# Exercise as it relates to Disease/The effects of exercise on chronic back pain

Back pain is considered chronic if it lasts for more than three months. Chronic back pain affects a wide array of people usually from the time they reach adulthood to late adulthood. Those affected by chronic back pain are at greater risk of unemployment, lost productivity in their workplace, functional limitations, economic difficulty, social limitation, and disability$^$. Chronic back pain can be classified into three different groups: simple musculoskeletal back pain, spinal nerve root pain, and serious spinal pathology. Simple musculoskeletal pain is the most common form of chronic back pain as it accounts for 95% of cases $^$.It affects people between the ages of 20-55, and is usually articulated as upper leg pain existing near the buttocks and the lumbosacral area $^{[1]}$. Spinal nerve root pain accounts for 4-5% of chronic back pain$^{[1]}$. It is generally described as pain extending from the knee to the foot, with well localized, sharp and electric shock-like pain $^{[1]}$.Serious spinal pathology is the rarest form of chronic back pain affecting only 1% $^{[1]}$. This type of pain is extremely noteworthy as it eludes to other health complications such as: spinal tumors, infection, inflammatory diseases, cauda equina syndrome, and trauma $^{[1]}$. The longer chronic back pain persists, the greater the risk will become for long-term disability $^{[2]}$.

## Side Effects and Complications of Chronic Back Pain

The presence of chronic back pain is linked to the following:
* Long-term disability $^{[2]}$.
* Depression $^{[3]}$.
* Increased levels of psychological distress $^{[3]}$.
* Negative impacts on sufferers' quality of life and personal functional performance.
* Limitation (conscious and unconscious) of activities which may bring about back pain due to the fear of injury.
* Restriction of movements $^{[5]}$.

## Exercise Goals in Relation to Chronic Back Pain

Exercise goals with aim to reduce chronic back pain include but are not limited to:
* Increase and or maintain musculoskeletal and cardiovascular function $^{[5]}$.
* Strengthen the back $^{[5]}$.
* Increase back flexibility $^{[5]}$.
* Increase cardiovascular fitness $^{[5]}$.
* Increase para-spinal musculature $^{[5]}$.
* Increase spinal movement $^{[5]}$.
* Decrease back pain intensity $^{[5]}$.
* Increase trunk-stability.
* Increase tissue length and tissue resilience.

## Treatment Options for Chronic Back Pain

The following methods are options for treating chronic back pain$^{[3]}$:
Drugs- The following drugs are prescribed to help manage and maintain chronic back pain:
* Non-steroidal anti-inflammatory drugs (NSAIDs)
* Optoids
* Acetaminophen
* Tricyclic antidepressants (used for neuropathic pain)
* Anticonvulsants (used for neuropathic pain)
* Methocarbamol (used for muscle spasms)
* Balcofen (used for muscle spasms)
* Benzodiazephines (used for muscle spasms)
Psychology- Psychology is utilised individually and in group settings to minimise pain and increase function. Cognitive behaviour therapy helps to educate people about the distinction between acute and chronic pain, and it also helps educate people on relaxation techniques.
Physical Therapies- Different physical therapies are used in patients with chronic back pain to improve disability through aerobic exercise. See exercise recommendations in Table 1 for further guidance.
Interventional Treatments- These treatments are conducted to reduce the need for back surgery. They include epidural injections in the caudal and lumbar regions to reduce musculoskeletal pain. They also include transforaminal nerve root injections which reduce the need for back surgery. Additionally, facet joint injections are performed to provide short term relief for musculoskeletal back pain, but are not yet proven to alleviate chronic back pain long term$^{[3]}$.
Transcutaneous Electrical Nerve Stimulation (TENS)- TENS units are applied to lessen pain short term in sufferers with chronic pain.
Spinal Cord Stimulation- Spinal cord stimulation can be very effective if it is preformed on carefully selected patients.
Acupuncture- Acupuncture has been found to alleviate chronic back pain temporarily.
Surgery- Surgery is a last resort option for treating chronic back pain, but has been found to positively affect nerve root pain.

