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Exercise Recommendations for Cardiac Patients with Chronic Nonspecific Low Back Ainp

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Exercise Recommendations for Cardiac Patients with Chronic Nonspecific Low Back Ainp Sacred Heart University DigitalCommons@SHU Exercise Science Faculty Publications Physical Therapy & Human Movement Science 12-2019 Exercise Recommendations for Cardiac Patients with Chronic Nonspecific Low Back ainP Peter Ronai Sacred Heart University, [email protected] Follow this and additional works at: https://digitalcommons.sacredheart.edu/pthms_exscifac Part of the Exercise Science Commons Recommended Citation Ronai, P. (2019) Exercise recommendations for cardiac patients with chronic nonspecific low back pain (2019). Journal of Clinical Exercise Physiology, 8(4), 144-156. doi: 10.31189/2165-6193-8.4.144 This Peer-Reviewed Article is brought to you for free and open access by the Physical Therapy & Human Movement Science at DigitalCommons@SHU. It has been accepted for inclusion in Exercise Science Faculty Publications by an authorized administrator of DigitalCommons@SHU. For more information, please contact [email protected], [email protected]. REVIEW Exercise Recommendations for Cardiac Patients with Chronic Nonspecific Low Back Pain Peter Ronai, MS, RCEP, CEP, EP-C, EIM III, FACSM1 ABSTRACT Musculoskeletal comorbidities (MSKCs) are the most frequent cause of activity limitations in persons with cardiovascular disease (CVD) and affect as many as 70% of this population. It has been observed that over 50% of new outpatient cardiac rehabilitation participants experience some musculoskeletal pain, with back pain reported by up to 38% of cardiac rehabilita- tion patients. Back pain can limit performance of activities of daily living (ADLs) and reduce exercise tolerance and compli- ance during outpatient cardiac rehabilitation (CR). This article will describe ways to facilitate CR exercise participation in patients who have comorbid, chronic nonspecific low back pain (CNSLBP) and have been medically cleared to exercise. Journal of Clinical Exercise Physiology. 2019;8(4):144–156. Keywords: nonspecific low back pain, exercise, cardiac rehabilitation INTRODUCTION cardiac rehabilitation (CR) programs (7,15–17). Patients who Aerobic endurance training (AT), musculoskeletal strength reported MSKCs at entry to outpatient CR had a poorer (resistance) training (RT), and flexibility training (FT) are health profile than those without MSKCs, including lower recommended as complementary forms of training for levels of physical activity (PA) and cardiovascular fitness, patients participating in outpatient cardiac rehabilitation and unfavorable anthropometric measures (16). Back pain (CR) exercise programs (1). These recommendations are has been reported in as many as 38% of CR patients. Low consistent with and resemble those from the American Col- back pain can limit performance of activities of daily living lege of Sports Medicine (ACSM) and the United States (ADLs) and reduce exercise tolerance and compliance during Department of Health and Human Services (USDHHS) for outpatient CR. Low back pain is associated with cardiovascu- persons with and without chronic diseases and health disor- lar illness, other musculoskeletal conditions, and poorer ders (2–6). general health (7,8,15–18). Therefore, an individualized It is estimated that over half of patients hospitalized for approach is warranted to prescribing and modifying exercises coronary artery disease (CAD) suffer from comorbid muscu- to limit pain and reduce the risk of injury (5,19–25). loskeletal conditions (MSKCs) (7). While CAD is the leading This article will describe ways to facilitate safe, effec- cause of death globally, MSKCs result in the most global tive CR exercise participation in patients who have comor- disability (8–14) and are the most frequent cause of activity bid, chronic, nonspecific LBP (CNSLBP) and who have limitations in persons with cardiovascular disease (CVD), been medically cleared for exercise. Examples of appropri- affecting as much as 70% of this population (15). Knee and ate modifications to and substitutions for some exercises low back pain (LBP), most frequently attributed to arthritis commonly performed during outpatient CR workout ses- and strains and sprains, are the two most reported MSKCs in sions will be provided. 