Training Program Design for Low Back Pain

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CONTENTS

Introduction......................................................................................................................1

Background of the Study.................................................................................................. 2

Subjects Background.......................................................................................................3

Type of Injury................................................................................................................... 4

Treatment......................................................................................................................... 4

Fitness Evaluation............................................................................................................ 5

Study Design....................................................................................................................6

Data collection..................................................................................................................6

Designing Training Program............................................................................................. 6

Training Goals..............................................................................................................6Type of Exercise ..........................................................................................................7Intensity........................................................................................................................ 7

Frequency....................................................................................................................7Training Program..........................................................................................................7

Result.............................................................................................................................25

Discussion......................................................................................................................26

Summary........................................................................................................................27

References..................................................................................................................... 28

TRAINING PROGRAM DESIGN FOR LOW BACK PAIN

Introduction

Nearly all adults experience back pain at some point in their working lives. This common

problem is one of the leading causes of lost work days and individual suffering. If steps

are not taken to maintain a healthy back, the pain can become long-term and

disabling(Occupational Safety and Health Administration., 2007). Back pain is one of the

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most common medical problems in America. Eight out of ten people will experience back

pain at some point in their life. Back pain is ranked second only to headaches as the

most frequent location of pain (Rice & Pollard, 2002). Normally back injuries tend to

peak between the ages of 35 and 45 in people who are still active but less fit

(Occupational Safety and Health Administration., 2007). However, it can experience by

anyone who undergo injury on spine structure. Chronic low-back pain afflicts millions of

persons each year and is associated with significant impairment in physical and

psychosocial functioning. The chronic pain experience is recognized to be a

multidimensional syndrome with many different causes, which is influenced by varying

socio-environmental factors, predispositions, and personalities (Risch et al., 1993). A

back problem can present as a dull ache or an excruciating stab, shooting pain or

tenderness to the touch. There may be stiffness and pain in the lower back, or a person

may experience pain and/or numbness radiating from the back, down into the legs

(Shaari & Rahman, 2003). Exercise is one of the most frequently used modalities in the

rehabilitation of subjects with chronic low back pain. The primary goals of physical

exercise in the management of chronic low back pain are to gain muscle strength,

flexibility and endurance, to restored injured tissues and to contribute to the ability to

sustain normal life activities such as those at work (Kofotolis & Kellis, 2006).

However, many of us still do not know causes, symptom and proper treatment for

low back pain. Therefore, the purpose of this case study is to design proper training

program for patient who suffer low back pain and examine its effect in more detail.

Background of the Study

The study was implemented at Kolej Matrikulasi Londang, Melaka. Initially this case

study has selected subject with obese problem. The objective of this subject is to reduce

fat and increase calorie expenditure. Thus, the researcher designs a training program for

obese person with stated objective. Training program has been sustained for only four

weeks before he has posting to Kolej Matrikulasi Gopeng, Perak. Although the

appointment of posting date on 19 April 2009, the subject has refused to continue theprogram with reason can not commit with program. The letter of appointment to a job is

attached in appendix A.

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Picture 1: Gymnasium which is training program conducted.

Therefore, in order to replace the subject the researcher takes one week to find a new

subject. In one week time, the researcher was introduced with a new subject who

suffered low back pain injury. Based on the discussion with the subject, he has agreed to

follow the training program. At the same time, the subject is under supervision of

physiotherapy treatment from Hospital Tentera Kem Terendak Melaka. Therefore, in

order to cope with the treatment, the researcher has meeting with specialist doctor who

supervise the subject. The objective of the meeting is to explain the training program and

discuss the subjects condition and his level of injury in more depth. Based on the

discussion, the doctor has agreed the subject to follow the program providing that the

program does not worsen subjects condition.

Subjects Background.

