Active IQ Level 4 Certificate in Physical Activity and Lifestyle Strategies for Managing Low Back Pain (sample manual)

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Level 4 Certificate in

Physical Activity and

Lifestyle Strategies for

Managing Low Back Pain

Version AIQ004315

Section 1: The classification and

prevalence of low back pain

Defining low back pain

Section 1: The classification and prevalence of low back pain

Low back pain (LBP) can be defined as pain, muscle

tension or stiffness localised below the costal margin and

above the inferior gluteal folds, with or without leg pain

(sciatica) (van der Heijden et al, 1991). Low back pain

is classified as acute when it persists for less than 12

weeks (Bigos et al, 1994). Some researchers have further

sub-classified acute low back pain of less than 12 weeks’

duration into acute (

Section 1: The classification and prevalence of low back pain

increase in activation of other muscles, including the external oblique, rectus abdominis and hamstrings (van Dieen

et al, 2003; Silfies et al, 2005). This alteration in recruitment patterns can modify movement patterns and control

of the spine and pelvis. This alters the load distribution through the spine, sacrum and pelvis causing an increased

irritation to spinal structures leading to LBP (van Dieen et al, 2003; O’Sullivan, 2005). The pelvic floor muscles have

also been shown to influence pelvic alignment and pelvic mechanics (Bendova et al, 2007). Evidence suggests that

people experiencing pain in the sacroiliac joints (SIJ) of the low back have altered recruitment of the pelvic floor muscles

(O’Sullivan et al, 2002).

Other possible causative factors associated with functional movement and alignment have been identified in other parts

of the body. For example, some evidence suggests that a lack of functional movement of the first metatarsophalangeal

joint (MTP joint) affects hip and pelvic motion. This may lead to increased activation of the psoas muscle, altered pelvic

positioning (anterior tilt) and increased hamstring activation through a stretch reflex. All of which can influence the

pelvis, sacrum and lumbar spine and alter forces placed upon the low back (Dananberg, 1997).

Hyperpronation of the feet has also been shown to increase the anterior rotation of the pelvis (Khamis and Yizhar,

2007). An anteriorly rotated pelvis is associated with increased lumbar spine lordosis (an arch in the low back), which

can alter forces placed upon the discs, tissues and joints of the low back (Niosi and Oxland, 2004). It is therefore

likely that altered movement and alignment of the foot can affect the joints of the hips and low back, placing increased

mechanical load on these tissues, and possibly contribute to LBP. This necessitates observing a client’s movement and

alignment prior to exercise interventions.

Asymmetrical alignment and movement of the pelvis has been linked with low back pain. When the pelvis is asymmetrical

in the frontal plane (lateral asymmetry), or the ilia are rotated in the transverse plane, it can alter the mechanics of the

spine and pelvis. Individuals with an asymmetrical pelvis and LBP have shown a compensated movement pattern when

sitting and standing; it has been suggested that movement quality and not range of motion may be a better indicator of

altered function in this population (Al-Eisa et al, 2006).

Psychosocial factors

Psychosocial factors have recently become a major topic of discussion concerning low back pain. There are a growing

number of studies that show an association between psychosocial factors and LBP (Linton, 2000; Schur et al, 2007;

Leboeuf-Yde et al, 2008). Please refer to the discussion of the psychosocial components of LBP in unit 2.

Figure 1.2 illustrates a simplified progression of a possible route to chronic back pain. Any of the steps shown can

be re-configured and may be different based upon each individual. Genetic predisposition may lay the foundation

for possible onset of an LBP episode, especially combined with mechanical loading beyond an individual’s capacity

(assuming no structural abnormalities exist). This overload/pain can alter muscle recruitment and alignment (or result

from altered recruitment and alignment). Alterations in recruitment and alignment can lead to abnormal movement

patterns, perpetuate abnormal stress to the tissues of the spine, and prolong pain or lead to recurrent episodes of pain.

