Special Populations

The Special Populations Column provides personal

trainers who work with apparently healthy or medically
cleared special populations with scientifically supported
background information.

COLUMN EDITOR: Peter Ronai, MS, RCEP, CSCS*D,

NSCA-CPT

Chronic Nonspecific Low

Back Pain and Exercise
Peter Ronai, MS, RCEP, CSCS*D, NSCA-CPT*D1 and Paul Sorace, MS, RCEP, CSCS*D2
1
Exercise Science Department, Sacred Heart University, Fairfield, Connecticut; and 2Hackensack University Medical
Center, Hackensack, New Jersey

SUMMARY Back pain is typically classified by the EPIDEMIOLOGY AND ETIOLOGY

CHRONIC NONSPECIFIC LOW
BACK PAIN (CNSLBP) IS A COM-
MON MUSCULOSKELETAL CONDI-
TION OFTEN RESULTING IN
PHYSICAL INACTIVITY AND DIS-
ABILITY. EXERCISE IS BENEFICIAL
TO IMPROVE HEALTH-RELATED
QUALITY OF LIFE FOR PERSONS
WHO SUFFER FROM CNSLBP. THIS
COLUMN DISCUSSES CNSLBP
EPIDEMIOLOGY AND ETIOLOGY AS
WELL AS EXERCISE EFFECTS,
BENEFITS, AND GOALS FOR PER-
SONS WITH CNSLBP.
INTRODUCTION
ow back pain (LBP) is a com-
etiology, location, and duration of
symptoms (14).
Some evidence indicates that persons
with CNSLBP experience PA intol-
erance, lower levels of physical fit-
ness and function, and PA avoidance
and thus engage in a more seden-
tary lifestyle than age- and gender-
matched persons without CNSLBP
(58,19,21,23,24).
This column will discuss the epidemi-
ology, pathophysiology, benefits of
exercise, and exercise program goals
for persons with CNSLBP, whereas
the accompanying One-on-One col-
umn will discuss specific exercise pro-
gram recommendations. This article is
Evidence indicates that lower PA levels
(21,23), physical functioning (5), and
physical fitness (6,7,19) exist in persons
with CNSLBP. The reported lifetime
prevalence of LBP in westernized
countries ranges between 49 and 70%
and 70 and 85% in the United States
(3,14). LBP is generally classified by
its cause, location, severity, and dura-
tion (14). Typically, LBP is classified as
follows:
 Specific pain caused by unique or
unusual pathophysiologic mecha-
nisms (disc herniation, tumor, oste-
oporosis, arthritis, diseases, trauma,
mechanical disorders or spinal
pathology)
 Nonspecific pain not caused by a spe-

L mon musculoskeletal disorder

affecting 7085% of people in
the United States at one or more times
in their lives (4). Chronic nonspecific
low back pain (CNSLBP) is the second
leading cause of physicians visits, the
leading cause of lost time at work, the
second leading cause of disability, and
most common cause of physical activ-
ity (PA) limitations in persons younger
than 45 years (3). The annual estimated
medical cost of back pain in the United
States is approximately $50 billion (4).
not intended to help exercise profes-
sionals diagnose, treat, or rehabilitate
clients with LBP of any type (specific,
nonspecific, acute, subacute, or
chronic). Information within this col-
umn pertains to clients who have been
discharged from rehabilitation and
medically screened and cleared to
engage in a comprehensive fitness/
exercise program. Clients with new
or worsening symptoms of LBP
should be referred to their physician
or health care provider.
cific disease or spine pathology
 Acute pain lasting less than 6 weeks
 Subacute pain lasting 612 weeks
 Chronic pain lasting longer than 12
weeks (14).
Table 1 lists a number of red flags
(identified by qualified health care pro-
viders) as conditions often accompany-
ing specific LBP that can indicate
possible underlying spinal pathology,
nerve root problems, and a need to
consult the clients physician or health
care provider.