The subject has suffered low back pain for eight months ago. Before he undergone low

back pain, his lifestyle is quite active playing volleyball. It was started when he plays

volleyball on August last year. Based on the discussion, he told that improper landing

when he jumps for spike the ball is the causes of he suffers low back pain. Since then,

his movement, range of motion and flexibility become limited. Besides that, since the

Body Mass Index of the subject is classified as overweight (28.1), I do believe that

overweight problem is one of the factors contributed to worse the injury. Consequently,

the subject gets a treatment in Hospital Tentera Kem Terendak Melaka for five days in

ward for the past seven months. Treatment in the hospital is based on traction for three

times per day and followed by heat therapy three times per weeks. Here is the subjects

personal biodata:

Name : Sazuaranie b. Hanapiah

Job : Lecturer

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Age : 33 years old

H/P : 019-6653441

Gender: Male

Height : 179 cm

Weight : 90 kg

BMI : 28.1 (Over weight)

Experience in weight training: Never

Medical history: Appendicitis (long time ago)

According to the subject, he also takes calcium magnesium as his medication in order to

cure his low back pain. The medication is provided by the hospital as part of a treatment.

Type of Injury

The subject has suffered chronic low back pain which the pain persists more than three

months. According to the record of diagnosis by specialist doctor at 94 Hospital

Angkatan Tentera, Kem Terendak Melaka, his low back pain injury is classified as

prolapsed intervertebral disk which is known as herniated disk or slipped disk. The L4/5

and L5/S1 was slipped out of original structure which pressing on the nerve roots.

Therefore, it causes back pain and sciatic pain cause severe pain spreading

down on his left leg and often into the foot. The symptoms of the pain are limited

in range of motion, pain on L4/5 and L5/S1 disk, hip muscle numbness, hard to stand inlonger duration and limited in movement. This is supported by University of Missouri

(2001), which stated that pinching and inflammation of these nerve roots (the long

arms of the nerve that stretch out from the nerve body) are just likely to cause

numbness, pain, or motor problem in the leg or arms to which they connect than to

cause back pain at the side of the pinching. Based on the discussion with the subject, he

claimed that the pain has affected his sleep and his life style.

Treatment

In order to treat the injury, the subject was referred to The 94 Hospital Angkatan

Tentera, Kem Terendak Melaka on February and was investigated where Magnetic

Resonance Imaging (MRI) done on 23 February 2009. Based on the investigation, his

injury is classified as the impression of diffuse L4/5 and L5/S1 prolapsed intervertebral

disk (PID). He was then referred to the Physical Rehabilitation and Physiotherapy

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Department and was assessed using Oswestry Disability Index (ODI) with score 18%

minimal disability. The treatments that were applied to the subject are traction,

analgesic, electrotherapy (Short Wave Diathermy-SWD), medication, and exercise

without supervision and proper training program. However, at the same time the subject

also tries alternative treatment which traditional massage was chosen. Among all of

these treatments, only Short Wave Diathermy (SWD) is still continues for once a week at

the hospital. Based on the discussion with the doctor, the subject is in the phase of

physiotherapy which SWD as a treatment to cure the injury. SWD has been applied on

the site of injury for 20 minutes every session of treatment.

Picture 2: The subject is treating using Short Wave Diathermy (SWD).

Fitness Evaluation

The subject has been evaluated in order to examine the level of fitness and condition of

pain. Screening tests to detect the level of seriousness in herniated disk include asking

about the presence of sciatica, the straight leg raise, and the crossed straight leg raise

(i.e., raising the contralateral, unaffected leg). The evaluation is based on the

observation of flexibility and range of motion of hip and several basic movements. Based

on the evaluation, the researcher found that, range of motion of hip joint is very limited.

The range of motion is limited due to pain on back hip and sciatic pain on his left leg.

Besides that, his average resting heart rate is about 80 beats per minute (bpm) which

shows that his fitness is above normal heart rate. Oswestry Questionnaire also was usedas an instrument to evaluate level of fitness of the subject. Based on the interview, since

he suffer low back pain, his daily life become passive compared to before undergo low

back pain.

