Male personal trainer correcting young female doing low back pain stretch with a stability ball. How to train clients with low back pain
Male personal trainer correcting young female doing low back pain stretch with a stability ball. How to train clients with low back pain

How To Train Clients With Low-Back Pain

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As trainers we will no doubt have clients who are coming to us with Lower back pain (LBP).

It is estimated that 80 percent of adults in North America will have at least one episode of low-back pain severe enough that they need to take time off work.

LBP is associated with reduced quality of life, human suffering, and enormous financial and social burdens.

Exercise is one of the cornerstones of both the prevention and treatment of lower-back pain.

We need to have a good understanding of causes, anatomy and exercise selection for rehabilitation with the goal of intervention,  primarily directed toward improvement of function verses just treating the pain itself.

Male personal trainer assisting a female client doing a side plank

Factors that Contribute to LBP:

Lifestyle:

  • Physical inactivity
  • Overweight or obese
  • Poor posture, sleeping positions
Graphic of different words associated with low back pain like bad posture, obesity, stress, and mental health
  • Jobs that require prolonged sitting, repetitive bending or rotating (this also causes chronic LBP).
  • Exposure to vibration
  • Tabacco and nicotine have been shown in studies to increase the frequency of chronic LBP or repeated acute bouts of pain.

Psychosocial:

that may be linked to chronic LBP

  • Stress in the work place
  • Depression
  • Dysfunctional family relationships
Depressed woman sitting by a window in the dark looking out onto a street

Epidemiology:

Defined as pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds with or without leg pain (sciatica).

Categorized into three presentations:

Acute:

 Nonspecific LBP with a duration of six weeks or less

  • Usually a result from muscular skeletal strain (Esses,1995;Macnab, 1977; Carfin & Vaccaro, 1977)
  • Typically mechanical in nature: activity related e.g.
  • strenuous activity not normally performed
  • sports activities
Illustration showing low back pain in a transparent male body
  • lifting heavy objects, reaching, sudden jolt.
  • Symptoms vary, ranging from muscle ache to shooting or stabbing pain and can be severe for a few days but tend to alleviate significantly within two to four weeks.
Young woman sitting on blue yoga mat in the sun listening to music on head phones
  • Individuals will feel better when resting
  • Bending, twisting and lifting can exacerbate the symptoms
  • Many studies have shown that symptoms can be expected to resolve in 80% of individual within four to six weeks.

TRIAD of Treatment

1. Activity modification:
  • certain postures may aggravate their condition e.g. sitting may place more stress on the low back than standing or lying (Esses, 1995;Garfin & Vaccaro, 1997).
An illustration of people sitting in chairs from bad posture to good posture
  • Forward flexion many increase low-back loads
  • Whatever position provides them with maximum comfort is what we should encourage

As trainers we should teach proper sittng, sleeping and lifting techniques

2. Physical modalities:
  • There is good evidence that cryotherapy and heat (A physician or therapist only should initiate this treatment). Along with therapeutic exercises are of benefit.
Young woman applying a heat pack to her shoulder
3. Medication:
  • Often prescribed by physicians: Non-narcotic analgesics, nonsteroidal anti-inflammatory agents and muscle relaxants.
  • Trainers should have an understanding of the effects of the clients medication on their physiological responses and performance at rest and while exercising.
Rows of different pills of vitamins and supplements

Although it is not usually necessary for doctors to make a specific diagnosis for those patients with acute LBP, you as the trainer should understand when it is necessary to refer.

For instance when there is radiating leg pain and/or a history of LBP that is not activity related.

Chronic:

Pain that persists for more then three months. Often difficult to determine the cause.

Possible causes:
  • Most instances are thought to be due to degenerative disk disease.
  • Disk rupture or outward bulge placing pressure from the spine being overly compressed or strained.
  • Spinal stenosis, osteoporosis causing fractures, scoliosis, kyphosis, lordosis.
  • Smoking and nicotine use have been linked to chronic low-back pain.
Man smoking the last bit of a cigarette
  • As with Acute LBP, jobs/activities that require prolonged sitting, repetitive bending, vibration have been shown to be associated with and increased frequency of chronic LBP or recurrent acute exacerbations of pain. (Esses, 1995; Macnab, 1977).
  • We should encourage our clients to make changes to those activities that are causing the problem
  • e.g. take standing/movement breaks during their work day.
Team of young professionals looking over some blue prints on a wooden table

Other non-operative options that are considered for those who do not respond to the Triad of Treatment protocol are:

  • pain management techniques such as biofeedback, transcutaneous electrical nerve stimulation, acupuncture, lumbar orthoses and manipulation

Once cleared by their Physician / Physical Therapist clients with Chronic LBP can follow the Triad of Treatment.