Copyright National Strength and Conditioning Association Strength and Conditioning Journal | www.nsca-scj.com 29
Special Populations

Table 1 EXERCISE BENEFITS FOR

CHRONIC NONSPECIFIC LOW
Red flags indicating possible spinal pathology or nerve root problems
BACK PAIN
Onset age , 20 or . 55 y Exercise has been shown to be effec-
tive in increasing PA tolerance, phys-
Nonmechanical pain (unrelated to time or activity)
ical fitness, strength, HRQOL, pain
Thoracic pain tolerance, and overall PA participa-
tion levels in persons with CNSLBP
Previous history of carcinomas, steroids, or HIV
(4,1113,15). Although home-based
Feeling "unwell" exercise programs have been found
to be beneficial, significantly greater
Unexplained weight loss
physical benefits and compliance rates
Widespread neurological symptoms (including saddle area numbness) have been observed in persons engag-
ing in supervised individualized exer-
Structural spinal deformity
cise programs (4,15). Both aerobic
Spontaneous or persistent pain at night or with lying supine training (AT) and resistance training
(RT) programs have produced
Indications for nerve root problems
increased PA tolerance, physical fit-
Unilateral leg pain . LBP ness, and HRQOL in persons with
Radiating pain to foot or toes CNSLBP (4,9,1113,15). Periodized
progressive RT programs have been
Numbness and paresthesias in same distribution well tolerated and proven effective
Straight leg raising test induces more leg pain for increasing strength and PA partic-
ipation levels and in reducing disabil-
Localized neurology (pain/symptoms limited to one nerve) ity levels in sedentary and athletic
HIV 5 human immunodeficiency virus; LBP 5 low back pain. populations with CNSLBP (1113).

Adapted with permission from Van den Hoogen et al. (22).
CNSLBP is generally diagnosed or
ruled in when red flags, magnetic res-
onance imaging, and x-ray results are
found to be negative for spine or nerve
pathology, respectively (14). CNSLBP
is generally defined as pain, muscle ten-
sion, or stiffness localized below the
costal margins (ribs) and above the
inferior gluteal folds with or without
leg pain (sciatica) (14). Persons with
CNSLBP are typically treated with
nonsteroidal anti-inflammatory drugs
and acetaminophen and are advised
to stay active and avoid bed rest (14).
Occasionally, muscle relaxants and
narcotic analgesics, which can cause
drowsiness, increased reaction time,
and impaired judgment, are prescribed
for severe pain.
CNSLBP can contribute to the
following:
 Recurring pain and increased
severity
 Lost work time
 Decreased health-related quality of
life (HRQOL)
 Decreased neuromuscular function
 Decreased physical fitness, strength,
and function
 Decreased PA levels
 Fear/avoidance of PA secondary
to pain anticipation (4,68,10,11
13,15,18,19,24).
EFFECTS ON EXERCISE
RESPONSE
Although many persons with
CNSLBP are less physically active
and physically fit than apparently
healthy aged-matched cohorts,
CNSLBP does not exert specific
effects on the exercise response (18).
Exercise response limitations are typ-
ically affected by the following:
 Individual pain severity and location
 Physical fitness and strength
 Body positions required during exer-
cise testing and training. Prolonged
standing, sitting, and frequent bend-
ing (trunk flexion) can exacerbate
CNSLBP symptoms and prevent cli-
ents from obtaining their best exer-
cise and/or testing efforts (18).
EXERCISE PROGRAM GOALS FOR
CHRONIC NONSPECIFIC LOW
BACK PAIN
Exercise program and PA goals for medi-
cally cleared persons with CNSLBP are
similar to those previously established
for apparently healthy populations with
appropriate adjustments (1,2,16,18,20).
Current PA guidelines encourage per-
sons with diseases/disabilities to main-
tain an active lifestyle, avoid being
sedentary as much as possible, and
strive to meet the same PA guidelines
set for apparently healthy individuals
(1,2,20).
Common exercise program goals for
clients with CNSLBP are to increase
the following:
 Health and well-being
 Exercise tolerance
 Physical function/functional capacity
 HRQOL (15,18).
Components of a comprehensive exer-
cise/fitness program include RT, AT,
flexibility training, and neuromotor
(1,2,16,18).
Because of the potential physical
deconditioning and pain/discomfort,
a slower rate of exercise program

30 VOLUME 35 | NUMBER 1 | FEBRUARY 2013

progression, volume, and intensity
Peter Ronai is an associate clinical
might be warranted in some individu-
professor in the exercise science depart-
als. Exercise program goals should be
ment at Sacred Heart University.
individualized, and exercise selections
should be determined by client toler-
Paul Sorace is a clinical exercise phys-
ance (4,9,15). Clients with CNSLBP
iologist for The Cardiac Prevention and
should monitor their ratings of per-
Rehabilitation Program and the program
ceived exertion with both the Borgs
coordinator for The Bariatric Rehabili-
scale (1) and the OMNI perceived
tation Program at Hackensack Univer-
exertion scale for resistance training
sity Medical Center in Hackensack, New
(OMNI-RES) (17) (Table 2) and report
Jersey.
any new or increasing symptoms of
LBP to the exercise professional
immediately.
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and no source of funding.
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Special Populations

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