Spinal medicine consultant Dr Nigel Kellow kicks off a new series on therapeutic exercises with a guide to low back pain and when exercise programmes are appropriate. A patient information leaflet and full video is online
Mechanical low back pain (MLBP) is one of the biggest health problems in the UK. Most people will experience back pain at some point but it is normally self-limiting and goes away with a little rest or some simple analgesia.
Almost 2% of workers take at least one day off every four weeks through back pain, and in the UK an estimated 52 million working days are lost to back pain each year.
Around 95% of patients who have a consultation for back pain will have simple MLBP. Around 4% will have nerve-root compression, and only 1% will have serious spinal pathology.
MLBP becomes a problem when it interferes with normal life or the ability to work. If a patient presents with a single episode of back pain it is reasonable to prescribe simple painkillers and to advise them to rest for a few days.
But if the pain persists they should be referred to a specialist team for active assessment and management because sickness absence related to back pain can rapidly become a significant problem for patients, their employers and healthcare professionals.
MLBP is normally felt across the low back, but it can also be felt in the buttocks or upper thighs. MLBP is never felt below the knee. If there is pain below the knee, this could be radicular pain (sciatica).
The most effective way to combat MLBP is to combine simple analgesics with specific exercises that increase the strength and flexibility of the lumbar spine. Two of these exercises are bilateral knee rolls and pelvic tilts as outlined in the video and patient information leaflet available at www.pulsetoday.co.uk/video/exercises.
For bilateral knee rolls, patients lie on their back with knees bent, positioned about hip-width apart. Keeping the feet relaxed, the knees are gently rotated from side to side.
For pelvic tilts, patients lie on the floor, knees bent, making sure there is a space between the floor and the lower back. The bottom is then gently raised up while putting downward pressure towards the floor with the upper part of the back. The position is held for 10 seconds, then relaxed.
The lumbar spine is supported by strong muscle groups at all sides, all of which need to be exercised equally. It is not appropriate to exercise one group in isolation. It is a common misconception that the rectus abdominis muscles support the spine anteriorly but this is not the case.
The anterior spinal support comes from psoas major and minor muscles, and from transversus abdominis. These muscles require specific exercises. Lateral support comes from the internal and external oblique muscle groups and from quadratus lumborum, and posterior support comes from a large number of muscle groups including erector spinae.
Some patients may find their pain gets worse with exercise. This can happen with radicular pain, serious pathology, or in older people with spondylotic changes affecting multiple sites. If this happens the patients should be referred to a specialist team.
Otherwise there are no contraindications to lumbar spinal exercises.
Refer any patient whose symptoms get worse with exercise or who cannot do
them at all.
Just 20 minutes a day.
Dr Nigel Kellow is a consultant in pain and interventional spinal medicine at the the
London Orthopaedic Clinic,
Exercise programmes leaflet for patients with low mechanical back pain Exercise programmes leaflet Patient leaflet