Beating back pain: six of the best

As an athlete who has personally suffered from bouts of back pain in the past, I can tell you that if you have never suffered from low back pain, you should consider yourself very fortunate! Indeed, data from the UK indicates that no less that 49% of the UK population reports back pain lasting at least 24 hours at some point each year, and 4 out of 5 adults will experience back pain at some point in their life⁽¹⁾. Moreover, given that obesity and inactivity are known to be risk factors for developing lower back pain⁽²⁾, the incidence of back pain in the general population has almost certainly increased with each passing year.

Low back pain in athletes

Athletes are leaner, stronger and more active than the general population, so naturally you might expect the incidence of lower back pain/injury to be much less of a issue. The problem is that low back pain (LBP) can and does occur in athletes, and is very debilitating and frustrating when it does. LBP can result in missed training days, missed competitions, and missed opportunities for selection. And while it’s often possible to train around many other injuries, a lower back injury is very limiting. When someone is suffering from acute back pain or spasms, even the lightest activity and movements can become too painful to endure.

When it comes to the incidence of LBP in athletes, the data shows that while it varies across different sports, it is not an insignificant problem. A systematic 2023 review and meta-analysis study (a powerful methodology that pools data from a number of previous studies to provide more robust evidence than a single study) found that elite soccer players have a substantial prevalence of LBP, with at least 32% of male players and 50% of female players experiencing at least one LBP episode in their career⁽³⁾.

Another review study reported on previous research indicating that the incidence of LBP in athletes is actually significantly higher than that in non-athletes (possibly brought about by higher spinal loading than in the general population)⁽⁴⁾. Furthermore, other research has reported that more than 30% of athletes can be expected to develop LBP during training and about 75% of elite athletes have had a history of one or more episodes of LBP^(5,6).

Beating back pain

When a lower- back injury strikes an athlete, training and competition become nigh impossible so getting back to full fitness as rapidly as possible is critical. In the early stages of a back injury, it’s likely that normal activity will be severely curtailed, with rest and anti-inflammatory medication the only treatment initially. However, following the initial phase, doing nothing at all is not a good route to rapid recovery, and the continuation of normal daily activities is now recommended by medical practitioners for those patients with non-specific causes of low back pain⁽⁷⁾. This is preferred to bed rest, which has not been shown to have a positive effect.

The question of course is what kind of rehabilitation activities are recommended and most effective for helping athletes get full sporting functionality back, and (just as importantly) preventing a relapse? This is a tricky question to answer as there are a multitude of LPB causes and each individual is likely to respond slightly differently to a treatment or course of rehab exercises. One thing that is not in doubt however is that numerous studies prove some kind of exercise therapy is both effective in reducing pain and disability, and also cost-effective^(8,9). Moreover, in 2017, the American Medical Association stated that ‘exercise therapy is the preferred treatment for LBP’⁽¹⁰⁾, while in Europe, exercise therapy is recommended as a first-line intervention for the management of chronic LBP⁽¹¹⁾

Core principles

Common to many exercise therapy modes used to rehab LBP is the concept of ‘core stability training’. Core training is based on the principles of motor learning methods and emphasizes the neurological activation of the deep muscles of the tummy and lower back, particularly the transversus abdominis and multifidus muscles. By strengthening these deep core muscles, the vertebral segments of the spine can be stabilized during global movements, allowing better coordination of the trunk muscles in the abdomen, back, and buttocks. This is turn enhances trunk muscle endurance, providing more stable support for the spine and effectively reducing the burden on the lower back muscles⁽¹²⁾. Research shows that during core training, the body continuously receives sensory information from muscles, joints, the inner ear, etc, which can not only regulate the nerve reflex arc, accelerate the nerve conduction speed, but also improve proprioception (the sense of where the limbs are in 3-D space), correct postural disorders, and further enhance the stability of the spine⁽¹³⁾.

Comparing approaches

There are many exercise therapy approaches to help overcome LBP that incorporate core activation and strengthening. Some of these include core stability training, Yoga, Tai Chi and aquatic therapy, but if you’re recovering from a lower back injury, which of these is most effective? To date, no research has been carried out to investigate this question, but now a brand new study by Chinese researchers has come up with some fascinating findings⁽¹⁴⁾.