Low-Back Pain and Sciatica: 

Clients presenting with LBP and leg symptoms

  • if the pain down the leg follows a specific pattern it is most likely radicular (radicular refers to symptoms that are of nerve root origin).
  • There is pain sensory disturbances, such as:
    • Numbness, tingling or cramping
    • Motor weaknesses
Illustration of sciatica pain
  • There are non-operative treatments: exercise, epidural steroids, nerve root block, and nonsteroidal anti-inflammatory agents.
  • Those who are functionally disabled with the symptoms are considered for surgery.

These clients need to be referred to and assessed by their physician. They are often referred to an Ortopedic surgeon and will see a Physiotherapist.

Once cleared by Physician, follow the guidelines laid out by Physiotherapist.

Exercise and Low-back Pain:

Guidelines:

Clients with LBP should be cleared by their physicians prior to beginning and exercise program with a personal trainer

Male personal trainer showing young female information on a clip board
  • You as the Personal Trainer will be able to work with the client on the exercise prescription designed by the Physiotherapist reinforcing the skills and exercises.
  • There is NO “one size fits all”. You will need to work with the client on an individualized basis. What works for one client may exacerbate symptoms for another
  • Those clients with good cardiovascular fitness, strong abdominal musculature and good paravertebral strength have shown a decrease in the frequency and severity of chronic LBP.
  • Muscular endurance as opposed to muscular strength has been shown to have the strongest positive results in regards to low back health.
  • Emphasize proper technique at all times
  • Adequate warm up and cool down before and after each workout session.
  • Maintain neutral pelvic alignment and neutral spine.
  • Avoid head-forward positions in which the chin is tiled up.
  • Monitor all activity for complaints of pain, weakness and radicular symptoms.
  • Sitting exercises may place more stress on the low back then standing or lying.
Five young people in a group fitness class doing a single leg lunge together
  • Educate clients on proper body mechanics, and postural awareness

Please also read the article on “Understanding Core Anatomy and Stability” to get a clear understanding of the muscles involved with the core and their function.

An individuals with lower back pain may have difficulty learning how to recruit their transverse abdominis and multifidi muscles.

These are crucial to stabilizing the spine. You may need to refer these people to a physical therapist.

Key Concepts:

Woman's legs walking on a treadmill looking over a view of a forest
  • Cardiorespiratory training as well as resistance training that incorporate basic core exercises should be the primary components of the training program.
  • Pain while performing the exercise will indicate improper technique and/or and exercise that should be avoided
  • AVOID:

    • Unsupported forward flexion
    • Twisting at the waist with truned feet, especially when carrying a load
    • Lifting both legs at the same time when in a prone or supine position
    • Rapid movements involving spinal flexion, extension, hyperextension or rotation
    • Prolonged sitting, repetitive bending or vibration

Program Design:

Short Term Goals: focus on reinforcing the skills and training exercises that were begun by the therapist.

Long Term Goals: work towards the ability to complete all functional activities without limitations. Trunk strength and lower-extremity strength within functional limits.

Collection of fitness equipment including yoga mat, bosu ball, stability ball, and foam roller

Frequency:

  • 2 – 3 times per week. As client progresses increase as appropriate up to 5 days per week.
  • While there is a common belief that exercise sessions should be performed at least three times per week, it appears that low-back exercises have the most beneficial effect when performed daily (Dr. Stuart McGill, 2007)

Intensity:

  • Light to moderate intensity is recommended initially.
  • As their symptoms dissipate and their conditioning improves some may be able to progress to moderate to vigorous activity.
  • Activities should be continued and progressed as tolerated.
Personal trainer assisting elderly man do a bicep curl with a dumbbell
  • As their symptoms dissipate and their conditioning improves some may be able to progress to moderate to vigorous activity.
  • Activities should be continued and progressed as tolerated.

Time:

An alarm clock next to a blue yoga mat and skipping rope
  • Gradually build up to 30 – 60 minutes per session.
  • Multiple shorter sessions such as 10 minutes at a time are also ok for those who need it.

Type:

  • More focus on building muscular Endurance. Higher repetitions and lower resistance.
  • Strength gains should not be overemphasized at the expense of endurance.
  • Stretching and strengthening of low-back
  • Postural stabilization
Yellow diamond shaped sign with the words good things take time
  • Strengthening and endurance activities: variety is good.
    • Weight circuits with light resistance.
    • Possibly elastic resistance exercises
    • Cardio training such as walking and/or stationary bike (as long as the seated position is tolerated)
    • swimming
  • Stretching focus:
    • liopsoas
    • Hamstrings
    • Piriformis
    • gluteal complex
    • quadriceps
    • quadratus lumborun
Young woman lying on a black yoga mat stretching her hamstring with a yoga band
  • Postural Stabilization progressions for:
    • Hamstrings
    • Quadriceps
    • Low-back estensors
    • Trunk flexors
  • Occupational and functional demands on the body can be integrated into the routine as the client progresses.