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The subject is also rare in applying physical exercise after he suffers low back

pain. Although he was informed by physiotherapist to exercise, the subject seldom

exercises or stretches his muscle. This is due to lack of knowledge and no proper

training program to be followed. Therefore, based on the evaluation, I do believe that

fitness level of the subject is very poor in term of fitness components and need to be

trained in order to strengthen the core muscles and hip muscle to be functional.

Study Design

The case study design was utilized experimental pre and post test design. The design

include pre-test measured before training program followed by the treatment (training

program) for six weeks. Then, when the training program was completed, post-test

measured to examine the effect of training program on the subject. The reason why theduration of training program only planned for six weeks has been explained by the

researcher in the background of the study.

Data collection

The data is collected by using Oswestry Low Back Pain Disability Questionnaire (r =.99)

a self-assessment score for chronic back pain patients. The Oswestry index is based on

a patients subjective impression on his or her own state of disability. Though the

questionnaire is rather old, it has been validated and its reliability and sensitivity to

changes in functional status have been proved (Niskanen, 2002). As discuss before, the

data was gathered before training program (pre-test) and after training program (post-

test).

Designing Training Program

The training program was designed based on the fitness evaluation and subjects

background, medical history and depth discussion with the doctor who supervise the

subject for the whole treatment. Therefore the researcher has design the training

program and these variables are expected to influence the effect of training program.

Training Goals

The goal of this training program is to reduce pain which suffered by the subject

for almost eight months. Meanwhile, other goals are to improve strength,

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mobility, coordination, endurance, increase range of motion (ROM), increase

blood flow and increase flexibility gradually.

Type of Exercise

Type of exercise in this training program is based on two strategies. Theresearcher has planned to design the program basically base on isometric and

isotonic exercise. Unfortunately, isometric strengthening is joint-angle specific;

that is, strength gains occur only at the angle used. Therefore, the training was

performed isometric exercise at multiple angles. While isotonic exercise involves

training with constant external resistances, the amount of force to move the

resistance varies, depending primarily on joint angle and the length of each

agonist muscle. Basically, the type of exercise that has been chosen is based on

special consideration of low back pain injury. The exercises were identified by thejournal and specialist as a specific exercise special for treat low back pain

population.

Intensity

Based on the type of injury and medical history of the subject, the researcher has

planned the training program with low intensity and then increase gradually. This

is because of to allow strength gain to occur with an intensity low enough that the

newly formed collagen fibers are not disrupted.

Frequency

Since the program is designed with low intensity, the frequency of training is

three days per week. The training was conducted on evening from 5.30 pm to

6.30 pm for the first four week and extended from 5.00 to 6.30 pm for the

following weeks.

Training Program

Training 1

The program for week 1 is designed to give the subject chances of adaptation.

However, the subject is not forced if pain stressful. The objective of this week is

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to develop foundation of training since the subject does not get use with

resistance training.

Week: 1

Day: Monday

Warming Up: Cycling 10 minutes

Stretching: Passive static stretching

Time: 5.30-6.30 pm.

Intensity: Very Low

Cool Down: Static stretch (low intensity).

Training 2

Week: 1

Day: Wednesday


Stretching: Static stretching

Time: 5.30-6.30

Intensity: Very Low

Target Muscle Exercise Set 1 Set 2

Rep Time Rep TimeHamstring Hip flexor stretch 1 5 sec

Abdominal muscle Partial curl 1 5 sec

Lower back muscle Superman 1 5 sec

Hamstring Gluteal stretch 1 5 secQuadriceps Seated leg raise 1 5 sec

Lower back muscle Pelvic tilt 1 5 sec

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Cool Down: Passive static stretch (low intensity)

Training 3

Week: 1

Day: Friday


Stretching: Passive static stretching

Time: 5.30-6.30

Intensity: Very Low


Rep Time Rep TimeLower back muscle Hip flexor stretch 1 5 sec



Hamstring Gluteal stretch 1 5 secQuadriceps Leg raise 1 5 sec


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Cool Down: Passive static stretching (low intensity).

Training 4

Based on the observation and verbal communication with the subject, the subject

has adapted to the initial program. Therefore, the intensity of the training is

increased and variation has been added on for current training in relation to the

principles of progression and individuality. PNF stretching also has been applied

in order to generate isometric contraction.

