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[Physio Explained] Back on track: effective exercise for low back pain with Thomas Dekkers

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In this episode with Thomas Dekkers we discuss the evidence for exercise in low back pain. We discuss:

  • Is exercise an evidence based treatment for back pain?
  • Which type of exercise is best? 
  • Limitations of research in back pain
  • Importance of education in this population
  • How to improve our exercise prescription
  • Individualised programs for rehabilitation

Thomas is a Physiotherapist, researcher, and educator with almost 20 years experience in the field of musculoskeletal and sports medicine. Currently he works as a Specialist spinal Physiotherapist as part of the Neurosurgery team at Cork University Hospital in Ireland and he also consults in private practice on patients with complex spinal pain. In addition to his clinical work he is currently completing a PhD at Technological University Dublin investigating the rehabilitation of athletes with back pain and has numerous peer-reviewed publications. He is also a passionate educator and teaches his course, 'The Rehabilitation of Back Pain’.  internationally. 

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Our host is @James_Armstrong_Physio from Physio Network

UNKNOWN:

Thank you.

SPEAKER_02:

I don't give exercise to nearly every person or I don't always change their exercises, but I will give education to every single person. So education is the backbone, I think, of what we do. So if you're setting up a trial and you're giving people exercise without the education part, you're not going to get the real bang for your buck from exercise. If that person doesn't know why they're doing that, they don't know the direction of treatment or they don't understand their condition, right, they're not going to get the buy-in. And so it's the communion, really, of education and exercise that I think is where we have to most benefit technically.

SPEAKER_01:

Welcome to the PhysioExpand podcast. Today we're joined by Thomas Deckers, a spinal specialist physiotherapist with over 16 years of experience in musculoskeletal and sports medicine. Thomas has worked with a range of patients from Olympic athletes to those with complex spinal pain and is actively involved in research on spinal function and pain. He's also a passionate educator teaching internationally in the field of spinal rehabilitation. Now in today's episode, we'll be discussing the current research on exercise for low back pain. pain and the challenges of applying this research into clinical practice. and how you should be prescribing exercise for lower back pain to achieve better outcomes with your patients. With Thomas's extensive background in both clinical practice and research, he'll provide valuable insights into the most effective exercise strategies for managing and rehabilitating lower back pain. Stay tuned because by the end of this episode, you'll have a deeper understanding of how to improve your approach to teaching and treating lower back pain, and you might just rethink how to prescribe exercise for your patients. Let's get into the episode. I'm James Armstrong and this is Physio Explained. Thomas, welcome to the Physio Explained podcast. It's great to finally meet you and have you on the podcast.

SPEAKER_02:

Yeah, thanks for having me. I'm really excited.

SPEAKER_01:

Brilliant. So we're talking about a topic that I'm sure many listeners are going to be really interested to hear your thoughts and get up to speed with, and that's exercise prescription for back pain, particularly kind of talking about lower back pain here. So first of all, we're going to talk about the research. What does the research say? We're then going to talk about how we put that into practice. And then most importantly, how we should be prescribing exercise and are the better ways of doing it. And I'm sure from that, there's going to be lots of clinical takeaways for the listeners. So let's dive straight in then, Thomas. The research, what's it telling us at the moment?

SPEAKER_02:

Yeah, sure. So when it comes to the research on exercise for low back pain, I suppose exercise is probably the most promoted intervention there is for low back pain. It's pretty much recommended by every guideline from the WHO to the NICE guidelines, Australian guidelines, American guidelines on back pain would all recommend exercise as a first line conservative management strategy for back pain, right? Those recommendations come off the back of a lot of evidence that has been done in the area, really nicely summarized by Jill Hayden and colleagues in a Cochrane review a few years ago, 2021, where they found they looked at about nearly 250 randomized control trials. And what they found was that effectively that exercise is an effective treatment strategy for those with low back pain, more so than placebo, more so than usual care, which is considered to be the GP or to no treatment at all. Okay. So that would be the baseline. I suppose the headline would be that exercise is an effective treatment strategy for low back pain. Although there's more to the story, but that would be the headline.