Exercise Selection:

The following exercises will enhance the motor control system, challenge the muscles to ensure spine stability is maintained in all other activies.

Remember one size does not fit all so what may be appropriate for one client may not be for another. Reps & Sets should be adjusted based on your clients abilities.

Woman on black yoga mat doing cat exercise head facing down and back rounded
Woman on black yoga mat on all fours with lower back head facing up

Cat – Cow:

Purpose: Start with this motion exercise to warm-up… and to reduce spine viscosity  (internal resistance and friction).

How to Perform:                   

1. On all fours, knees under hips and hands under shoulders.

2. Round back up towards ceiling, tuck chin into chest, short pause.

3. Move into an arched back position looking up, short pause.

Slow continuous movement. 5 – 8 cycles  of flexion moving into extension

Woman on black yoga mat on all fours with lower back head facing down
Woman on black yoga mat doing bird dog exercise arm and leg extended

Bird Dog:

Purpose: This is an excellent exercise to train the body how to stabilize the lumbar spine (low back) during upper and lower extremity movement. 

How to Perform:                   

1. Start on all ours, hands under shoulders and knees under hips.

2. Extend the left leg behind keeping the hips level.

3.  Extend the right arm in front with the thumb facing the ceiling.

4. Keep the abdominals engaged and stabilize the left shoulder so the shoulder blade doesn’t collapse into the pose.

Hold for 7-8 seconds and repeat on the opposite side

Susan on blue yoga mat doing advanced bird dog exercise arm and leg out stretched
Susan on blue yoga mat doing advanced bird dog elbow to knee exercise

Elbow to knee Bird Dog (more advanced):

Purpose: This is a more advanced exercise adding to the stabilization factor you also add more oblique involvement.

How to Perform:

1. Start on your hands and knees with your back flat and stomach tight. Straighten one leg behind you and reach the opposite hand overhead.
2. Bring your elbow under your body toward your opposite knee, while bringing the opposite knee towards the elbow and pause.
3. Rotate your elbow and leg back through to the starting position and hold for 1 to 2 seconds. 
4. Complete the set on one side before repeating on the other side.

Be sure to: Start with a small range of motion and gradually increase.

Woman on black yoga mat doing forearm plank abdominal exercise

Elbow Plank:

Purpose: This is a modified Plank. Planking strengthens all the muscles that run up and down your spine, which helps you to stand, rotate, bend and lift with ease.

How to Perform:

1. Laying face down on your mat with the elbows bent underneath the shoulders and the forearms and palms firmly planted into the ground.

2. Tuck the toes under 

3. Engage the abdominals, inhale, and on the exhale press the body up onto the knees and forearms. 

Hold 10 – 20 seconds. Repeat 3 – 5  times
Keep the neck in neutral (looking down to the floor)
You should be in a straight line from head to knees.

Woman on black yoga mat doing toe plank abdominal exercise

Elbow Toe Plank (more advanced):

Purpose: To strengthen all the muscles that run up and down your spine, which helps you to stand, rotate, bend and lift with ease. It also strengthens your arms, shoulders, glutes and legs.

How to Perform: 

1. Laying face down on your mat with the elbows bent underneath the shoulders and the forearms and palms firmly planted into the ground.

2. Tuck the toes under and contract the quadriceps (front of thigh) and glutes (buttocks) so the knees come slightly off the floor.

3. Engage the abdominals, inhale, and on the exhale press the body up onto the forearms.

Hold 10 – 20 seconds. Repeat 3 – 5 times.
Keep the neck in neutral (looking down to the floor)
You should be in a straight line from head to toes. 

Woman on black yoga mat doing side plank exercise

Modified Side Plank:

Purpose: Strengthens the lateral muscles of the torso which are important for optimal stability. This move increases shoulder-blade stability and strength. 

How to Perform:                   

1. Laying on your right side, prop yourself up on your forearm. Do not allow your upper body to sink down. Keep your neck in a neutral position.

2.  Bend the bottom knee  

3. Lift the hips off the ground.

4. Lift the left arm overhead. (Optional)

5. Hold 10 – 20 seconds. Bring hip back down. Repeat 3 – 5 times5. 

Illustration of a young woman doing rotational plank exercise

Plank with Thoracic Spine Rotation (more advanced):

Purpose: contracting all layers of the abdominal fascia, to strengthen the core. Deep abdominal muscles become stronger. 

