Powerlifting is safe and effective for people with chronic low back pain


Chronic back problems are common among Australians, affecting 16% of the total population. It’s also the most common cause of disability in Australia, affecting 28% of the total population, costing the economy $4.8 billion every year.

It can affect a person’s quality of life and in addition to pain, patients typically suffer from physical and psychological distress. By definition, chronic low back pain is pain that has lasted longer than three months.

Contemporary management of chronic back pain typically involves pain education and combined exercise such as traditional bodyweight and “core” exercises. However, a new study published in Clinical Rehabilitation by UNSW Sydney researchers suggests powerlifting style training is a safe, effective alternative to these bodyweight movements.

“The key findings of this paper were that powerlifting is safe and effective for people with chronic low back pain when combined with education around how pain works. This was compared to more traditional bodyweight and ‘core’ exercises, and we found no difference between groups,” explained Dr. Mitchell Gibbs from the School of Health Sciences at UNSW Medicine & Health.

Gaps in current literature

The paper highlighted a gap in the literature in terms of whether any exercise mode was better accompanied with pain education. The purpose of the study was to compare general callisthenic exercise with a powerlifting style program, both paired with consistent pain education, for chronic low back pain.

“Within the context of the body of literature, this study furthers that exercise and pain education can help people with chronic low back pain. The novelty of this study is that it is one of the first to explore different exercise types when paired with the same education. What this tells us is that exercise of all forms can be beneficial, meaning we can prescribe the best program for the person rather than the condition,” said Dr. Gibbs.

Dr. Gibbs said the main implication of the finding was that exercise for chronic low back pain did not need to subscribe to traditional systemized approaches and heavy lifting is both safe and just as effective.

“This is important as it means we are able to dose exercise appropriately for people with chronic low back pain to achieve positive health-related outcomes, rather than focus our prescription only on the individuals low back pain.”

During the study, the powerlifting group performed a one-repetition maximum (1RM) for the squat, bench press, and deadlift, which means they lifted the most amount of weight they could for one-repetition. “This shows us that loading shouldn’t be avoided for people with chronic low back pain,” explained Dr. Gibbs.

More tools for practitioners to treat back pain

The researchers said they were optimistic about how the findings may be able to assist exercise-based practitioners to treat people with chronic low back pain.

“It has been reported that 50–70% of people with chronic low back pain do not adhere to an exercise program, which may be owing to the rigid and systemized nature of exercise prescribed. This introduces the ability to prescribe meaningful exercise, allowing practitioners to focus on these key elements of exercise, such as enjoyment and adherence by giving the individual agency in the consultation process.”

Dr. Gibbs said these findings provide practitioners with more tools in the metaphorical toolbox to be able to reach and help many Australians with chronic low back pain. Further, the ability to appropriately dose exercise for people with chronic low back pain to achieve health-related outcomes allows practitioners to prioritize and inform individuals of the broader benefits of engaging in physical activity.

The authors of the study acknowledge a key limitation of this study is the advertisement as an exercise-based trial, which was previously suggested as a potential bias to only recruit patients with positive beliefs about physical activity. This recruitment method may explain the low initial clinical and behavioral score as compared to previous literature.

Dr. Gibbs said further research is needed to understand if involving individuals in the prescription process to find the type of exercise to best benefit the person – regarding overall health and adherence – provides better outcomes for people with chronic low back pain.

The barbell deadlift exercise is a free weight exercise in which a barbell is lifted from the floor in a continuous motion by extending the knees and hips. When performing the deadlift, the spine should maintain its neutral alignment, which requires the extensibility of muscles around the hip (11) and the activation of stabilizing muscles (8).

Although the deadlift was originally an exercise used exclusively in competitive powerlifting, many strength and conditioning professionals (7) and high-school athletes (5) also use the deadlift in their weight-training regimen to enhance their hip, thigh, and back strength.

In healthy individuals, the deadlift exercise has been shown to activate the trunk muscles, specifically the longissimus and multifidus muscles, to a greater extent than exercises commonly performed with a Swiss ball do (22). Because patients with low back pain reportedly have decreased strength and endurance in their back extensor muscles compared with healthy individuals (16), exercises that focus on improving back strength might be effective as rehabilitative exercises.

Recently, a case study (14) and randomized controlled trial (1) indicated that deadlift training with an individualized progression in intensity and volume might be effective in reducing pain and disability in patients with a dominating pattern of mechanical low back pain. The randomized controlled trial (1) showed that two-thirds of the patients achieved a clinically meaningful improvement (>30% change (24)) in pain intensity and activity after an 8-week training period (1).

The patients also increased their trunk muscle strength and endurance (1). Still, the finding that one-third of patients did not achieve a clinically meaningful improvement in pain intensity and activity raises the question of whether and in what aspect these patients differ from those who benefitted from deadlift training.

