Back pain: an opportunity for exercise professionals
Low back pain is now considered to be the most widely experienced health complaint in the world and the leading cause of disability. As a personal trainer you are likely to encounter clients with this condition. Do you have the skills to help?
Most of us at some time in our lives will experience an episode of back pain. Often this has no obvious cause and is nothing more than a minor inconvenience for a few days. However, some people can suffer severe pain rendering them permanently disabled.
Although back pain can be the result of a serious pathology such as a tumour, infection or trauma, the vast majority of cases, some 85%, have no identifiable cause (Simmonds and Derghazarian, 2009). This non-specific form of back pain is sometimes referred to as simple back pain or mechanical back pain.
In fact, low back pain is now considered to be the most widely experienced health complaint in the world and the leading cause of disability. 80% of the population, or 4 out of 5 people, will have an episode of back pain at some point in their lifetime. (Enhrich, 2003, Palmer et al., 2000, Norris, 2004) and up to 33% of the population will be suffering from back pain at any one time (WHO, 2012).
Rather alarmingly, it appears that the prevalence of back pain in school children is close to that of adults (CSP 2004) and the rate of increase in back pain is 14 times greater than the population growth (Norris, 2008)!
The potentially debilitating effects of low back pain and the sheer number of people who suffer the condition make it very costly in terms of the burden it puts on the individual, society and the economy (WHO, 2012). It is estimated to cost the UK economy £12.3 billion per year, which is equivalent to 22% of annual budget for NHS (CMO, 2009). According to research, the total cost of back pain corresponds to between 1-2% of gross domestic product (Norlund and Waddlle, 2000).
Challenging traditional approaches to treatment
The traditional approach to the treatment of low back pain was to view it as a structural condition that required rest. Physical activity was discouraged for fear of causing further injury. Current medical literature now suggests that exercise has, at worst, a neutral effect and may actually reduce slightly the risk of future back injuries.
In fact, most studies of exercise have noted an overall reduction in back pain intensity after exercise treatment ranging from 10%-50% (Rainville et al, 2004). Furthermore, research has shown there is no evidence that exercise typically increases the risk of additional back problems or work disability for people suffering low back pain.
There is strong evidence that exercise therapy is more effective than GP care for reducing pain/disability and promoting a return to work within 3-6 months (Airaksinen et al, 2006).
The role of exercise in the treatment of low back pain – the dangers
Although rest is still sometimes required in the treatment of low back pain, recent evidence has shown that prolonged bed rest can be harmful and that back pain can in part be a functional change that requires functional management (Norris, 2008).
This requires the client’s role to change from being the passive recipient of treatment to being an active participant in reducing their pain and restoring function. At the very forefront of this new approach is exercise (Norris, 2008).
Exercise, however, is a very general term and some types of exercise can be potentially damaging for the back while others can reduce the risk of injury and pain. For example, traditional straight leg sit-ups impose approximately 3300 N (about 730lb) of compression on the spine. The National Institute of Occupational Safety and Health (1981 cited by McGill 2007) set the action limit for low back compression at 3300 N. That is, repetitive loading above this level is linked with higher injury rates in workers, yet this load is imposed on the spine with each repetition of the sit-up!
Even worse is the prone leg and trunk extension or superman; this exercise imposes up to 6000 N (over 1300 Ib) on a hyperextended spine! (McGill, 2007). On the other hand there is considerable evidence that an appropriate stability training programme can be effective in decreasing pain and the risk of injury and improving physical function in people with chronic low back pain (Wang et al., 2012).
Opportunities for personal trainers
Due to the prevalence of low back pain, most personal trainers are likely to encounter clients with this condition. As exercise professionals they are ideally suited to working with these clients using exercise to manage their back pain to regain and improve function.
However, working with clients with low back pain requires more than a sound knowledge of the most appropriate forms of exercise. The phenomenon of back pain is more complex than commonly assumed.
There is an understandable tendency to associate pain with the presence of trauma and disease. For example, you may feel pain when you pull a muscle whilst exercising or perhaps you experience painful joints with a flu virus. There is also a tendency to associate the level of pain we experience with the extent of the damage present, i.e. the greater the damage, the greater the pain. However, the way in which we experience pain and the factors that influence our perceptions of pain are far more complex. For example, 95% of amputees experience chronic ‘phantom pain’ in a limb that no longer exists (Doidge, 2007).
The level of pain we experience is determined to a significant degree by factors including our brains and minds, our emotional state, our past experiences of pain, our psychology and gender. Consequently the treatment of pain must focus on more than the tissues of the body if we are to address all of the causes and consequences.
Becoming a low back pain exercise specialist
In light of this, VTCT has developed the Level 4 Award in Exercise for the Management of Low Back Pain. This will provide exercise professionals with the underpinning technical knowledge and practical skills to safely and effectively train clients with non-specific or mechanical low back pain.
In order to attain this qualification, students will be required to have a sound understanding of a diverse range of subjects such as the functional anatomy of the spine, pathophysiology of low back pain, and the influence of psychosocial factors on the development of back pain and its progression to chronicity. In addition they will need to possess the practical skills to be able to clients with back pain and prescribe a safe and effective programme of exercise.
Students will be assessed via a long answer externally set exam, a case study and an observation of their work with a back pain client. To undertake this qualification, students will need to hold a Level 3 exercise referral qualification.
The Level 4 Award in Exercise for the Management of Low Back Pain will help to enhance the professional standing of exercise professionals and allow them to work more closely with a range of health care professionals as part of a multidisciplinary team. It will also serve to further increase the acceptance of exercise as an effective therapeutic tool and the role of exercise professionals in the management of chronic health problems.
This article also appears in the autumn edition of VTCT news
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