Anxiety, depression, poor coping strategies and emotional issues can further affect the pain and healing cycle and

sustain the recurrence of LBP.


muscle recruitment




loading beyond






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Figure 1.2 Example progression of non-specific low back pain

Section 2: Current strategies for the management of low back pain

Tramadol also prevents the reuptake of serotonin and can have a mild anti-depressant

effect; care must be taken when used in combination with SSRI type anti-depressants as

serotonergic syndrome can develop. Hyponatraemia (the dilution of sodium in the blood to

dangerous levels) is an uncommon side effect of tramadol that may affect exercise safety. It

is important to make clients aware of the need to eat one to three hours before exercising

and to avoid exercising for long durations in heat. Although it is unlikely that most low

back pain clients would do this, if it is a necessary part of training for any reason they

would be best advised to consume a fluid that contains electrolytes rather than just water

for rehydration.

In summary, correctly administered analgesics in the acute phase of low back pain can

prove a useful tool. Unfortunately, pain is commonly avoided by changing movement

patterns or through inactivity, and this can exacerbate low back pain through loss of

strength and flexibility. Feeling unable to move around and get things done independently

can lower self-esteem, and when this is combined with interrupted sleep, it can often result

in depression. Once negative behavioural patterns have developed and willpower has been

lost, recovery is far more challenging. Pain relief medication can prevent the development

of this negative cycle, and if introduced where necessary in the acute phase of pain, can help the patient to maintain a

more positive attitude. As state of mind has a profound effect on physical ability, patients will be more willing and able

to perform corrective exercises and/or stretches, leading to a successful and swift recovery. Considerations regarding

the type of analgesic being used must be taken into account, as all medications have side effects. Due to the severe

drowsiness and altered perception that can be experienced when taking opioid medications, exercise prescription may

be affected. A reduced ability to operate equipment safely and to perform techniques correctly, which is essential in the

case of spinal dysfunction, may prevent the client from participating in some forms of exercise.

Surgery for low back pain

As previously discussed, over 85% of low back pain cases are not attributable to any specific, identifiable trauma.

For the small minority of people with specific, identifiable causes for their back pain, surgical procedure may be an

appropriate intervention.

It is highly unlikely that a specialist exercise instructor will work with anyone who requires and is awaiting surgery, or

who is in the immediate post-surgical recovery period. During this time, a course of physiotherapy may be prescribed to

help the patient improve mobility and function to give the best possible outcome from the operation. It is possible that

referral or self-referral to a specialist exercise instructor will be made following physiotherapy rehabilitation to continue

to support the recovery of full function and activities of daily living in a supervised programme.

Surgical procedures that may be carried out for low back pain include:

• Lumbar decompression (laminectomy or discectomy).

• Lumbar fusion.

Lumbar decompression surgery may be offered to people with severe radiculopathic or sciatic pain in an attempt to

reduce the pressure on the nerve root in order to allow the nerve to heal. This pain can be caused by a prolapsed or

herniated disc or by spinal stenosis.

There are two main ways of doing this:

• A laminectomy involves cutting away a small part of the vertebral bone (lamina) that passes over the foramen

where the nerve exits the spinal cord, to give it more space.

• A discectomy involves shaving away a section of a damaged intervertebral disc to create more space around the

nerve and relieve pressure on it.

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Section 1: Factors that contribute to the development of low back pain

In a less direct relationship, obesity correlates with lower levels of physical activity. The impact of inactivity on low back

pain incidence is well-known, and anything that correlates with high levels of physical inactivity will therefore correlate

with increased risk of low back pain.


During pregnancy a woman’s body undergoes many structural and hormonal changes.

Several of these can increase the risk of low back pain. In the second and third trimesters

it is normal to gain around 20lb or more. Unlike obesity, the vast majority of this load is

in the abdomen, immediately anterior to the lumbar spine. This places additional strain

on the posterior chain muscles, with the added complication of lengthened and separated

abdominal muscles. This changes the agonist-antagonist relationship between anterior and

posterior trunk muscles and weakens the supportive cylinder of the abdomen. This means

that less intra-abdominal pressure can be generated to stabilise the spine. Movement

patterns are necessarily altered as spinal flexion becomes restricted.

