Like many of us I think I spend too much time on social media. Every now and again I find Twitter throws up some interesting studies however.
Here’s one that caught my attention on the value or otherwise of manual therapy and exercise for back pain. Behind the science speek the authors draw an interesting conclusion, exercise, directed by somebody who knows what they’re doing, works for back pain. When compared to other treatment strategies, namely spinal manipulation, if works really well.
There are other studies that have investigated exactly what the best form of exercise for back pain is. The results are generally inconclusive. Some studies suggest that there isn’t a best form per say and that any movement within certain parameters will produce results.
Now if that were entirely true most people who go to the gym wouldn’t have back pain. This certainly isn’t the case however. In fact, in my line of work gyms are the best places to find people who need assistance.
Client case study.
In an effort to define those parameters a little better for you, here’s an interesting example. Meet Rose (not her real name). Rose is an active 30 year old City professional who had an episode of back pain some years ago and has suffered with it sporadically ever since. She recently found herself unable to run due to pain in her lower legs, which is why she sought my help.
After a few sessions addressing weakness in her lower legs and hips we began working on her trunk. With her history I guessed this would be an important part of the jigsaw.
When most rehab professionals diagnose weakness in their patient’s trunk (or core to give it it’s fashionable name) they do so via postural analysis. In other words they look at where your bones are positioned and from that decide what action needs to taken.
This is the equivalent of a mechanic telling you what’s wrong with your car without even lifting up the bonnet. It’s a nonsense and in terms of solving back pain has little scientific validity.
To use an extreme example to illustrate the point, my granny was bent 3 different ways into trunk flexion. If we had carried out a postural analysis on her it would’ve indicated she had ‘tight’ trunk flexors. If only! She was weak everywhere.
What something looks like from the outside gives you no indication of what’s actually happening on the inside.
Back to Rose. Through muscle testing we found she had some serious weakness in the muscles of her left erector spinae group. In some positions she was unable to offer any resistance to the tests.
We set about improving this with both a manual therapy technique and some low level isometrics.
Not only did this improve the strength of those target muscles, she was able to run without pain the next day. So far so good.
Now here comes the really interesting bit. In order to get those weak back muscles stronger, we experimented with an exercise. A simple spinal extension movement over a Bosu ball, with a focus on the lumbar spine. Rose managed 5 no problem.
Whenever I begin to transition my clients from the treatment table to exercise I like to use muscle tests afterwards to measure the effect. If the tests are strong I know the exercise is at the appropriate level, if they’re weak I make the exercise easier.
What I found with Rose is that every single muscle that had previously tested strong on the table had shut down. We were back at square one with Rose unable to offer any resistance to the tests.
Why is this story so relevant?
It shows how an exercise that may be regarded as ‘easy’ can create an excessive challenge for particular muscles.
It’s this that leads to inconclusive results when investigating what the best exercise for back pain is. How can there be a best exercise when everybody’s tolerance of force is different?
Not only that, there is little point in addressing weakness in the spinal muscles if there are larger issues elsewhere being ignored. How many studies consider the foot, ankle or hip when investigating the best exercise for back pain? None that I’m aware of. Pain anywhere is an indication that there’s most likely weakness everywhere.
Just like when you are considering how far you should run as you progress towards a marathon, you need to be accurate when you are challenging muscles that are particularly weak.
There is no best exercise for back pain, only the ones that help get you stronger in the areas you are weak. Those areas and those exercises are going to be different for everybody.