SPEAKER_01:

So that's the headline. And I think one of the things that we're always after, especially any sort of new grads listening to this, and I know I was always looking for that recipe, that prescription. What do we give people with lower back pain? Is the research veering us towards any particular type of exercise prescription? I know we're probably going to touch on this a bit later on, but.

SPEAKER_02:

So that's one of the things that's really undecided in the research. So although the research comes across and say that exercise is a good idea for us to give to low back pain, so we're all working within an evidence-based practice model, if you like, if we are prescribing it, the research is really unclear as to what's the best type, all right? So we see benefits to nearly every exercise modality if applied to low back pain. So pretty much every exercise approach has been tested for low back pain. So yoga, Pilates, core stability mobility, strength work, aqua jogging, Nordic walking, you name it, it's been tried and it has been shown to be effective for low back pain. And there's, generally speaking, very little difference between the different modalities. A systematic review came out recently by a Spanish group, Fernandez Rodriguez, and they would say that maybe the Pilates and the strength approaches would be slightly better at improving pain and disability, but all modalities really across the board will show a greater benefit than doing no treatment at all and there's very little between them.

SPEAKER_01:

Moving on to Translating that research into clinical practice, this is always the bit that sometimes becomes more tricky. So what are the issues that we've got when trying to take that research and use it with our next patient in clinic who's presented with lower back pain? Excellent question.

SPEAKER_02:

So look, at the end of the day, the first part is that, okay, if we're prescribing exercise, we're doing the right thing, inverted commas, for the vast majority of our patients. But the way in which the research has been done doesn't really reflect with how clinical practice actually runs in real life. And that would be my main issue with maybe how difficult it is to translate the research into clinical practice. So I'll qualify that statement, right? So of those 250-odd randomized control trials in that systematic review I just spoke about, The vast majority of those studies will have an inclusion criteria that looks like this. They'll have pain in the lumbopelvic region, normally from T12 to the gluteal fold, plus or minus radicular presentations. Then they will have patients anywhere from the age of 18 to 64. They'll have that duration of pain for over three months to ensure that they're considered chronic. And then they won't have any red flags. They won't have any signs of serious pathology. If you walk down the street and you take that population of people with low back pain, it's absolutely huge. They've treated back pain as a very homogenous group. Then those studies have gone on to then apply an exercise modality, let's say Pilates versus another exercise modality, let's say a conditioning program on the bike. They've put people through a program a couple of times a week over an eight to 12 week period. And at the end of that period of time, they're going to compare A versus B. And lo and behold, in most circumstances, there's not a huge difference between them. But the way the exercise has been prescribed is very prescriptive in that it's very much a one size fits all model. It's the same exercises in the same sequence, at the same reps and sets, at the same load, at the same frequency. And so if you're taking back pain as a homogenous group, you're not stratifying those patients in any way based on the multifactorial factors that are going on in their life. And we know this from the tons of research in the pain fields, in the back pain fields. The pain is complex, right? So we're taking a complex problem, but we're treating it as a very uniform issue. And then we're applying exercise that we know can be manipulated in so many ways, but we're applying it in a one size fits all model towards a very complex problem. And is it any wonder then that we see kind of moderate results? And I would say that would be a real reason why. And it also means that it's very hard to translate to clinical practice, because I don't know a single therapist who treats every person with back pain that comes into them in the exact same way and gives them the exact same exercise. exercise at the same frequency and the same dose. So the evidence is telling us that exercise is beneficial, but it's telling us exercise is beneficial in the way that that research has been conducted. And what I would argue is that actually we can be probably more efficacious with our exercise prescription if we learn to tailor it to the individual person. but there's no research to tell us that just yet. So that's the disconnect. But that's the part that makes me excited because imagine if we could learn to prescribe exercise better and really treat it like a medicine and know the dosage that would work and the type that would work for individual people. And that means that our work is not done with research for exercise, not by a long shot.