1Center for Healthcare Education, Sacred Heart University, Fairfield, CT 06825 USA Address for correspondence: Peter Ronai, Sacred Heart University, Center for Healthcare Education, Dept. of Exercise Science, 5151 Park Avenue, Fairfield, CT 06825-1000; (203) 416-3935; e-mail: [email protected]. Conflicts of Interest and Source of Funding: None. Copyright © 2019 Clinical Exercise Physiology Association 144 EXERCISE AND LOW BACK PAIN 145 Please note that this article is not intended to help readers diagnose, evaluate, or treat low back pain or any musculo- BOX 1: CLASSIFICATIONS OF skeletal injury or disorder. Exercise professionals are encour- LOW BACK PAIN ETIOLOGY aged to terminate exercise sessions and notify the patient's Etiology physician if new or worsening symptoms occur. For the pur- RE • Specific: pain caused by unique or unusual patho- pose of this article, it is assumed that patients have already V physiologic mechanisms (disc herniation, infection, IE been medically cleared to participate in a supervised CR tumor, ankylosing spondylitis, fracture, osteoporosis, W exercise program with their pre-existing, comorbid CNSLBP. arthritis, diseases, trauma, inflammatory process, Scope radicular symptoms or cauda equine syndrome, or spinal pathology) Musculoskeletal diseases affect more than one out of every • Nonspecific: pain not caused by a specific disease or two persons in the United States over the age of 18, and spine pathology nearly three out of four persons aged 65 and over. LBP is one of the most common reasons for physician visits (26–30). Timeline or Duration of Symptoms In any given year, between 12% and 14% of the US • Acute: pain lasting less than 6 weeks adult population will visit their primary care physician with • Sub-acute: pain lasting 6 to 12 weeks a complaint of back pain (31). LBP is the leading cause of • Chronic: pain lasting longer than 12 weeks (11,12, disability and years living with disability throughout the 27,30,32,36,56). world. More than 540 million people have been affected by activity-limiting LBP (9–14,32). The burden from LBP has doubled in the last 25 years, and the prevalence of the condi- (9,10,12,14,32,35,56). As people age, LBP is accompanied tion is expected to continue to increase with an aging and by numerous activity limitations (10). Low back pain is increasingly obese population (9). In the United States, LBP often attributed to either nociceptive (sensitization of pain accounts for more lost workdays than any other musculo- receptors in spinal/mechanical structures and fascial tissues), skeletal condition (31). Data from a recent investigation in neuropathic (radicular or nerve related pain), or central (sen- Australia indicate that there is a moderate to high level of sitization within the brain) sources (56). Traditionally, LBP comorbidity amongst LBP patients; diabetes, arthritis, is categorized by its etiology (causes), location, and duration hyperlipidemia, osteoporosis, and coronary artery disease of symptoms. Classifications are noted in Box 1. are within the top 10 most frequently reported comorbidities In 80% to 90% of cases, a specific pathoanatomical (18). LBP is the leading chronic health problem forcing cause of LBP cannot be determined; therefore, the majority older Australian workers to retire prematurely (33). While of LBP is considered to be nonspecific low back pain LBP is the most common cause in Europe of medically certi- (NSLBP) (9,10,12,27–29,32,35,36). This article primarily fied sick leave and early retirement, occurrence rates vary addresses this population. Chronic low back pain is described substantially among European countries (34). LBP affects as discomfort and pain, localized below the costal margin between 49% and 70% of persons living in westernized and above the inferior gluteal folds, with or without leg pain, countries and 70% and 85% of persons living in the United that has been present for 3 months or longer States in their lifetimes; it is the fifth most common reason (11,12,27,30,36,56,57). Chronic nonspecific low back pain for physician visits (28,29). Specific causes of LBP are often (CNSLBP) is further defined as chronic low back pain not unknown and, in approximately 80% to 90% of afflicted attributed to recognizable, known, specific pathology (e.g., patients, a specific pain source and cause cannot be identi- infection, tumor, osteoporosis, ankylosing spondylitis, frac- fied (9,10,12,27–29,32,36). A number of investigators con- ture, inflammatory process, radicular syndrome, or cauda clude that persons with CNSLBP experience PA intolerance, equina syndrome) (9,10,12,27–29,32,35,36). During medi- lower levels of physical fitness and function (37–42), cal examinations of patients with LBP, physicians or quali- increased disability (42,43), PA avoidance (due to fear of fied healthcare providers (HCP) conduct screening proce- increased pain with activity) (9,12,32,44–47), lower PA par- dures to “rule in” or “rule out” more severe pathology. ticipation levels (48,49), and reduced health-related quality “Red Flags” are symptoms or conditions experienced of life (43). An association exists between CNSLBP and by patients with LBP that may warrant further medical obesity (9,50–53), smoking (9,54), and sedentary lifestyle evaluation (9,11,12,27,32,35,58–62). Their presence or (9). A recent cross-sectional analysis
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