## Exercise Recommendations

Exercises recommended to decrease chronic back pain:
| Form of Exercise | Benefit(s) | Recommendations |
| Stretching | Increases flexibility$^{[7]}$, restores trunk range of motion (ROM)$^{[5]}$, and decreases pain frequency and severity.$^{[4]}$ | Perform 3 sets of 30 seconds per stretch. Allow for 30 second intervals between stretches.$^{[4]}$ |
| Calisthenics | Decreases pain$^{[5]}$, decreases work absenteeism$^{[7]}$, and increases the likelihood of exercise maintenance.$^{[5]}$ | Join a regular calisthenics group (usually calisthenics are performed 3 times per week).$^{[5]}$ |
| Motor Control Exercises | Increases core strength, increases lumbar strength, $^{[4]}$ increases spine stabilization. | Perform 2 sets of 10 repetitions with 30 second rest intervals between series.$^{[4]}$ |
| Aerobic Treadmill Training | Increases cardiovascular fitness$^{[5]}$ | Warm up for 5 minutes at a speed of 5–8 km/h. Perform a 20 minute run at 40-80% maximum heart rate (MHR), then perform a 5 minute cool down with gentle speed reductions. $^{[4]}$ |
| Cardiovascular Endurance Training | Improves cardiovascular fitness, $^{[4]}$ improves and maintains musculoskeletal and cardiovascular functions $^{[4]}$. | Perform 3 times per week at 75% of MHR for a minimum of 15 minutes each session. Types of exercise that are deemed acceptable include but are not limited to: tredmills, exercise bicycles, other exercise equipment, walking, running, dance, cycling, swimming, and other forms of aerobics. $^{[5]}$ Ideally, it is recommended that the victim of chronic back pain chooses an aerobic exercise that they enjoy. |
| Lower Limbs Strengthening | Increases rectus abdominus strength (core strength). $^{[5]}$ | Perform 3 sets of 12 repititions for each leg with 30 second intervals for rest in between series. |
| Trunk Extension | Increases range of motion (ROM).$^{[7]}$ | Perform 3 sets of 10 repititions with 30 second rest intervals between series. $^{[4]}$ |
Table 1

## Further reading

Transcutaneous Electrical Nerve Stimulation (TENS) and Exercise for Chronic Back Pain Sufferers
http://www.nejm.org/doi/full/10.1056/NEJM199006073222303#t=articleTop
Chronic Back Pain Exercise Recommendations
http://www.sciencedirect.com/science/article/pii/S0304395903004342
Treatment Recommendations for People with Chronic Back Pain
http://www.nejm.org/doi/full/10.1056/NEJM199502093320602#t=articleDiscussion

## References

* ↑ Ferreira, M. L., Smeets, R. M., Kamper, S. J., Ferreira, P. H., & Machado, L. C. (2010). Can We Explain Heterogeneity Among Randomized Clinical Trials of Exercise for Chronic Back Pain? A Meta- Regression Analysis of Randomized Controlled Trials. Physical Therapy, 90(10), 1383-1403. doi:10.2522/ptj.20090332
* ↑ Krein, S. L., Metreger, T., Kadri, R., Hughes, M., Kerr, E. A., Piette, J. D., & ... Richardson, C. R. (2010). Veterans walk to beat back pain: study rationale, design and protocol of a randomized trial of a pedometer-based Internet mediated intervention for patients with chronic low back pain. BMC Musculoskeletal Disorders, 11205-215. doi:10.1186/1471-2474-11-205
* ↑ Jackson, M. A., & Simpson, K. H. (2006). Chronic back pain. Continuing Education In Anaesthesia, Critical Care & Pain, 6(4), 152-155. doi:10.1093/bjaceaccp/mkl029
* ↑ Magalhaes, M., França, F., Burke, T., Vidal Ramos, L., de Moura Campos Carvalho e Silva, A., Leao Almeida, G., & ... Marques, A. (2013). Efficacy of graded activity versus supervised exercises in patients with chronic non-specific low back pain: protocol of a randomised controlled trial. BMC Musculoskeletal Disorders, 14(1), 1-6. doi:10.1186/1471-2474-14-36
* ↑ Rainville, J., Hartigan, C., Martinez, E., Limke, J., Jouve, C., & Finno, M. (2004). Exercise as a treatment for chronic low back pain. Spine Journal, 4(1), 106. doi:10.1016/S1529-9430(03)00174-8
* ↑ Hayden, J. A., Van Tulder, M. W., Malmivaara, A. V., & Koes, B. W. (2005). Meta-Analysis: Exercise Therapy for Nonspecific Low Back Pain. Annals Of Internal Medicine, 142(9), 765-W184.
* ↑ Cohen, I. I., & Rainville, J. J. (2002). Aggressive Exercise as Treatment for Chronic Low Back Pain. Sports Medicine, 32(1), 75-82.
* ↑ Hentschke, C., Hofmann, J., & Pfeifer, K. (2010). A bio-psycho-social exercise program (RÜCKGEWINN) for chronic low back pain in rehabilitation aftercare - Study protocol for a randomised controlled trial. BMC Musculoskeletal Disorders, 11266-276. doi:10.1186/1471-2474-11-266