SPEAKER_00:

Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you. Our team of experts summarise the latest and most clinically relevant research Do you think that is

SPEAKER_01:

possible with research? Because a lot of the times it's just really hard to do the research that we're going to do in practice. And from your point of view, do you think it's possible for us to create good quality research that does enable us to manipulate exercise, prescriptions? individually and show whether that's more

SPEAKER_02:

effective? Yeah, I look, I really, I really do. I would hope so. You know, that's, I've got plans post PhD to be leaning into that question. But look, ultimately the Restore group, so Peter O'Sullivan, Kieran O'Sullivan's group at the CFT group have done fantastic work with their recent study in the Lancet, right? So they have taken that complexity of people with back pain and they have treated them at an individual level based on their entire multifactorial nature. And then they've treated them with exercise, but with cognitive approaches as well. And they've shown that to be more beneficial. than other approaches, I would see that the application of exercise is no different to that and that we understand the person at a very individual and a very granular level. But then we need to also understand our exercise at a granular level and stop treating it like a one-size-fits-all model. And we learned that manipulating the doses can be very beneficial for different people and the types of exercise and how we communicate, how we get people to do the exercise is really important as well. There's so much detail to be explored in this area, I think.

SPEAKER_01:

And then that's exactly it. I think a lot of the time, it's not just the exercise we prescribe and how wonderful that exercise is. It's how we do it, the communication skills, the reassurance. It's all of those things, isn't it? And that's really hard

SPEAKER_02:

to unpick. It's hard to unpick. And that would be another thing about the research that I think is maybe a disjoint to clinical practice is that I'm a huge proponent of exercise for back pain, obviously, is how I practice, it's what I teach. But at the same time, I don't give exercise to nearly every person or I don't always change their exercises. But I would give education to every single person. So education is the backbone, I think, of what we do. So if you're setting up a trial and you're giving people exercise without the education part, you're not going to get the real bang for your buck from exercise. If that person doesn't know why they're doing that, they don't know the direction of treatment or they don't understand their condition, right? They're not going to get the buy-in. And so it's the communion really of education and exercise that I think is where we have the most benefit technically.

SPEAKER_01:

So in terms of those listening to this, wanting to prescribe exercise for lower back pain, the question is, how do we do it best? What is the best way that we can do it? And we sort of touched upon it a little bit here, but in your eyes and where we are at the moment, how should listeners be thinking about prescribing exercise for lower back pain?

SPEAKER_02:

