© National Strength & Conditioning Association
SPECIAL POPULATIONS
Strength Training
and Low Back Pain
Thomas E. Dreisinger, PhD
Progressive Spine Care & Rehabilitation
Columbia, Missouri
BACK PAIN IS AN INSIDIOUS AND
common occurrence in American
society. Seven out of 10 adults in
this country will suffer low back
and/or neck pain during their
lives (8). At any given time,
15–20% of Americans may be
suffering from some amount of
low back pain (LBP; 8). Symp-
toms may manifest themselves
as pain, numbness, or tingling
in the leg, buttock, or central
back. LBP can range from a
minor irritation to being com-
pletely debilitating. Besides the
human suffering, costs for LBP
are also quite high, estimated to
be in the neighborhood of 56 bil-
lion dollars per year (2). Al-
though it is not as serious a con-
dition as vascular diseases or
cancer, it is the most common
cause of disability in the United
States for people under the age
of 45, and second to the com-
mon cold as the most frequent
reason for visiting the doctor (3).
Unlike other orthopedic in-
juries (e.g., rotator cuff tear or
anterior cruciate ligament in-
jury), health care practitioners
are often unable to determine
the exact cause of back pain
56
Volume 25, Number 6, page 56–59
symptoms. Indeed, one might
present the same symptoms to a
family practice physician, physi-
atrist, orthopedist, physical
therapist, and chiropractor and
be given a dif ferent diagnosis
from each of them. This adds to
the overall confusion about the
best way to treat this common
malady. The good news, howev-
er, is that successfully treating
LBP does not necessarily require
knowing exactly what the specif-
ic “pain generator” is.
With few specific exceptions,
the majority of LBP can be clas-
sified as “mechanical” (5). Me-
chanical LBP refers to symptoms
that are intermittent in nature
and wax and wane in intensity.
This means that there may be
times of the day or positions
(e.g., sitting, lying, standing,
walking, etc.) when the symp-
toms are better or worse. The
clinical implication of this is that
the precise source of the symp-
toms is less important than the
ability to treat them.
For this reason, a good me-
chanical assessment of the low
back is essential as part of the
history and physical examina-
Strength and Conditioning Journal
Tom LaFontaine
Column Editor
tion. McKenzie (5), a physical
therapist from New Zealand, de-
veloped a unique method of me-
chanical diagnosis and therapy.
It is considered the most valid
and reproducible assessment in
determining how significant the
mechanical component of back
pain is. The hallmark of this
method is the ability, on physical
examination, to cause the symp-
toms to “move” either distally
(farther away) or proximally (clos-
er to) the center of the low back
(5). If the symptoms can be
moved one way or the other, the
potential for a positive clinical
outcome for the patient is greatly
enhanced. The movement of
symptoms in a patient is termed
“directional preference” (symp-
toms migrating distal are termed
“peripherilization,” whereas prox-
imal migrating symptoms are
considered “centralization”). The
outcome of the mechanical as-
sessment guides the subsequent
active rehabilitation.
Active programs have been
recognized as important interven-
tions and treatment for people
with back pain. The Agency of
Health Care Policy and Research
December 2003
(AHCPR), when reviewing back
pain problems in this country,
stated that physical activity is a
key element in treatment (1). Al-
though the AHCPR did not provide
specific exercise guidelines, it
strongly encouraged active exer-
cise programs. This has led to a
de-emphasis of the use of passive
modalities and an increased em-
phasis on and growing promi-
nence toward aggressive and early
activation of patients with injuries
to the lumbar spine. This kind of
rehabilitation uses quantitative
equipment such as treadmills,
stationary bicycles, weight train-
ing machines, and back assess-
ment devices as part of the clinical
armamentarium. This permits ob-
jective measurement to monitor
the progress a patient makes dur-
ing clinical treatment.
Part of the increased interest
and awareness in the impor-
tance of exercise has also come
about because of the drive to-
ward accountability in medical
practice. The language support-
ing evidence-based/outcomes-
driven medicine, which is ap-
pearing more and more in the
literature, reflects this. Giving
patients medication and sending
them down for “a little PT” is be-
coming less acceptable in the
management of LBP. Rehabilita-
tion specialists are being asked
for defensible rationales for pre-
scribed treatment plans.