In addition to these changes, the increased levels of the hormone relaxin in the bloodstream

make ligaments and joints more lax, reducing stability and potentially permitting unwanted

movement. This requires the muscular system to work harder to create stability, calling

on muscles to perform functions they normally wouldn’t. This can lead to muscle spasms and soreness, in addition to

weakening the ligaments of the spine and permitting the lordotic curve to arch more than normal. Excessive movement

in the sacroiliac joints can also occur, which is another source of pain in the low back region.

Psychosocial considerations in low back pain

In addition to lifestyle and behavioural risk factors, there are a set of risk factors associated with particular psychological traits

and social environments that may predispose a person to low back pain or make an incidence of low back pain last longer.


inability to

cope with









Perceived inability to cope with stress

Everyone experiences pressure in life; the popular term for the effects of various pressures on a person is ‘stress’. Stress

can be physical or psychological in nature. A certain amount of pressure, or stress, is necessary in order to motivate

action and can be rewarding as it provides challenge and the resulting sense of achievement when challenges are

overcome. This kind of positive stress can be called ‘eustress’. Stress can become problematic when the perceived size

of the challenge is outside of the person’s current perceived ability. This kind of excessive stress can be called ‘distress’

and is associated with negative health implications. It is the individual’s beliefs about him- or herself and their ability

that are important, rather than their actual ability.

Experiencing distress for a prolonged time, or on a regular basis, is psychologically and physically harmful. It suppresses

immune system function, creates endocrine (hormonal) imbalances and can increase musculoskeletal tension. Certain

emotions are associated with particular ‘emotional postures’. Body positions associated with fear and anxiety tend to

involve curling up into a ball, i.e. spinal flexion, which removes the natural lordotic curve from the spine and places it

at a disadvantage for load bearing. In addition, when the body experiences stress, it diverts blood to muscles and away

36 | Copyright © 2017 Active IQ Ltd. Not for resale

Section 2: Anatomical and neurological changes that can cause low back pain

Figure 2.2 The primary bones of the lower back

The lumbar vertebrae are unique in their size and shape. They are the largest and strongest of the vertebrae, which

allows them to accept and transfer a large amount of weight and force (see figure 2.3). The lumbar vertebrae have

short, thick projections called processes. There are transverse processes, a spinous process, the lamina connecting the

spinous process to the body, and superior and inferior articular processes (Tortora, 1995). Despite the apparent strength

of the lumbar vertebrae, the lumbar spine is the most common site for compression fracture. This is due to a weak spot

located in the anterior aspect where the density of the bone is reduced (American Osteopathic Association, 2003) and

that this area is subjected to greater forces than the other regions of the spine. Vertebral fractures should be considered

a possibility if there is a recent history of major trauma, such as a road traffic accident or a fall from a height.

Within the vertebrae, compressive force is transmitted by both the shell of cortical bone around the vertebrae and the

cancellous bone within it. Up to the age of 40, the cancellous bone provides between 25% and 55% of vertebral

strength. After this age, a greater proportion of vertebral load is carried by the cortical shell, as the strength and stiffness

of cancellous bone decreases with increasing age-related losses in bone density (Rockoff et al, 1969).

Figure 2.3 The lumbar spine and vertebrae

There is a hyaline cartilage end plate that rests on the surface of each vertebra and protects the vertebral body from

excessive pressure. This plate is approximately 1mm thick at its outer edge, getting thinner towards its centre. After the

age of 20-30 years the end plate starts to ossify and become increasingly brittle. End plates can fracture when vertebrae

are subjected to excessive compressive loads. The presence of end plate imperfections is associated with a more active

lifestyle (Hardcastle et al, 1992), and end plate damage occurs in virtually all types of athletes.

