Deadlift training for patients with mechanical low back pain A comparison of the effects of a high-load lifting exercise and individualized low-load motor control exercises Lars Berglund

Marklyftsträning för patienter med mekanisk ländryggssmärta En jämförelse av effekterna av en högbelastande lyftövning och individanpassade lågbelastande övningar för rörelsekontroll Lars Berglund

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Uppväxt i Sollefteå Styrkelyft! Leg sjukgymnast 2009 Master sjukgymnastik 2011, 2016 Doktorsexamen 2016 – Ulrika Aasa, Peter Michaelson, Lillemor Lundin Olsson, Ulrika Bergström

Low back pain • • • • •

Marklyftsträning vid ländryggsbesvär! Vår kollega och Med Dr Lars Berglund berättar om sin forskning kring denna träning. Hur undersöks patienterna? I mån av utrymme praktisk genomgång av övningar och tester och ”tänket” bakom dem. Hur som helst får vi veta allt som Lars tycker är viktigt!

Low back pain • Common and costly – North of Sweden 44 % [Bjorck-van Dijken 2008] – 1860 million EURO [Ekman 2005] • Origin unknown – unrelated to specific pathology [Burton 2006] • Posture and movement patterns important? [Sahrmann 2002, O’Sullivan 2005]

– Sub-groups of patients where the pain is aggravated or eased by certain posture and/or movements [Smart 2012]

Low back pain • Classification of low back pain – Duration • Patients with persistent (>3 months) low back pain • Compared to healthy individuals: – Sit differently [Dankaerts 2006] – Move differently [Dankaerts 2006, Luomajoki 2008] – Decreased strength and endurance [Alaranta 1995, McNeill 1980]

– Decreased size and symmetry of back muscles [Hides 2008, Beneck 2012]

Treatment for persistent low back pain • Exercise and education – recommended! [Pillastrini 2012] • One theory as basis for the design of exercise interventions: • Correction of impairments to the function of the low back: – Address pain provocative movement patterns [Luomajoki 2010]

– Improve strength/endurance of back extensors [Steele 2013] – Increase the size of the muscles of the lumbar spine [Hides 2008]

Low-load motor control exercises • Commonly used and evaluated in studies [Ferreira 2007, Hides 2008, Costa 2009, Macedo 2012]

• Recruitment of key muscles, re-training of movement control • Exercises with low-load - high-load not recommended [Richardson 2004]

High-load lifting – Deadlift exercise • Commonly used resistance training exercise [Ebben 2004] – Strength, hypertrophy • Demands proper technique/movement control – involving recruitment of stabilizing muscles of the spine [Hamlyn 2007, Nuzzo 2008]

Rationale • Studies evaluating specific exercise interventions for specific sub-groups of low back pain [Pillastrini 2012, van Middelkoop 2010] • Effects of low-load motor control exercises, also when using a high-load lifting exercise, the deadlift? • Effects of deadlift training not previously evaluated in an RCT – Evaluate which patients benefit from deadlift training

Aim • The overall aim of this thesis was to evaluate and compare the effects of a high-load lifting exercise and individualized low-load motor control exercises for patients with nociceptive mechanical low back pain

Method • Randomized controlled trial • 70 participants (30 men, 40 women) • Persistent low back pain • Dominating pattern of nociceptive mechanical low back pain [Petty 2011, Smart 2012]

• Verification examination – Diagnostic triage – Movement assessment – provocative, easing factors

Method

Method • Dominating pattern of nociceptive mechanical low back pain [Petty 2011]

Method • Dominating pattern of nociceptive mechanical low back pain [Smart 2012]

Method • Verification examination – Diagnostic triage – Movement assessment – provocative, easing factors

Method • High-load lifting exercise, the deadlift (n=35) • Individualized low-load motor control exercises (n=35) • Education about mechanical pain and movement patterns • Intervention period 8 weeks – 2 sessions per week, first 4 weeks – 1 session per week, last 4 weeks • Follow-up measures immediately after intervention period and 12 months after

Method

High-load lifting – Deadlift exercise

Individualized low-load motor control exercises

Method • Pain (VAS) • Activity (PSFS) • Disability (RMDQ)

Method • Physical performance tests

Method • Physical performance tests

Method • Lumbar multifidus thickness

• Lumbo-pelvic alignment

Results 1. Aasa B, Berglund L, Michaelson P, Aasa U. Individualized low-load motor control exercises and education versus a high-load lifting exercise and education to improve activity, pain intensity, and physical performance in patients with low back pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2015 Feb;45(2):77-85, B1-4. doi: 10.2519/jospt.2015.5021. 2. Berglund L, Aasa B, Michaelson P, Aasa U. Sagittal lumbo-pelvic alignment in patients with low back pain and the effects of a high-load lifting exercise and individualized low-load motor control exercises – a randomized controlled trial. (Submitted) 3. Berglund L, Aasa B, Michaelson P, Aasa U. The effects of low-load motor control exercises and a high-load lifting exercise on lumbar multifidus thickness – a randomized controlled trial. (Accepted, Spine Nov 2016) 4. Berglund L, Aasa B, Hellqvist J, Michaelson P, Aasa U. Which Patients With Low Back Pain Benefit From Deadlift Training? J Strength Cond Res. 2015 Jul;29(7):1803-11. doi: 10.1519/JSC. 0000000000000837.

Results – Paper 1 • Individualized low-load motor control exercises and education versus a high-load lifting exercise and education to improve activity, pain intensity, and physical performance in patients with low back pain: a randomized controlled trial.

Results – Paper 2 • Sagittal lumbo-pelvic alignment in patients with low back pain and the effects of a high-load lifting exercise and individualized low-load motor control exercises – a randomized controlled trial Low Lumbar Lordosis

High Sacral Angle

Results – Paper 3 • The effects of low-load motor control exercises and a highload lifting exercise on lumbar multifidus thickness – a randomized controlled trial Lumbar multifidus thickness (cm) 3,5 3,0

Thickness (cm)

2,5 2,0 Baseline 1,5

Follow-up

1,0 0,5 0,0 Small side n=65/61

Large side n=65/61

Results – Paper 4 • Which Patients With Low Back Pain Benefit From Deadlift Training? • Low disability, low pain intensity and high performance on the Biering-Sørensen test

Conclusions • Individualized low-load motor control exercises superior • Similar effects over time for pain intensity, lift strength • Effects on lumbo-pelvic alignment • Effects on lumbar multifidus muscle thickness

Implications • Deadlift training could be considered for patients with mechanical low back pain • Importance of specificity of training to improving function in specific activities • Clinicians do not have to be ”afraid” of using complex resistance training exercises in rehabilitation • High intensity exercises have great potential for stimulating multiple organ systems. Further benefits of HLL in the long run?

Questions?