The introduction of the field of
exercise science has helped move
the objective management of LBP
patients forward. Clinical exercise
physiologists (CEP), working with
physicians and physical thera-
pists, have brought a more quan-
titative thought process to this
arena. The CEP’s ability to mea-
sure human performance has
aided in the process of moving
conservative spinal care forward
in a more objective manner.
December 2003
Strength training of patients
with back pain is very important
for a successful rehabilitation
plan. It is interesting to note, how-
ever, that there is a hesitance
among many rehabilitation spe-
cialists to strengthen the lumbar
spine during rehabilitation. No
one would argue the need to
strengthen the quadriceps follow-
ing an anterior cruciate ligament
injury. Passive and active motion
is critical to prevent adhesions
from developing and to keep the
vastus medialis from withering
away. It would almost be consid-
ered malpractice in the knee not to
do active rehabilitation even in the
face of patient pain. What makes
the lumbar spine any different?
Nothing!
Why is strength training im-
portant in the spine? Repair of in-
jury to soft tissue is really an
issue of cellular nutrition. The
better the supply of nutrients to
the area of injury, the better op-
portunity for that tissue to be-
come healthy. Because blood flow
is in parallel and not in series, re-
gional blood flow is a function of
the “need” expressed by the exer-
cising muscle. Strengthening the
extensors of the low back encour-
ages blood flow to the area or in-
jury, and consequently enhances
the opportunity for healing to
take place. Blood flow may be oc-
cluded during the actual exer-
cise, but immediately following
the activity fresh blood and nutri-
ents flood the exercised muscle.
From a clinical standpoint,
aggressive strength training of
the lumbar spine has been shown
to overcome structural weak-
nesses in patients with LBP (7). It
has been shown to “lay down
bone” in the lumbar spine follow-
ing a training regimen (4). It has
also been used as a successful
strategy in the reduction of pain
and increased physical function
Strength and Conditioning Journal
(4). Finally, strengthening of the
lumbar spine has been shown to
reduce the need for surgery, de-
crease reuse of the health care
system, and consequently great-
ly reduce health care costs for
back care (6).
Another value of strength
training in the clinical setting is
that it provides immediate feed-
back to the patient. Often pa-
tients are given lifting restric-
tions (e.g., 15–20 lb), which are
very subjective. This may be a
disservice to patients because it
creates an artificial limitation to
their activities of daily living. It
also engenders fear, in that near-
ly everything they consider lifting
will be perceived as potentially
dangerous. Once patients per-
ceive this imposed limitation as a
danger, they will find themselves
in a downward cycle of decondi-
tioning and further loss of con-
trol in their lives. Strength train-
ing is a marvelous tonic for this
debilitating mental thought
process. Allowing patients to see,
feel, and per for m safe move-
ments with specific weights pro-
vides them with important kines-
thetic feedback. This feedback
tells patients objectively what
they can actually lift safely.
Other benefits that occur from
strength training are the reduced
risk of injury and increased sense
of well-being that comes from this
activity. In unpublished data from
2 major airlines, low back injury
costs were reduced by over 70%
following a systematic strength
training program focusing on the
lumbar extensor muscles. With
these principles in mind, let us
take a look at a specific outcomes-
based conservative care (i.e., non-
operative) spine center, Progressive
Spine Care and Rehabilitation. The
program focuses on testing and
training the muscles of the low
back and peripheral joints, which
57
are important for good postural
support.
■ Progressive Spine Care
and Rehabilitation: A Model
This program is evidence-based
and outcomes-driven. This means
that assessment and treatment
protocols are based on published
scientific literature that guides the
clinical course of our patients. A
touch-screen computer system
acquires patient demographics,
health and work history, as well as
outcomes information in the form
of the SF-36 (quality of life), Os-
westry (disability score), and the
Spinal Function Sort (physical
function). These well-validated
and reliable outcomes question-
naires help determine the success
of the rehabilitation program for
the patient, insurance companies,
and referring doctors. Real-time
data acquisition permits ongoing
and im mediate access to summa-
ry data of the clinical population.
A key part of the approach is
strengthening of the extensor mus-
cles of the lumbar spine. Assess-
ment of strength and range of
motion (ROM) begins the rehabili-
tation process. Strength is mea-
sured isometrically in several posi-
tions throughout the measured
ROM. Once maximal strength is
known, it is a simple matter to pro-
vide a safe dynamic strength pre-
scription within an appropriate
ROM. Objectively testing strength
and range of motion is critical be-
cause it provides a “snapshot” of
where the patient is. The exercise
prescription is tied to the principle
of progressive overload that per-
mits a safe incremental increase in
work over the rehabilitation course.