Week: 2

Day: Monday



Rep Time Rep TimeLower back muscle Hip flexor stretch 1 5 sec



Hamstring Gluteal stretch 1 5 secQuadriceps Leg raise 1 5 sec


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Time: 5.30-6.30 pm.

Intensity: Very Low

Cool Down: Passive static stretching (low intensity)

Training 5

Week: 2

Day: Wednesday



Time: 5.30-6.30 pm.

Intensity: Low

Target Muscle Exercise Set 1 Set 2Rep Time Rep Time

Lower back muscle Cat and camel 1 8 sec


Lower back muscle Leg raise 1 8 sec

Hamstring Gluteal stretch 1 8 sec

Quadriceps Leg raise 1 8 sec


PNF stretching

Lower back muscle Trunk flexion 1 8 sec

Lower back muscle Trunk extension 1 8 sec

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Cool Down: Static stretch (low intensity)

Training 6

Week: 2

Day: Friday



Time: 5.30-6.30 pm.

Intensity: Low


Rep Time Rep TimeLower back muscle Cat and camel 2 10 sec



Hamstring Gluteal stretch 2 10 secQuadriceps Seated Leg raise 2 10 sec


PNF stretching



Hamstring Hip extensor 2 10 sec

Quadriceps Hip flexor 2 10 sec

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Cool down: Passive stretch (low intensity)

Training 7

The researcher found that the subject has been adapted with the previous

program. Therefore, the variables (intensity and repetition) have been

manipulated in this week in order to be more effective.

Week: 3

Day: Monday



Time: 5.30-6.30 pm.

Intensity: Low


Rep Time Rep TimeLower back muscle Cat and camel 2 10 sec

Quadriceps Seated Leg raise 2 10 sec


Hamstring Gluteal stretch 2 10 secAbdominal muscle Partial curl 2 10 sec


PNF stretching





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Cool down: Passive stretch

Training 8

Week: 3

Day: Wednesday



Time: 5.30-6.30 pm.

Intensity: Low


Rep Time Rep TimeLower back muscle Superman 5 5 sec

Quadriceps Swiss ball squat 6 -

Abdominal muscle Swiss ball partial curl 5 5 sec

Soleus, Gastrocnemius Standing calf raise 5 5 sec

Lower back muscle Swiss ball single leg bridge

and curl

6 -

PNF stretching





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Training 9

Week: 3

Day: Friday



Time: 5.30-6.30 pm.

Intensity: Low


Rep Time Rep TimeLower back muscle Superman with plate (1kg) 4 8 sec



Soleus, Gastrocnemius Standing calf raise 8 -Lower back muscle Swiss ball single leg bridge

and curl

4 8 sec

PNF stretching





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Training 10

Since the program has entered week 4, the researcher has designed to add on

set of training. Based on the observation, the subject has improved in term of

pain (reduced) and core strength (increased). Therefore, a little adjustment on

training program has been made to cope with principle of variety and fun which

swimming has been chosen as a part of training program. The chosen of

exercise also mostly based on dynamic exercise.

Week: 4

Day: Monday



Rep Time Rep TimeLower back muscle Superman 5 5 sec



Soleus, Gastrocnemius Standing calf raise 10 -Lower back muscle Swiss ball single leg bridge

and curl

5 5sec

PNF stretching





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Time: 5.00-6.30 pm.

Intensity: Low-moderate


Training 11

Week: 4

Day: Wednesday

Warming Up: Active movement.


Time: 5.00-6.30 pm.



