Part 1: Establishing classification and examples of a management framework
Each patient has a problem that will behave specifically to their pathology. This can include lower back pain with and without leg symptoms, neurologic deficits, nerve scarring, as well as post surgical conditions. We need to consider how the patient experiences pain in including the movement sensitivity they experience. These observations give clues on the diagnosis and how to apply intelligent exercise progression that is specific to the individual. The aim of this article is to provide an overview of the presentation, suggest a framework for management and restore ability that may have been lost to pain.
By classifying the pain, the patient’s experience with pain, and how it presents with movement and in different postures will offer valuable insights into how the patient’s program should be structured. Pain presentation can be classified in three different groupings:
1. Intermittent - Pain that is produced with an activity, but there MUST be a time during the day where the patient is 100% pain-free. This should be an easy problem to fix.
2. Constant - There is never a time when the patient is pain-free. Postural sensitivity exists and may worsen with even lighter activities. This may present as low-level pain, numbness, aching, but it is constant and will experience this will any exercise. The goal is to find the least offensive progressions
3. Chronic - Pain that has been present for three months but may be present at different levels throughout the day. There may be periods of time where there is no pain but there remains movement or postural sensitivity and repeated experiences of acute flare ups. Chronic pain syndromes tend to reduce in intensity, in some cases can go away but most often will be residual at a low level with the primary goal to stabilize at a low level.
4. Location – the location of pain, central in the lower back, radiating away from the midline, into the gluteal, above or below the knee if symptoms have entered the leg.
Guidelines for Exercise Prescription
Step 1: Assess pain behavior. Does the pain come on with exercise or does it come on later in the day after exercising? If symptoms occur later then proceed with caution because exercises prescribed may take several hours to show sensitivity.
Step 2: Select an exercise the patient is familiar with and progress from there. Beginning with light loads and progressing to <80% of RM or an RPE of 7-8. For example, if a patient is familiar with box squatting and experiences an onset of pain at 70% of their RM then they should work up to a load that does not produce pain (in this example 70% RM). Avoid changing the height of the box and intensity (load on the bar) at the same time during the cycle. With no pain during the selected exercise, continue to train with submaximal loads that do not exceed 3-5 RMs particularly if you are early in reintroducing exercises. The rationale here is to allow the body to adjust to the loading pattern for a complete block of training that would usually lasting 4-8 weeks.
Step 3: Choose Assistance Work. These exercises are geared to addressing weaknesses and building towards the primary goal. They can be included at moderate volumes with lower loads than the primary exercise. For example, between 2 and 4 sets of 8 to 12 repetitions of the selected exercise. An important factor to consider is how the patients pain responds to this loading. Choose one exercise that focuses on hip, quadricep, hamstring, and abdominal development. The exercise selection may increase to a more demanding exercise choice or an increase in volume, but this should not be done simultaneously. Additionally, this progression is contingent on there being no pain with the initial exercise selection.
Individuals suffering with chronic pain
Most patients with chronic low back pain will get worse with exercise and some have the tendency to get much worse in the hours after exercising. With these patients, we begin with a box up two inches higher than parallel.
Step 1: Patients will only perform their primary exercise because we are concerned about what will happen later that day. NO ASSISTANCE WORK is to be performed. The rationale is to assess the effect of the primary exercise on the individual.
Step 2: The chronic pain athlete will repeat the same load during the next heavy work out. If that workout did not increase pain or only low increase in pain, then they can add ONE assistance exercise. This will be repeated rep for rep with the same weight for the following workout. If the pain is minimal again, then we stay with these exercises.
The process is: introducing an exercise, stabilizing the response, and then progress the exercise.
This will require performing the same workout a few times to stabilize the response. Unlike a healthy patient, who needs a greater stimulus to improve, the chronic low back pain athlete needs a workout where the primary goal is to minimize increase in pain.
Consistency is key so avoid changing variables regularly in chronic lower back pain conditions. The chronic painful spine does not like routine changes. Establishing safe training guidelines and building from there will result in positive outcomes. Repeated tasks can be very successful at improving the condition.
Repetition of movements that are mildly provocative can foster symptom stability, improve strength and desensitize the nervous system. By adding assistance exercises with no regard to the response, will leave you spinning your wheels at best, or at worst backtracking.
Part 2 will outline suggestions for correct exercise selection and sequencing.
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