In this study, which was published in the journal ‘BMC Musculoskeletal Disorders’, the researchers compared six types of exercise therapy that have been proposed to help the recovery from and the prevention of back pain⁽¹⁵⁾. These exercise therapies were as follows:

·        Conventional core stability training

·        Tai Chi

·        Aquatic therapy/water exercises

·        Yoga

·        Sling exercise

·        Combined training (combinations of two or more items such as muscle strength training, flexibility training, core stabilizer muscle training).

Box 1 describes these therapies in more detail and the scientific rationale for their inclusion in the study.

Box 1: Six exercise therapies for lower back pain recovery and prevention

Core activation – is a training method focused on activating and recruiting the core stability muscles, notably the erector spinae and multifidus. The activation of these core muscles depends on a diffuse neuronal network. Studies show that in patients with LBP, these networks are abnormally organized, and there is a delay in postural adjustment, leading to instability in the vertebra of the lower spine^(16,17).

Tai Chi is a traditional Chinese training method known to enhance muscle strength and endurance, and also improve the body’s balance and coordination abilities, significantly reducing lower back pain^(18,19). When practicing Tai Chi, the goal is to concentrate attention and coordinate with breathing, which helps practitioners relax both physically and mentally, reducing mental stress, in turn reducing tension-related pain of the lower back muscles.

Aquatic therapy is a therapeutic approach that utilizes the properties of water to relieve pain, relax muscles, and promote motor function⁽²⁰⁾. The buoyancy of water can effectively reduce the pressure on the lower back and relieve the load on the intervertebral discs. At the same time, the stimulation of water can also enhance proprioception, improve neuromuscular control ability, and maintain the stability of the spine⁽²¹⁾.

Yoga is a complex exercise therapy that involves multiple aspects such as the musculoskeletal system, respiratory system, and nervous system. Research shows that there are a number of mechanisms by which yoga can relieve LBP, including strengthening the deep muscles of the lower back, such as the erector spinae and multifidus, as well as the strength of the gluteus maximus (buttocks) and core muscle groups, lengthening and relaxing the lower back muscles, alleviating soreness and stiffness and expanding the range of motion of the lumbar joints, promote the secretion and circulation of synovial fluid, and thus relieve LBP caused by joint problems^(22-24).

Sling training is a high-order core stability training method, which is conducted in an unstable support environment, thus prompting the body to recruit more deep muscles to participate in activities to maintain balance and stability. This training method can not only effectively improve the activity performance of tranversus abdominis and multifidus, but also prevent the recurrence of LBP by maintaining the stability of spinal segments^(25,26).

Combined training integrates various exercise methods and training techniques, which can comprehensively improve physical functions and athletic abilities. Through the superimposed training of muscle strength and stretching, the muscles and fascia of the lower back and its surrounding areas can be lengthened and relaxed, and the adhesion between muscle fibers reduced - thus relieving the tension of the muscles and fascia and reducing pain and discomfort in the lower back⁽²⁷⁾.

What they did

Based on the above, the researchers used a meta-analysis approach to verify the effectiveness of six exercise intervention therapies in treating LBP. In particularly, they looked to see how exercise session duration, exercise frequency, exercise intervention period affected the outcomes achieved. In total, 42 studies covering these six methods met the inclusion criteria and were included for analysis. All of these studies contained an exercise intervention and a control group, allowing the researchers to assess how effective an exercise intervention was for alleviating LBP compared to no intervention (ie doing nothing other than resting). The included studies were divided into three groups for training session duration: less than 30 minutes, 35 to 50 minutes and 60 minutes or more. Likewise, the included studies were sub-grouped to frequency categories of less than 3 times per week, 3-4 times per week, and more than 4 times per week. The length of exercise intervention was also investigated to see how it impacted outcomes; the researchers looked at interventions of 1-4 weeks, 5-8 weeks and longer than 12 weeks.