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Exercise In Mechanical Low Back Pain
Objective
- Restoration of joint biomechanics
- Prevention of chronic pain development
- Prevention of relapses
- This prevents loss of function and improves physical adaptation.
Restoration Of Joint Biomechanics
- Muscle strength, endurance, flexibility
- By increasing the range of motion of the joint
- Provided by preventing contractures
Prevention Of Chronic Pain Development In Exercise
- Effects Providing Primary Analgesia
- Endorphin release: Large muscle groups
- Door control mechanism
- Effects Providing Secondary Analgesia
- Increases local blood supply. Improved muscle and intervertebral disc nutrition
- Resolution of contracture and spasm
- Improves depression and increases the patient’s self-esteem
Relapse Prevention
- Preservation of joint biomechanics
- Reduction of the load (30%) on the intervertebral disc (physiological brace)
Exercise Programme
- Exercise should be made a habit.
- Exercising more than once a day is better than a single exhausting session.
- Exercise should not cause pain.
- Exercises should start with warm-up exercises and end with stretching and relaxation exercises.
- The least challenging movements should be started. (Floor exercises)
Recommended Exercise Types In Patients With Mechanical Low Back Pain
- McKenzie exercises
- Dynamic stabilisation egz
McKenzie Exercise
- One of the most effective exercises
- The position where pain decreases the most is determined (Centralization phenomenon)
- The first movements can increase pain
- Repeating joint range of motion exercises are performed
- Isometrically exercise is done to the back extensors in extension
- In the acute period, the exercise is performed 10 times with an interval of 1-2 hours
- If the pain is centralizing within the first 2 days, it responds well to conservative treatment
- It gives better results in acute cases than in chronic cases
Dynamic Stabilisation Exercise
Basic Principles
- Objective: Reduction of cumulative microtraumas
- Method: Neutral spinal position is taught
The neutral spinal position is the position in which the spinal column best meets the mechanical load.
- Adjusted according to individual characteristics and disease
- Applied under supervision
What Are The Causes Of Cumulative Microtrauma?
- Staying in the same position for a long time
- Sitting, standing
- Major Movements
- Getting in and out of the car, lying down and getting up
- Movements requiring strength
- Push, pull, climb
For Protection From Cumulative Microtraumas
- Muscular strength, good flexibility and endurance are not sufficient
- Healthy muscles need to contract at the appropriate time and this should be realised in activities of daily living
CONCLUSIONS: Neutral spinal position should be maintained during activities of daily living.
Dynamic Stabilisation Exercise
Exercise Techniques
- Muscle strength, endurance, coordination exercises
- Abdominal muscles (abdominal bracing)
- Lower limb muscles
- Flexibility (stretching) exercises
- Paraspinal muscles
- Hip flexors and extensors
- Aerobic exercises
- Walking and swimming recommended
- Increases the release of endorphins
- Increases physical capacity
Exercise Prescription Scheme In Low Back Pain
- Acute Low Back Pain
- Stay active and avoid bed rest
- Aim: modulate symptoms, reduce activity; pharmacological treatments and other therapies are applied as adjuncts to activate quickly
- Subacute low back pain
- Start an aerobic exercise programme as tolerated
- Start with general lumbar exercises aimed at trunk stabilisation
- Objective: recommended to be active; return to normal activity; improve fitness level if necessary
- Return to normal activity/Secondary prevention
- Continue aerobic exercise and trunk stabilisation programme as home exercise
- Purpose: prevent repetition
- Continue aerobic exercise and trunk stabilisation programme as home exercise
- Purpose: prevent repetition
Treatment Approach In Patients With Acute/Subacute Low Back Pain
- Acetaminophen: fewer side effects, efficacy is controversial
- Nonsteroidal anti-inflammatory drugs are recommended: one is not superior to the other
- Muscle relaxants
- Opioids are not recommended: not superior in return to work and pain control.
