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Lower back pain management in clients for PTs

Updated: May 26, 2023

Low Back Pain (LBP) remains a prevalent issue worldwide, often impairing individuals' mobility and daily functioning. As personal trainers, addressing this concern effectively is paramount to help clients achieve their fitness goals.

Understanding 'Core Stability' and LBP

Historically, researchers linked LBP to a lack of spinal stability, asserting that muscles and the nervous system work in unison to control spinal motion. Dysfunctional timing of trunk muscles, such as delayed firing of the transverse abdominis during arm lifting, was suggested to be a common issue in individuals with LBP.

However, recent studies have indicated that correcting muscle timing does not necessarily lead to less pain or clinical improvements1. While core stability training is still beneficial and recommended by the American Physical Therapy Association, it's essential to align it with our current understanding of LBP.

Incorporating Updated Treatments

Traditional core stability training methods can still work, but the reasons behind their effectiveness may differ from the original theories. For example, exercises like bird-dogs can be useful for loading the spine and training anti rotation training - rather than enhancing spinal stiffness or muscle timing which is what was originally proposed.

Use of Walking and Deep Core activation in recovery

Avoiding movements during the day that overload the back's tissues beyond their current tolerance can be one strategy, another one being to introduce weight bearing low impact activities such as walking to activate the core muscles.

Furthermore, no return to regular exercise activities such as deadlifts and overhead pressing until time is taken to reload the deep core muscles instead of promoting the stronger outer motor units to work such as in compound lifts which would increase risk of re-injury.

Balancing Pain Avoidance and Exposure

A balanced approach to managing LBP involves initially minimizing pain by avoiding certain movements, followed by gradual exposure to those movements. This practice, often referred to as "poking the bear," can help build tolerance to previously painful positions. For instance, if a client experiences pain during lower back extension, you might initially use flexion exercises to find the positions of respite, then slowly reintroduce extension-oriented exercises like bird-dogs to build tolerance. Remember that your client will have centralised sensitisation so it will be hard to distinguish what is normal muscle working feelings vs what is bad pain. Coach them appropriately to understand the differences.

Recognizing the Multifaceted Nature of Back Pain

LBP arises from various factors, including biological, psychological, and social elements. While it's essential not to downplay potential tissue damage evident in imaging findings, focus on aspects within your clients' control to aid recovery.

One way of explaining this to clients uses the "cup analogy": the body is a cup, with the water representing pain contributors. When the cup overflows, pain ensues. These contributors can range from tissue-specific stress to psychological stress and poor sleep. By addressing a broad spectrum of relevant factors, you can help optimize your clients' recovery.

Key Takeaways for Personal Trainers

  1. Traditional treatments, like motor control training, can still be beneficial. However, it's essential to reframe them in the context of our current understanding of LBP - as tools for enhancing movement and progressively gently loading the back.

  2. It's crucial to balance pain avoidance and exposure. While certain painful positions might initially need to be avoided, gradually reintroducing these movements can build tolerance and aid recovery. Work with an experienced Physiotherapist to estabilish parameters.

  3. Utilize the "cup analogy" to explain the multifaceted nature of LBP. Highlight the diverse factors contributing to pain and emphasize the importance of addressing all relevant elements.

If you are in need of some extra help with LBP, do check out my course for personal trainers on back pain, it is a great way to be able to help clients get better long term outcomes.

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