Mechanical LBP is thought
to have its origins in poor pos-
ture (5). Consequently, we be-
lieve it is important to strength-
en peripheral muscles that
support the low back. Whole
58
body strengthening, therefore, is
an integral part of the rehabilita-
tion. Specific muscle groups
such as quadriceps, hamstrings,
rhomboids, and latissimus dorsi,
among others, are trained. These
ancillary muscle groups act to
support good posture, and
therefore the low back.
All objective data are entered
either daily by the therapist or
electronically directly from the
strengthening machine. This per-
mits clinical notes to reflect, on a
daily basis, changes that occur
from baseline measures.
In addition to progressive
functional strength changes in pa-
tients, the outcomes measures are
very important to the clinic’s suc-
cess. For example, when looking
at quality of life measures, our
clinic population has shown a
28% and 65% increase in physical
and general health, respectively,
following early phase rehabilita-
tion and at 6 months follow-up.
Perceived disability decreased by
25% at discharge from early phase
rehabilitation and 50% by 6
months. Finally, perceived physi-
cal function increased by 38% by
the end of early phase rehabilita-
tion and maintained a 23% gain at
6 months follow-up. These data
demonstrate the empowerment
that comes when patients learn
what they can and cannot safely
do in their lives. This is the ulti-
mate purpose of a rehabilitation
program—enhancement of the pa-
tient’s quality of life.
Strength training should be
an integral part of the clinical re-
habilitation of patients with LBP.
Its value can be observed on
many levels. First, it increases
the structural integrity of the pa-
tient’s musculoskeletal system—
the low back being paramount
here. It provides immediate feed-
back to patients as to the
amount of weight they can actu-
Strength and Conditioning Journal
ally lift. It increases their sense
of well-being by demonstrating
gains in strength that are made
as a result of the rehabilitation
program. It introduces patients
to a form of exercise that can en-
hance the quality of their lives in
the short term through success-
ful treatment of their LBP. Final-
ly, strength training acts as an
encouragement to make perma-
nent lifestyle changes that will
increase the quality of their
lives. ▲
■ References
1. Bigos, S.J., R. Bower, G.
Braen, et al. Acute low back
pain problems in adults. Clini-
cal Practice Guideline, Quick
Reference Guide No. 14.
Rockville, MD: U.S. Depart-
ment of Health and Human
Services, Public Health Ser-
vice, Agency for Health Care
Policy and Research, 1994
(AHCPR Publication No. 95-
0643).
2. Cleary, L., et al. Occupational
low back disability: Effective
strategies for reducing lost work
time. AAOHN J. 43:87–94.
1995.
3. Cunningham, L., and J.
Kelsey. Epidemiology of mus-
culoskeletal impairments and
associated disability. Am. J.
Pub. Health. 74:574–579.
1984.
4. Graves, J.E., J. Mayer, T.E.
Dreisinger, and V. Mooney. Re-
sistance training for low back
pain and dysfunction. In: Re-
sistance T raining for Health
and Rehabilitation. J.E. Graves
and B.A. Franklin, eds. Cham-
paign, IL: Human Kinetics,
2001. pp. 357-383.
5. McKenzie, R., and S. May. The
Lumbar Spine Mechanical Di-
agnosis & Therapy (Vol. 1 and
2, 2nd ed.). Waikanae: Spinal
Publications, 2003.
December 2003
6. Nelson, B.W., D.M. Carpenter,
T.E. Dreisinger, M. Mitchell,
C.E. Kelly, and J.A. Wegner.
Can spinal surgery be pre-
vented by aggressive strength-
ening exercises? A prospective
study of cervical and lumbar
patients. Arch. Phys. Med. Re-
habil. 80(1):20–25. 1999.
7. Pollock, M.L., J. Graves, D. Car-
penter, D. Foster, S. Leggett,
and M. Fulton. Muscle. In: Re-
habilitation of the Spine: Science
and Practice. S. Hochschuler, H.
Cotler, and R. Guyer, eds. St.
Louis: Mosby, 1993. pp.
263–284.
8. Waddell, G. The Back Pain Rev-
olution. New York: Churchill
Livingston, 1998.

Thomas E. Dreisinger is with

Progressive Spine Care and
Rehabilitation in Columbia,
Missouri.

December 2003 Strength and Conditioning Journal 59