- Superficial heat applications
- Manual therapy
- Corset
- Acupuncture
- Continue activity, avoid twisting and bending
- Patient education
Treatment Approach In The Patient With Chronic Low Back Pain
Function-orientated approach
- Education: focussed on overcoming the patient’s fear of movement
- Exercise motor control exercises, aerobic exercises, core stabilisation exercises, strengthening exercises, flexibility exercises, stretching exercises, balance exercises, pilates, yoga, thai chi
- Cognitive behavioural approaches and stress management
- Multidisciplinary rehabilitation
- Acupuncture
- Massage
- Manipulation
Pain-orientated approach
- NSAID short course
- Opioids: As effective as NSAIDs, but many patients discontinue treatment
- Muscle relaxants:?
- Duloxetine, antidepressants
- Corticosteroids: no different from placebo
- Epidural corticosteroid injections
- Use pharmacological and nonpharmacological treatments together, start treatment primarily with nonpharmacological treatment, if it is not sufficient or if you cannot apply it, use pharmacological treatment
- Physiotherapy applications
- Dry needling, prolotherapy
- Kinesiological taping
Surgical Treatment
- Indications for definitive surgical treatment of low back pain
- Development of cauda equina syndrome
- Progressive motor deficit
- Unresponsiveness to conservative treatment
Red Flags In Low Back Pain
- Age > 50, especially women and men with osteoporosis or compression fracture
- Age > 70
- Unexplained fever, urinary or other infection history
- Unexplained weight loss
- Trauma, cumulative trauma
- Night pain
- Cauda equina syndrome (saddle anesthesia, urinary or fecal incontinence)
- History of osteoporosis
- History of cancer/strong suspicion of cancer
- Long-term use of corticosteroids
- Intravenous drug use
- Immunosuppression or diabetes mellitus
- Progressive or focal neurological deficit accompanied by symptoms of disability
- Back pain lasting longer than 6 weeks
- History of previous surgery
Yellow Flags In Low Back Pain
- Psychosocial factors that may be effective in low back pain
- Psychosocial barriers to recovery that can increase the risk of long-term disability and work loss
- Yellow flags should be identified and treated early to prevent chronicity in low back pain
- The belief that pain is harmful and can lead to serious disability
- Avoidance of activities due to fear of pain
- Belief in passive treatment rather than active treatment
- Low or negative mood
- Job dissatisfaction
- Overprotective family or lack of family support
- Many things can happen on an MRI.
- Many people have problems with their MRI
- If the patient’s complaints and clinic are not compatible with the problem detected on MRI, it is incorrect to say that it is caused by this.
- If you do not think of additional serious problems, treatment is planned and followed up.
PROTECTION
- Modification of daily living activities
- Choose the right shoes
- Lift heavy objects with your legs, not your back, and keep them close to your body
- When bending forward to work, bend without excessive bending or twisting of the back, avoid positions that increase inter-vertebral pressure, and bend at the knees or hips
- When carrying heavy objects, carry them close to the body and balance the center line without bending to the side
- Use your arm, core, and hip muscles when lifting weight, not your back
- Keep your spine straight when standing
- Move while maintaining the erect position of the spine while bathing
- Dress in a pain-free position when dressing, and if pain occurs when dressing while standing, dress while lying down
- Sit upright in a chair, lean slightly back to support your back, and sit with your legs apart
- Stand up and move around from time to time when sitting, and change positions
- Avoid sudden movements. When getting out of bed, turn sideways, dangle your legs, and get up with support from your arms. When sitting in a chair, sit with your back straight, then pull your body back, and when getting out of a chair, come forward first, then support yourself with the arms of the chair and get up with your back straight.
- Get in the car sideways first and then take your body inside
- When driving, sit with your back straight and support your back with a slightly reclined back
- Sleeping on a firm and orthopedic mattress, bending your legs slightly during sleep and placing a pillow under your calves in supine position, placing a small pillow between the two legs in side position, and placing a thin pillow under your stomach and lower leg in prone position to relieve pain.
- When brushing your teeth, washing your hands and face, do not bend over the sink, keep your back as straight as possible and do your work.
- Exercise
- Flexibility
- Strengthening
- Conditioning
- Elimination of other risk factors
- Do not smoke
- Pay attention to your weight, eat a balanced diet
- Psychological factors