Because the results of the aforementioned studies might encourage strength and conditioning professionals to suggest training involving the deadlift exercise to individuals with low back pain, it is important to establish which factors characterize patients who benefit from using the deadlift as a rehabilitative exercise.

Low back pain is a multifaceted condition, and results concerning which factors might be associated or could predict the outcome of rehabilitation remain inconclusive. Earlier studies have shown that pain intensity (2,3), disability (2,3), pain-related fear of movement (2), and nonoptimal movement patterns of the lumbopelvic region (11) are associated with low back pain and can predict outcomes of low back pain rehabilitation programs.

For example, Beneciuk et al. (2) showed that patients with high pain intensity at baseline did not benefit from physical therapy treatment. Yet, the number of studies investigating potential predictive variables of treatment success after exercise interventions remains limited.

The present study thus aimed to evaluate which individual factors measured at baseline could predict activity, disability, and pain intensity in patients with mechanical low back pain after an 8-week training period using the deadlift as a rehabilitative exercise. This will provide information to strength and conditioning professionals about which patients can benefit from deadlift training.

Deadlift Exercise

Training took place in an exercise facility with resistance training barbells and weight plates with a diameter of 45 cm. For all lifts, participants stood in front of a barbell with weights (Figure 1A). Participants were first taught to find a neutral position of the lumbar spine and then to stabilize the spine by taking a deep breath and contracting the stabilizing muscles (i.e., bracing).

This was done so that the participants would maintain the lumbar spine in a neutral position throughout the entire lift. Participants were next instructed to squat with the knees at approximately 90°, have the lumbar spine in a neutral position, suspend their arms straight down, and grasp the barbell (Figure 1B). A simultaneous extension of the knee and hip was performed (Figure 1C) to complete the concentric phase of the movement (Figure 1D) and to come to an erect position.

Figure 1: A–F Execution of the deadlift exercise. The person shown in Figures 1 A–F has given full permission to be included in the figures of this submission to Journal of Strength and Conditioning Research. Reprinted with permission from Aasa et al. 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. 45: 77–85, 2015. http://dx.doi.org/10.2519/jospt.2015.5021. Copyright ©Journal of Orthopaedic & Sports Physical Therapy®

The eccentric phase of the lift was initiated by lowering the barbell through hip flexion and keeping the bar close to the thighs until it passed the knee cap (Figure 1E), whereupon knee flexion concluded the descent (Figure 1F). The eccentric phase took roughly twice as long as the concentric phase. Between repetitions, participants let go of the barbell and paused in a standing position before initiating the next repetition. The rest between each set lasted 5–10 minutes, or as long as it took to change the weights on the barbell and to ensure that the participant had recovered from the set and could perform the next set with optimal technique.

During the initial 4 weeks of the training period, participants trained twice weekly with 2–3 days between sessions. During the final 4 weeks, participants trained weekly with 5–7 days between sessions. Participants did not receive any special instructions regarding activities beyond the deadlift training, other than that they should attempt to use the lifting technique learned during deadlift training in their everyday activities.

The first sessions of the training period focused on both controlling spinal alignment throughout the exercise and optimizing the movement pattern, including the activation of the stabilizing muscles. All participants started with 10–20 kg. When the lifting and lowering phases could be performed with control of the movement pattern, spinal and hip-knee alignment, the volume and intensity were gradually increased by number of lifts per session and/or weight on the bar.

Initially, 3–5 sets with 10 repetitions per set were performed. As training intensity progressed, to emphasize an increase in maximal strength, yet to ensure that every lift was performed with the correct technique, repetitions were gradually reduced to 3–5 per set, whereas sets increased from 5 to 8 per session. As a result, training volume increased along with intensity during the first weeks of the training period, but thereafter volume was kept at a more constant level, whereas intensity increased until the end of the training period (Figures 2 and 3). The precise number of sets and repetitions for each patient was left to the discretion of the physical therapist supervising the training.

Figure 2: The progression of the group mean of maximal intensity per session during the intervention period.
Figure 3: The progression of the group mean of training volume during the intervention period.

As training progressed beyond the initial sessions, cognitive behaviors that influenced the pain behavior were also targeted (35). Participants who experienced pain-related fear of movement and were apprehensive about stressing their low back by lifting weights were individually reassured that, by maintaining the neutral position of the spine during daily activities, the risk of aggravating their symptoms would be minimized and the progression of strenuous activities made possible.

reference link : https://journals.lww.com/nsca-jscr/Fulltext/2015/07000/Which_Patients_With_Low_Back_Pain_Benefit_From.6.aspx

More information: Mitchell T Gibbs et al, Does a powerlifting inspired exercise programme better compliment pain education compared to bodyweight exercise for people with chronic low back pain? A multicentre, single-blind, randomised controlled trial, Clinical Rehabilitation (2022). DOI: 10.1177/02692155221095484


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