Yeah, sure. So look, we've got two options in this, okay? So you can choose your favorite paper from the research that has shown their exercise program to be efficacious, to reduce pain and disability. Go with that, go with their program, and you'll probably see moderate or good results in some people and not so good results in other people. Or you go down another path, which is where we really have to clinically reason and individualize that exercise to develop a bespoke program for that individual person. And most clinicians are going to choose the latter because we instinctively know, certainly with complex problems, we need to be working at an individual level. All right. So if we're asking me how to do it best or how to do it better, the first thing that I would advocate is that we understand that person's presentation across a number of different domains. So understand their back pain factors from their pathoanatomical differences, their pain processing differences. Have they nociplastic pain or neuropathic pain? Have they certain psychosocial factors? Have they lifestyle factors that might impact? Have they certain physical factors like the way they move or strength and endurance deficits? Understand that big picture of the person because each of those areas are going to lend to a different direction of treatment. So if I take, for example, the pathoanatomical factors, if I've got a patient with a stenosis or and who generally doesn't like extensions, then I'm probably not going to give them a large degree of exercises into extension or that increased axial load of their spine because it's probably going to flare their symptoms up versus someone with a disc protrusion and that person doesn't like flexion or rotation. I'm probably not going to give that as an exercise strategy. So each of those factors are going to let us know little directions in which we can go. And once we understand that initial back pain factor, that would be the first stage. The second stage of our reasoning process in which to prescribe exercise is then to understand the physical goals of that particular person. So we understand where they are. That's question number one. And now we understand where they want to go. So is this someone who wants to just be able to walk to the shops? Is this someone who wants to be able to just their housework with less pain? Is this someone who wants to be able to get down on the ground and play with their kids? Is this someone who, like I saw a gentleman earlier this week, who wants to do 100 mile races and he's got back pain, right? And so All of those people need a different program in my book. They all need a different exercise program that's going to match their physical goals. So understand where they are, understand where they need to go. That's number two. Number three, then you create a needs analysis. And that needs analysis is based on where they want to go and based on where they are at the moment. What does this person really need? Okay, they might need more confidence with bending or they might need to learn in a free, more carefree way of moving. Or they might need strength in certain muscle groups. Or they might need to learn how to improve strength or endurance in certain functional activities. Or they may need to not have so much of a performance-driven approach. They might just need to have more of an engagement-driven. So what I mean, they just need to be doing something because they're not doing anything at all. And that would come out of my needs analysis. Like what does that person really need to get them from point A to point B? And then lastly, we get onto the exercise prescription or the exercise selection. So I always reflect when I teach this on my courses, there's always people in maybe in the audience who, when we ask them, why did they come and come on the course? And they all, they will always say, oh yeah, I want to learn some new exercise techniques and to enhance my practice. But in that respect, look, there's merit in that, but also learning new techniques is not necessarily the most important thing. It's learning the understanding of why we're using the techniques. So the first three areas are so important. And now we come to the fourth one, which is exercise selection, which is the fun part, right? How do we choose that individual exercise that meets our needs analysis? And so then you can stand back and say, okay, what does this person need? And then we look at our big bank of exercises that we have in our head. We all have favorites. I have favorites, but I counted them up recently. I have hundreds of favorites. I have about 280 exercises that I said I would generally give for the lumbar spine at some stage, some more so than others. And each of those exercises, types can be parceled into one of three areas because exercises can blend a lot, but they're generally can be stratified along a continuum of how much a metabolic demand is needed for that exercise. So on one end of the continuum, you've got your, what I would say, your mobility exercises. These are going to be your range of motion exercise and your classic range of motion exercises, low load exercises. that take the spine through a full excursion of motion in a pain-free and a comfortable manner, whether that's static or in dynamic. The next level up from that is going to be more your control exercises. So these are exercises designed to improve the precision of movement. They're non-fatiguing, they're a higher load than a mobility exercise, but the focus is on getting you to perform a task well. So this might be something like changing how somebody moves or getting them to lock into a certain movement strategy that they're finding difficult to it. And then the third level of that would be those exercises where we start to challenge our capacity. And a capacity exercise is going to be an exercise where we're going to see the primary adaptations are going to be either aerobic changes like improved cardiovascular health or anaerobic changes, hypertrophy, strength, endurance. And those will be the physical factors that drive those different types of exercises. But with each exercise type, Each exercise type can reduce pain for a multitude of reasons. Each exercise type can have a multitude of factors on someone's psychological state as well. So I don't just choose exercises for the physical. I choose exercises for the psychological. I choose exercises on what is going to modify this person's pain. So you can get very creative at that end of the scale. But you have to understand the person first. Otherwise, you're shooting in the dark a bit.

SPEAKER_01:

Brilliant, Thomas. That's fantastic. It's just going through those stages. So actually what you're saying to us is whilst we're talking about exercise prescription for lower back pain, we need to hit those other two points before we get to that first. And before we can do it well, we need to understand the patient, where they need to be, where they are now, so we can then think about that exercise prescription person-centred at the end of the

SPEAKER_02:

day. Absolutely, absolutely. So you go through those four stages. What are the factors involved in their presentation? What are their physical goals? Number two, what's the needs analysis of that person? And then what exercise best fits that needs analysis, not just from a physical point of view, from a biopsychosocial point of view. That for me is therapeutic exercise prescription, contemporary therapeutic exercise prescription that I truly believe is a very effective treatment modality. And I think that We're probably always scratching the surface of how good it can be done. Doing it in research is very hard. There's no doubt about that. But we see the benefits every day in our practice. Instinctively, when I ask clinicians this when I teach, We know that certain exercises bother patients. We know certain exercises don't change them at all. We know certain exercises will probably help patients. So how can we learn more about those exercises that can help people? How can we see the patterns? And I think it's a really exciting area.

SPEAKER_01:

Definitely. And a great way to finish the podcast with a real thought-provoking statement there from you, Thomas. Thank you so much for your time on the podcast. Time has flown by and I think we'll definitely need to have you back on if you're willing to come back on again and maybe talk more on this. And certainly at some point in the future, I hope with some research that I'm sure you're going to go on and do, which should help all of our clinicians listening to the podcast and in the future.

SPEAKER_02:

Sure. It's been a real pleasure. Thanks for having me on. Thanks, Thomas.