// Low back pain part 2 - the better back program

by Paul Wright

In the Winter 2009 issue of Network (available online) I presented an overview of the fundamentals of low back pain, including a review of the potential causes of pain, the problems in identifying the exact pain-producing structure in the end pathology, and the six stages that a patient needs to complete to achieve full recovery. 

Here I outline a system of back pain rehabilitation that we have been using at Get Active Physiotherapy for a number of years called The Better Back Program. 

The Better Back Program originated due to a general frustration on behalf of myself and physiotherapist colleagues in regard to the lack of consistency and wide inter-therapist variability in the design of rehabilitation programs for low back pain patients. Even in our own organisation we had similarly trained therapists using many different protocols, exercises, testing methods and programs. This lack of consistency led to difficulties when therapists were unavailable for ongoing appointments with patients, an over- reliance on individual therapists and some confusion from patients as to the best exercises and protocols.

Who is suited to the better back program?

As this protocol is largely activity-based, the patient needs to: 

•    have mechanical low back pain with no neurological symptoms and/or nerve root irritation 
•    have had a thorough physical evaluation to determine suitability for the program 
•    be willing to commit to three sessions per week of activity / therapy for at least four weeks.

Program structure

The basic outline of The Better Back Program is divided into the following four stages: 

Stage 1: Alignment / CV fitness

The first stage of The Better Back Program involves attempting to encourage the patient to increase their available range of motion and flexibility, as the majority of back pain patients are so stiff and locked that it is almost impossible to activate muscular stabilisers and have normal movement. In this stage, patients are taken through a variety of mobility exercises including knee rolling, back arching, knees to chest and fitball mobility exercises, as well as some simple stretching activities – all geared to improve motion in their often stiff spinal segments. 

As a clinical physiotherapist, one of the biggest mistakes I have made in the rehabilitation of low back pain is my use of aggressive strengthening exercises too early in the rehabilitation program. This may have been as a result of my background as a physical education teacher, combined with an interest in weight training and bodybuilding, but I firmly believed that I could fix any condition with intensive strengthening programs. While this aggressive strengthening approach may prove useful for some patients, I am now of the belief that we should commence our programs more gradually and improve the patient’s range of motion before moving to more aggressive exercise options.

Stage 2: Inner unit / CV fitness

The majority of health and fitness professionals are aware of the complexities and importance of good core function. This section of The Better Back Program focuses on the ‘inner unit’ of the core, which for our purposes refers to the diaphragm as ‘the roof’, the pelvic floor as ‘the floor’, the transverse abdominus as ‘the front’ and the lumbar multifidus as ‘the rear’ of the inner unit. The success of this stage depends on the freedom of range achieved in stage one, but also on the realisation of the patient that the inner unit requires very specific and low intensity activity in the early stage of their inner unit retraining. 

In this stage we use exercises such as single leg lifts in supine, four point kneeling with leg lifts, fitball leg lifts in sitting and bent leg fallouts in supine, all aimed at encouraging the core to activate in low intensity exercises. This is also a good time to add low level balance training such as single leg squats and BOSU® activities to again encourage inner unit stability. 

Stage 3: Outer unit / CV fitness

This is where the fun really starts, as we are able to make use of our excellent gym facilities to allow the patient to experience higher level activities and build on the foundations laid by the ‘alignment’ and ‘inner unit’ stages. This stage involves the use of exercises that utilise the larger ‘sling’ stabilising systems that cross the spine and allow coordinated movement to occur, including lunging, squatting and pressing patterns. 

Great exercises at this level include travelling lunges, standing cable rows, standing cable presses, tricep pushdowns, deadlifts, woodchops and cable bicep curls. These may be common exercises, but they are very useful for building a base of back strength and stability in and around the spine, and they also prepare for the more intense exercises to come in the final stage. 

Stage 4: Maintenance / Athletic / CV Fitness

This final stage involves the patient adding more intense exercises with added load, speed or instability and also increased rotation elements. By this stage the patient has a good improvement in range of motion, has developed a solid ‘inner unit’, has progressed to more advanced ‘outer unit’ activities and at the same time has developed increased confidence in their own ability to perform more stressful tasks. This is also where the long term low back pain patient may return to sporting activities and training. 

A note on the CV component

In all stages it is essential that the low back pain patient commences and maintains some element of cardiovascular conditioning while undergoing The Better Back Program. This will improve general oxygen delivery, set up new feedback pathways that may help to override previous pain pathways and increase the patient’s feeling of wellbeing – all essential to good health. The form of CV training undertaken is up to the individual patient and therapist; however, it can involve cycling, treadmill or even swimming, as long as the patient enjoys it and achieves an elevated heart rate. 

Photo 1. Bent leg fallout 
In this exercise the patient activates the core and then gently lowers one knee – stopping before the opposite hip lifts. It is an excellent exercise to retrain lower level core control and is an excellent ‘inner unit’ exercise. 

Photo 2. Step up with shoulder press This exercise builds on the stable base provided by the ‘inner unit’ stage and promotes more advanced long lever patterns. This makes an excellent level 

Conclusion

While the topic of low back pain is broad and non-specific in many cases, the use of a systematic approach to rehabilitation at least allows a baseline for patients and health professionals to work from. Care needs to be taken when deciding to progress a patient to the next level, as increasing training demand too soon is one of the most common causes of program failure.  

While the topic of low back pain is broad and non-specific in many cases, the use of a systematic approach to rehabilitation at least allows a baseline for patients and health professionals to work from. Care needs to be taken when deciding to progress a patient to the next level, as increasing training demand too soon is one of the most common causes of program failure.


 

Paul Wright, BAppSc (Physio), DipEd (PE) 
Paul is the owner of Get Active Physiotherapy with clinics in St leonards (Sydney) and Kotara (Newcastle). Paul’s two-hour Core Stability and The Better Back Program DVD is an outstanding resource for all fitness professionals – Network members who order the DVD from www.getactivephysio.com.au will also receive Paul’s Lumbar Spine Injury Prevention and Rehabilitation DVD for FREE. You can also download Paul’s FREE e-book Injury Prevention Tests and Strategies while on the site. Paul can be contacted on 02 9966 9464.

NETWORK MAGAZINE • SPRING 2009 • PP58-59