Chronic low back pain is a leading cause of disability worldwide. With the current opioid crisis, chiropractic is in an excellent position to be the provider of choice by offering a multimodal approach that centers around the chiropractic adjustment, with exercise, soft-tissue work, lifestyle modification and nutrition rounding out our management toolbox.
Special Considerations for Chronic LBP Patients
Chronic low back pain is simply low back pain that has persisted for more than three months. The CLBP patient presents with special concerns that need to be considered.
Each CLBP patient needs individualized activity recommendations. For example, stenosis patients prefer flexion activities, whereas discogenic conditions may prefer a neutral-spine or extension exercise protocol.
Fear avoidance behavior creates deconditioning. The CLBP patient needs to realize pain does not equal harm. Be sure the patient knows the activities they need to avoid and reinforce that increasing endurance, strength and flexibility are the keys to pain management (activities that may be painful, yet beneficial).
CLBP needs to be managed. The patient needs to understand their condition will need ongoing management: reassessment of exercises, nutrition, periodic adjustments; and a commitment on their part to participate in the process.
The patient is not their pain. Patients often use their diagnosis to define their life and limitations, leading to further deconditioning and disability.
Exercise for Chronic LBP: The Power of Walking
As mentioned above, exercises for CLBP need to address flexibility, strength and endurance. The good news is the initial exercises for CLBP are the same as for any deconditioned patient. Start with cardiovascular activities to increase circulation, build endurance, stimulate metabolism, reduce pro-inflammatory biomarkers and improve cardiovascular risk factors. Research currently points to brisk walking as an effective approach to management of CLBP.
Clinical Tip: Lumbar stenosis patients respond better to stationary bicycle than walking to build cardiovascular and overall endurance.
Walking is beneficial for CLBP; however, walking needs to be approached like all exercises, meaning proper technique is essential for optimal results. As chiropractic doctors, we understand the importance of alignment and freely movable joints to enhance homeostasis, so capitalize on chiropractic rehab as part of your walking program for your patients.
Before you get your patients walking, introduce them to proper posture, especially in the sagittal plane, so they will reinforce strong posture and alignment as they walk. Posture while exercising will determine posture at rest. Initially, teach your patients to auto-correct their posture, and then translate that to walking tall and strong. Simply remember the lateral plumb line from the auditory meatus to the talus with balanced spinal curves, chest up and shoulders down.
Clinical Tip: If your patients hold on while walking on the treadmill, they are simply training themselves to use a walker.
After you introduce sagittal-plane alignment, check the feet and review the importance of maintaining a stable pedal foundation. If the feet are flexible and have poor arch support, prescribe strengthening exercises for the feet, such as Janda's short foot. You may also need to teach the patient to walk with the feet straight ahead in a normal heel-toe gait.
Orthotics are indicated if the navicular drop exceeds 10 mm or if there is excessive navicular drift. Regardless, the patient needs to be able to walk in a balanced and stable posture from the feet up.
Arm swing while walking is essential. The instructions are to keep an even arm swing from the shoulders with relaxed hands. Each hand needs to swing forward – not across the body – and to the same height, which maintains equal stride lengths.
Clinical Tip: Have the patient perform an abdominal brace while walking to assist in core stability.
When walking, a slight forward lean from the feet of 5-10 degrees is optimal. The sagittal plane line of the body can still be maintained. This is a slight anterior drift from the gravitational plumb line that allows gravity to assist in moving forward.
The research points to a 30-minute walking session for 5-6 days a week with a warm-up and cooldown period for best results in a walking program for CLBP. The warm-up can include using a massage stick or foam roller (if the patient can get on the floor), or a slow walk can even suffice. Cooldown is an excellent time to perform flexibility and stretching exercises.
Walking technique can be trained in the office if you have an appropriate hallway so the patient can look ahead, not down, as they practice the slight forward lean with sagittal-plane alignment, proper heel-toe gait, even arm swing and feet pointing straight ahead. The next progression is to add bracing or abdominal breathing for core stability. Placing a 3-inch-wide strip of painter's tape on the floor is a great visual for patients to keep their feet straight and head up.
Clinical Tip: Walking in an empty parking lot beside the center line is excellent. The painted lines are 3-4-inches wide, which is the optimal stride width, and the patient can easily look ahead at the center line to avoid looking down.
Finally, brisk walking has the added benefit of longevity. A study from Australia found that elderly men who were able to walk for three miles an hour for six miles lived longer.
Clinical Takeaway
Walking is an excellent activity for the CLBP sufferer and is the cornerstone of a multimodal approach to CLBP management. The clinician needs to realize the chiropractic approach to exercise with strong posture, optimal alignment, efficient biomechanics, core stability and symmetrical movement is the additional benefit chiropractic brings to the table in physical rehabilitation and corrective exercise.
Resources
- Paolucci T, Attanasi C, Cecchini W, et al. Chronic low back pain and postural rehabilitation exercise: a literature review. J Pain Research, 2019:12:95-107.
- Liebenson C. Rehabilitation of the Spine, 2nd Edition. Philadelphia: Williams & Wilkins, 2016.
- Stanaway FF, et al. How fast does the Grim Reaper walk? Receiver operating characteristics curve analysis in healthy men aged 70 and over, BMJ, 011;343:d7679.
- Suh K et al. The effect of lumbar stabilization exercises and walking on chronic low back pain. A randomized clinical trial. Medicine, 2019;98:26.
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