Welcome back to Spine IQ’s Back Blog! Last week we discussed why you might want to consider adding group exercise for low back pain to your office protocol. This week we will discuss how to incorporate group exercise in your practice! Two of the main barriers for clinicians on this topic are knowledge about how to implement the exercise process and perception of skills needed to implement them. (1) In order to overcome those barriers, studies have found that a pre-packaged program that is implementation-ready can help clinicians feel skilled and knowledgeable to use exercise in their practice. (2) One such program available in the published literature is GLA:D Back. (3) Below we outline an example of what supervised group exercise for low back pain can look like in your clinic using the published GLA:D Back literature as a guide:
This program provides a template that has been successfully implemented in numerous countries as well as a model on how to tailor exercises to the individual (3). Understanding and discussing each patient’s goals in advance will ensure that the group exercises meet individualized patient needs.
Warm-up session:
The Group standard is the warm up. This should be explained so the group understands the relevance of each portion of the Group Session. This can consist of any low intensity exercise that brings awareness and movement to the whole body along with getting the body temperature up. SpineIQ’s BackFacks exercise are perfect for these like: cat/camels, pelvic tilts, lumbar rotations, supine knee to chest and moving the whole body. The warm-up session can be relatively standardized for everyone.
Exercise session:
No one exercise has been shown to be superior for low back pain, (7) which gives you an endless amount of exercises to include here depending on your patients or the groups goals. These are some examples of progressions that have been published in the literature. (3)
Exercises that target the back and core muscles such as, planks and bird dogs. These exercises can be progressed as such: It will be helpful for your patients if you have handouts of the exercises when you are explaining them.
- Planks:
- Knees on the ground supporting the body
- Feet on the ground supporting the body
- Moving the elbows/forearms farther forward
- Lifting one foot and only using one foot on the ground to support the body
- Lifting one foot and opposite arm
- Bird dogs:
- Only extending legs
- Extending opposite leg and arm
- Putting an item on the low back to balance while extending opposite leg and arm
Exercises that target the lateral and posterior glutes such as, clam shells and glute bridges. These exercises can be progressed as such:
- Clam shells:
- Performing clam shells with no exercise band
- Putting progressively stronger exercise bands above knees while performing clam shells
- Extending legs straight and putting progressively stronger exercise bands around ankles while performing leg abduction
- Standing up and putting bands around feet while side stepping laterally (monster walks)
- Glute bridges:
- Performing glute bridge with both feet on the ground
- Performing glute bridge with progressively stronger exercise bands above knees
- Performing glute bridges with one leg extended in the air
- Performing glute bridges with one leg extended in the air with progressively stronger exercise bands above knees
Exercises that target the leg muscles such as, squats and lunges. These exercises can be progressed as such:
- Squats:
- Performing squats to box/chair that progressively gets lower/removed
- Performing squats with a progressively heavier weight in hands close to the body (goblet squat)
- Performing squats with the weight being held with arms extended, farther away from persons chest
- Performing squats with one leg
- Lunges:
- Performing lunges stationary
- Performing lunges in reverse by stepping one foot back, instead of forward
- Performing lunges with the rear foot elevated on a surface/box/step/chair (rear foot elevated lunge
- Performing lunges to the side by stepping laterally
- Performing any variation of the aforementioned lunges with progressively heavier weight in your hands holding close to your chest
How long? How often?
The average length for interventions to treat low back pain is suggest to be 8 weeks. (4) This is an appropriate length of program to implement group exercise in your clinic. Both the World Health Organization and the American College of Sports Medicine recommend 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity a week in addition to 2x/week resistance training (5,6). Due to these recommendations, group exercise classes twice a week in your clinic is an appropriate amount in order to reach the weekly aforementioned physical activity amount.
Conclusion:
Group exercise is an evidence based, guideline recommended way to treat people with low back pain. (8) Clinicians routinely report knowledge and perception of skill as barriers to implementing physical activity interventions in their practice. It has been shown that having a template, ready to be implemented can help increase clinicians comfortability in providing exercise as an intervention. We’ve provided a template that is based on the existing literature. (3) It’s important to remember that this is just a template and any exercise can be done in a group exercise class to help people suffering from low back pain. The most important thing to consider when choosing exercises is the patient’s current capabilities, goals and preferences. Stay tuned for next week’s blog where we dive into how to incorporate group exercise for older adults to address low back pain, frailty, falls and functional capacity in your practice!
References:
- Huijg JM, Crone MR, Verheijden MW, van der Zouwe N, Middelkoop BJ, Gebhardt WA. Factors influencing the adoption, implementation, and continuation of physical activity interventions in primary health care: a Delphi study. BMC Fam Pract. 2013 Sep 26;14:142.
- Ris I, Boyle E, Myburgh C, Hartvigsen J, Thomassen L, Kongsted A. Factors influencing implementation of the GLA: D Back, an educational/exercise intervention for low back pain: a mixed-methods study. JBI Evid Implement. 2021 May 10;
- Kjaer P, Kongsted A, Ris I, Abbott A, Rasmussen CDN, Roos EM, et al. GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain – development, theories and scientific evidence -. BMC Musculoskelet Disord. 2018 Nov 29;19(1):418.
- Du S, Hu L, Dong J, Xu G, Chen X, Jin S, et al. Self-management program for chronic low back pain: A systematic review and meta-analysis. Patient Educ Couns. 2017 Jan;100(1):37–49.
- Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020 Dec;54(24):1451–62.
- Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee I-M, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334–59.
- Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018 Jun 9;391(10137):2368–83.
- O’Keeffe M, Hayes A, McCreesh K, Purtill H, O’Sullivan K. Are group-based and individual physiotherapy exercise programmes equally effective for musculoskeletal conditions? A systematic review and meta-analysis. Br J Sports Med. 2017 Jan;51(2):126–32.