When done properly, the plank not only uses the deep abdominal muscles, it also recruits the hip, shoulder and upper-back muscles.

How to Perform:

1. Start in a standard high-plank position.

2. Press the right hand into the ground, rotate both feet and hips to the left while raising the left arm off of the ground and reaching towards the ceiling.

3. Rotate the left arm back down to the starting position.

4. Then repeat the move to the other side, pushing the left hand into the ground and rotating the right arm up.

Repeat for three to six repetitions on each side.

Woman on black yoga mat doing stability ball roll out exercise

Ball Roll-outs:

Purpose: to strength core and shoulder girdle muscles.

How to Perform:

1. Kneeling in front of the ball, sides of hands on the ball.

2. Slowly begin to roll the ball away from you, keeping your body in a straight line.

3. Roll out until your forearms are on the ball. Pause. 

4. Roll back to starting position.

Repeat 8 – 10 times.
This exercise can be modified by bend from the hip joint rather than pivoting from the knees.

Woman on black yoga mat doing supine hip bridge double leg exercise

Supine Hip Bridge:

Purpose: This exercise strengthens the posterior muscles of your body: the back, hips and legs. Your buttocks muscle tends to be one of the laziest muscles in the body and if it’s not doing it’s job then your low back has to take over which can lead to LBP.

How to Perform: 

1. Lie on your back with hands next to your sides

2.  place your heels near your buttocks.

3. Lift the hips into the air while keeping the feet and the shoulder blades pressed into the ground.

Hold for 10 – 20 seconds.  Lower back down and repeat 3 – 5 times.

Susan on blue yoga mat doing double leg hip bridge leg lift exercise
Susan on blue yoga mat doing single leg hip bridge leg lift exercise

Marching Hip Bridge:

Purpose: This exercise strengthens the posterior muscles of your body: the back, hips and legs. Adding the march challenges balance, increasing intensity and core bracing.

How to Perform: 

1.Lie on your back with hands next to your sides

2.  place your heels near your buttocks.

3. Lift the hips into the air while keeping the feet and the shoulder blades pressed into the ground.

4. Keeping core engaged and body stable, lift one foot off the floor. Pause.

5. Place the foot back down and repeat with the other foot.

March 8 – 10 times on each leg

Susan on blue yoga mat doing prone hands by ears back extension resting position
Susan on blue yoga mat doing prone hands by ears back extension lifted exercise

Prone Back Extension:

Purpose: To strengthen the Erector Spinae group through movement. 

How to Perform:

1. Lay prone (face down) on your mat.

2. Hands placement options (easiest to hardest)
a. forearms and hands on floor by shoulders, which will assist you on the lift.
b. by your sides
c. fingers behind your ears (this is the one demonstrated)
d. reaching overhead.

3. Slowly lift the upper body off the floor, pause.

4. Slowly lower back down to the floor.

Repeat 3 – 6 times.

Woman on black yoga mat doing knees to chest exercise
Woman laying on black yoga mat doing supine leg extension exercise

Supine Leg Extension:

Purpose:  To increases core strength and stability while extending the lower extremity. OPTION: A small rolled up towel under your lumbar helps to maintain a neutral spine while integrating movement in the lower limbs.  

How to Perform:             

1. Laying on your back with your knees bent and feet off the floor

2. Engage (tighten) the abdominals and, as you exhale, extend your right leg slowly out.
Only extend as far as you can go keeping alignment. Do not let the lower back arch off the floor.

3. Return to the starting position and, while maintaining tight abdominals.

4. Repeat with the other leg.

Repeat 8 – 12 times each leg.

Works Cited:

  • Roy B.,ACE Personal Trainer Manual Fifth Edition (2014)pp., 547-551
  • Harter R., Jo S., Essentials of Exercise Science for Fitness Professionals (2017), pp., 130-135.
  • Antonacci D., Esses S., Kohl H.,Clinical ACE Clinical Exercise Specialist Manual,(2007), pp.,338-345
  • ACE Advanced Fitness Specialist Resource guide(2008)
  • Buchbinder R, Blyth FM, March LM, Brooks P, Woolf AD, Hoy DG, Best Pract Res Clin Rheumatol. 2013 Oct; 27(5):575-89. Placing the global burden of low back pain in context.
  • Medical News Today; Petre B., Feinberg School of Medicine at Northwestern. Smoking linked to increased risk of chronic back pain, published (November 4 2014).
  • Garfin & Vaccaro, 1997, Saal & Saal, 1989, Saal, Saal & Herzog, 1990, Non-operative treatment for chronic low back pain
  • American College of Sports Medicine (2003) ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities

 

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