Tricep Standing Triceps Extension 8 2kg 8 2kg

External abdominal oblique,

Lattisimus dorsi, erector

spinae

Swiss ball oblique 8 - 8 -

QuadricepsSwiss ball squat with

dumbbell (1 kg)8 2kg 8 2kg

Abdominal muscle Swiss ball partial curl 5 5 sec 5 5 sec

Soleus, Gastrocnemius Standing calf raise 5 5 sec 5 5 sec

Lower back muscleSwiss ball single leg bridge

and curl5 5sec 5 5sec

PNF stretching

Lower back muscle Trunk flexion 3 10 sec 3 10 sec

Lower back muscle Trunk extension 3 10 sec 3 10 sec

Hamstring Hip extensor 3 10 sec 3 10 sec

Quadriceps Hip flexor 3 10 sec 3 10 sec


Whole muscleSwimming Tg. Bidara

Resort1 10 min 1 10 min

PNF stretching





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Training 12

Week: 4

Day: Friday



Time: 5.00-6.30 pm.


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Training 13

The researcher still continues with manipulating the variables of training. The

intensity and volume of the training has been reduced while repetition increases

in order to increase subjects adaptation.

Week: 5

Day: Monday



Time: 5.00-6.30 pm.



Rep Time Rep TimeTricep Standing Triceps Extension 8 2kg 8 2kg



spinae


Quadriceps Swiss ball squat with

dumbbell (1 kg)

8 2kg 8 2kg



Lower back muscle Swiss ball single leg bridge

and curl

5 5sec 5 5sec

PNF stretching





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Training 14

Week: 4

Day: Wednesday



Time: 5.00-6.30 pm.



Rep Time Rep TimePectoralis major Standing Bench Press 10 1.5kg 10 1.5kg



spinae



dumbbell (1 kg)10 1.5kg 10 1.5kg

Abdominal muscle Swiss ball oblique exercise 10 5 sec 10 5 sec




Hamstring Leg curl 10 1.5kg 10 1.5kg

PNF stretching



Hamstring Hip extensor 4 8 sec 4 8 secQuadriceps Hip flexor 4 8 sec 4 8 sec


Rep Time Rep Time



PNF stretching





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Training 15

Week: 5

Day: Friday



Time: 5.00-6.30 pm.



Tricep Standing Triceps Extension 8 2kg 8 2kg



spinae



dumbbell (1 kg)8 2kg 8 2kg


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PNF stretching



Hamstring Hip extensor 3 10 sec 3 10 secQuadriceps Hip flexor 3 10 sec 3 10 sec


Training 16

The subject has shown adaptability to resistance training program. Although, this

is the last session of training program for the case study, training program will be

continued soon in order to cope the subject needs. Oswestry Lower Back Pain

Disability Questionnaire was conducted at the last training session in order to

measure the effect of training program on low back pains impact on the activities

of daily living.

Week: 6

Day: Monday



Time: 5.00-6.30 pm.


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Training 17

Week: 4

Day: Wednesday



Time: 5.00-6.30 pm.




Rep Time Rep Time

GluteusStanding Hip abduction &

adduction12 - 12 -



spinae


HamstringHamstring curl with Swiss

ball12 2kg 12 2kg

Abdominal muscle Prone straight leg raised 12 5 sec 12 5 sec

Soleus, Gastrocnemius Seated calf raise on Swiss

ball with 2kg weight

12 5 sec 12 5 sec

Lower back muscle Superman with weigh plate 12 5sec 12 5sec

Quadricep Swiss ball squat with

dumbbell

12 2kg 12 2kg

PNF stretchingLower back muscle Trunk flexion 4 10 sec 4 10 sec







PNF stretching





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Result

Of the 18 session in six weeks training program, the subject has completed all training

session with successful. Based on the data collection for pre-test using the Oswestry

Low Back Pain Disability Questionnaire (r=0.99), subject scored 24% of its impact on the

activities of daily living. However, after doing the training program post-test indicates that

the scored is 12%.


Rep Time Rep Time

GluteusStanding Hip abduction &

adduction12 - 12 -



spinae


HamstringHamstring curl with Swiss

ball12 2kg 12 2kg

Abdominal muscle Prone straight leg raised 12 5 sec 12 5 sec

Soleus, GastrocnemiusSeated calf raise on Swiss

ball with 2kg weight12 5 sec 12 5 sec

Lower back muscle Superman with weigh plate 12 5sec 12 5sec

QuadricepSwiss ball squat with

dumbbell12 2kg 12 2kg

PNF stretchingLower back muscle Trunk flexion 4 10 sec 4 10 sec




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0

5

10

15

20

25

Pre-

Test

Post-

Test

Test

Figure 1: Comparison of pre and post test data.

