cause it provides a “snapshot” of tient’s quality of life. sistance training for low back
where the patient is. The exercise Strength training should be pain and dysfunction. In: Re-
prescription is tied to the principle an integral part of the clinical re- sistance T raining for Health
of progressive overload that per- habilitation of patients with LBP. and Rehabilitation. J.E. Graves
mits a safe incremental increase in Its value can be observed on and B.A. Franklin, eds. Cham-
work over the rehabilitation course. many levels. First, it increases paign, IL: Human Kinetics,
Mechanical LBP is thought the structural integrity of the pa- 2001. pp. 357-383.
to have its origins in poor pos- tient’s musculoskeletal system— 5. McKenzie, R., and S. May. The
ture (5). Consequently, we be- the low back being paramount Lumbar Spine Mechanical Di-
lieve it is important to strength- here. It provides immediate feed- agnosis & Therapy (Vol. 1 and
en peripheral muscles that back to patients as to the 2, 2nd ed.). Waikanae: Spinal
support the low back. Whole amount of weight they can actu- Publications, 2003.

58 Strength and Conditioning Journal December 2003


6. Nelson, B.W., D.M. Carpenter,
T.E. Dreisinger, M. Mitchell,
C.E. Kelly, and J.A. Wegner.
Can spinal surgery be pre-
vented by aggressive strength-
ening exercises? A prospective
study of cervical and lumbar
patients. Arch. Phys. Med. Re-
habil. 80(1):20–25. 1999.
7. Pollock, M.L., J. Graves, D. Car-
penter, D. Foster, S. Leggett,
and M. Fulton. Muscle. In: Re-
habilitation of the Spine: Science
and Practice. S. Hochschuler, H.
Cotler, and R. Guyer, eds. St.
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8. Waddell, G. The Back Pain Rev-
olution. New York: Churchill
Livingston, 1998.

Thomas E. Dreisinger is with


Progressive Spine Care and
Rehabilitation in Columbia,
Missouri.

December 2003 Strength and Conditioning Journal 59