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Section 2: Anatomical and neurological changes that can cause low back pain

Reducing compressive loads on the spine

When a vertebral body is compressed, blood flows from it into its surrounding venous network. Blood then returns as

the compressive load is removed. There is a latent period after the initial compression, before the blood returns to the

vertebra, where the shock-absorbing properties of the bone are reduced. Consequently, exercises that involve extended

periods of repetitive spinal compression are more potentially damaging for the spine than those that load the spine

for short periods but then allow time for the recovery of vertebral blood flow. Many common flexion exercises result in

considerable spinal compression. As an example, the traditional sit-up creates approximately 3300N of compression

on the spine (Axler and McGill, 1997). To put this into context, the National Institute of Occupational Safety and Health

(NIOSH, 1981) has set the action limit for low back compression at 3300N, since repetitive loading above this level is

associated with higher worker injury rates.

In summary, although psychosocial influences play a significant role in determining the ongoing course of low back

pain, from a purely mechanical standpoint, exercise programming for low back pain sufferers should take into account

levels of spinal loading. As the individual improves within a progressive and paced programme of exercise, the challenge

and the loads used can be increased.


Loading of the spine is still not well understood, and direct measurements of spinal loading through in vivo

studies are normally avoided because of concerns about the effect of introducing a transducer (a device that

measures pressure) into the intervertebral disc. Therefore, those involved in back pain management are left to rely

on the data that has its roots in the seminal work of Dr Alf Nachemson in the 1960s (Nachemson and Morris,

1964; Nachemson, 1966). Nevertheless, these findings have helped to shape understanding of disc compression

and how this varies in different body positions (see figure 2.32), and has consequently been applied broadly in

rehabilitation programmes and workplace recommendations.

While other research that has used indirect methods to analyse spinal loading shows conflicting results (Althoff

et al, 1992; Rohlmann et al, 1995), other research using transducer measurements of intradiscal pressure has

shown good correlation with Nachemson’s work (Wilke et al, 1999). The research highlights that disc pressure

increases dramatically as soon as the lumbar spine is flexed and tissue tension increases.

This information can ultimately serve as a guide for specialist exercise instructors working in the area of back

pain, particularly if working with discogenic patients or those at high risk of discogenic problems. It highlights

the importance of selecting appropriate starting positions for exercises. Exercises that start from a seated position

place considerably more pre-stress on discs compared to exercises starting in a supine position, or even standing.


Relative pressure change % (normalised to standing)




























Figure 2.32 Pressure changes in the third lumbar disc in different body positions

Copyright © 2017 Active IQ Ltd. Not for resale | 59

Section 3: Obtaining relevant information and consent to design physical activity programmes for clients with chronic non-specific low back pain


The process of postural assessment usually begins with

standing posture, which provides a strong visual reference

point for further investigation. The client is asked to stand

with feet hip-width apart (ideally with bare feet) and

behind a plumb line. From the side, the line should pass

through key bony landmarks (see figure 3.2). Any deviation

away from these landmarks suggests patterns of muscle

imbalance, which will consequently have an impact on

movement potential.

Patterns of posture

A number of common postures have a direct impact on

the position and function of the low back. These should

be considered in the design of any exercise programme for

a low back pain client (see figures 3.3 and 3.4). These

postures identify predictable muscle imbalances throughout

the body and highlight the importance of taking a systemwide

view of low back pain management. Causes of poor

posture include physical trauma, congenital or acquired

deformity or faulty loading patterns. Faulty loading patterns

may occur in everyday life or may be seen (and even

encouraged) in the sporting or fitness arena.










Figure 3.2 Optimal posture

• Flattened lumbar curve.

• Stiffness in lumbar spine.

• Posterior tilt of pelvis.

• Hip flexors lengthened.

• Hamstrings tight.

• Rectus abdominis tight.

• Anterior tilt of pelvis.

• Lengthened rectus abdominis.

• Gluteus maximus usually weaker

and inactive.

• Hamstrings tight (but not

necessarily shortened).

• Hip flexor shortened.

• Increased lumbar curve.

• Short erector spinae.

Figure 3.3 Flat back posture

Figure 3.4 Hollow back posture

Copyright © 2017 Active IQ Ltd. Not for resale | 89

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