Therefore, it is shows that the pain has significantly decreased to 12% of its impact on

the activities of daily living after doing training program. Based on the interview with the

subject, the researcher found that the feeling of comfortable and relaxation has

increased compared to before training program.

Discussion

The main finding in this case study is that, by doing proper training program for person

who undergone low back pain, its impact on the activities of daily living can be reduced.

Through observation, for the first week of training program, the subject claimed that the

pain being main constrain of doing exercise. However, when he has adapted to the

program, the pain gradually reduced. However, the intensity of the program was

designed from very low intensity and gradually increased to moderate. Since, the subject

know his level of pain, thus the researcher does not force him to perform precisely to the

training program. Another factor that influences reducing pain is a treatment at The 94

Hospital Angkatan Tentera, Kem Terendak Melaka.

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Picture 3: Lt. Kol. Dr. Zainal b. Othman

Based on the interview and discussion with the doctor who supervise the subject, he

claimed that the subject show improvement. The doctor has evaluated the subject by

using the same questionnaire and comparing the pre-test (administered on the day

referred to rehabilitation department) and post-test (administered on the day of

discussion) and found 10% improvement in disability. However, since the researcher

also used the same questionnaire, and measured on different period, the researcher

found 12% of improvement. The reason why both result is different because of after

post-test measured by the doctor the subject still continue doing training program and

measured again by the researcher a week after. Therefore, this may contribute to

differentiation of the result.

Summary

The current study showed that specific exercise of the low-back in chronic low-back pain

patients is important for increasing strength and reducing pain and psychosocial

dysfunction. This treatment did not ameliorate psychological distress or socio-

environmental influences. This implies that physical rehabilitation is an important

component of rehabilitation for chronic low-back pain patients and should be included

with psychological rehabilitation for maximizing return to work and improved daily

functioning. In conclusion, this study demonstrated that lumbar extension exercisestrengthened the low-back extensor muscles in a population of chronic low-back pain

patients. Associated improvements were also found in the experience of pain and

perceived physical dysfunction as measured by the Oswestry Disability Index.

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References

Kofotolis, N., & Kellis, E. (2006). Effects of two 4-week proprioceptive neuromuscular

facilitation programs on muscle endurance, flexibility and functional performance

in women with chronic low back pain.Physical Therapy, 86,(7).Niskanen, R. O. (2002). The oswestry low back pain disability questionnaire. A two-year

follow-up of spine surgery patients. Scandinavian Journal of Surgery, 91.Occupational Safety and Health Administration. (2007). Back injury prevention for the

landscaping and horticultural services industry. Kansas State UniversityAgricultural Experiment Station and Cooperative Extension Service, 7(56).

Rice, C. A., & Pollard, J. M. (2002). Back pain. Health Education Rural Outreach

(HERO), 6(3).Risch, S. V., Norvell, N. K., Pollock, M. L., Risch, E. D., Langer, H., Fulton, M., et al.

(1993). Lumbar strengthening in chronic low back pain patients physiologic and

psychological benefits. SPINE 18( 2).Shaari, A. H., & Rahman, H. A. (2003). Sakit belakang dan faktor yang

mempengaruhinya di kalangan penoreh getah di Pahang. Malaysian Journal of

Public Health Medicine, 3(1).University of Missouri. (2001). Handbook of disabilities: Chronic low back pain:

University of Missouri.

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APPENDIX A

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APPENDIX B

Medical Assessment Letter

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APPENDIX CTraining Session

Picture 4: Subject doing Alternate Arm/ Leg Raises

Picture 5: PNF exercise

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APPENDIX DThe Oswestry Disability Index (Pre and Post Test)

Training Program Design for Low Back Pain

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