CAN DEADLIFTS IMPROVE LOW BACK PAIN?

Can Barbell Deadlift Based Interventions

Be Efficacious In the Treatment Of Low Back Pain?

A RevieW

The prevalence of low back pain has resulted in a challenge to medical systems internationally and is also the leading cause of years lived with a disability (James et al., 2018). Low back pain is one of the most financially burdensome of all musculoskeletal disorders (Bell & Burnett, 2009). It is estimated that 40-90% of individuals will experience back pain during their lifetime (Scott et al., 2010). Van Tulder and colleagues (2006) define low back pain as discomfort or pain below the ribcage and above the inferior gluteal fold, in addition leg pain can be present or absent. In this literature review I will examine the neuromusculoskeletal training improvements asserted by the barbell deadlift in low back pain rehabilitation interventions. Back pain is classified by health care professionals as chronic; > 12 weeks, sub-acute; between six-twelve weeks of pain and acute when symptoms last < 6 weeks. (Van Tulder et al., 2006). Examination of low back pain presents a difficult task for health care professionals as there is an absence in validity of diagnostic tests to determine what musculoskeletal structures are generating the pain (Holmberg et al., 2012). As a result, 85% percent of low back pain diagnosis are classified as non-specific chronic low back pain based upon radiologic findings even when associated pathology is determined (O’Sullivan., 2005).

Low back pain is a complex and multi-factorial biopsychosocial musculoskeletal disorder resulting in difficulty diagnosing it clinically and therefore finding treatment interventions (O’Sullivan., 2005). Pathological analysis of persistent low back pain in patients’ origin of pain can be attributed to following anatomical structures; 39% intervertebral discs, 15-40% joint facets and 30 % sacroiliac joints (Manchikanti et al., 2001). Other neuromuscular etiological causes can be attributed to; maladaptive activation of stabilizing structure of the lower back due to spinal disturbances (Hodges & Richardson, 1999), sub-optimal movement patterns causing overload of the lumbar spine (Michaelson et al., 2016), hypotrophy of type two muscle fibers and back extensor musculature in chronic low back conditions (Holmberg et al., 2012), and altered alignment resulting in tissue stress and altered muscle activation patterns (Aasa et al., 2015). Additionally, associations have been documented between low back pain and muscular weaknesses of the musculature of the trunk (Hultman et al., 1993) and weakness of the lower extremities (de Souza., 2019).

Resistance training has demonstrated improvement in symptoms of low back pain and improved function in individuals (Hayden et al., 2005). Although, it remains unverified as to what specific exercises offer an effective treatment to various pathological disorders of low back pain, this question remains undetermined. This is because rehabilitative protocols often combine several modalities of interventions into low back treatment making it difficult to isolate specific exercise mechanics in which are most optimal for low back pain improvement (Tagliaferri et al., 2020; Escriche-Escuder et al., 2020; Tjøsvoll et al., 2020). However, the barbell deadlift has been shown efficacious in treatment of low back pain (Holmberg et al., 2012; Aasa et al., 2015; Berglund et al., 2015; Michaelson et al., 2016).

Electromyography analysis has shown that the deadlift activates the deep muscles of the back, including the multifidus in addition to the spinal erectors, abdominal, obliques and lower extremities; and greater activation of gluteus maximus and hamstrings group more than the quadriceps (Martín-Fuentes et al., 2020). In sum, the deadlift is an exercise which elicits overall strength increases and hypertrophy of the entire posterior musculature groups of the body. Deadlifts reinforces optimal motor control, trunk stabilization, co-ordination patterns while maintaining neutral spinal alignment through dynamic movement. These aforementioned components have been demonstrated to be dysfunctional in low back pain (Aasa et al., 2015). Furthermore, it is proposed that the barbell deadlift theoretically aids in cartilage regeneration (Jung et al., 2008 as cited by Holmberg et al., 2012). Holmberg et al., (2012) have also suggested that the barbell deadlift also improves spinal nourishment as reduction of metabolite transfer has been correlated with disk degenerative disease.

Previous literature has examined physical activity, generalized strength exercise and rehabilitative-specific exercise effect on low back pain, but few have examined the effect of deadlift only interventions in low back pain. Generally, interventions in clinical settings are coupled with several strength training modalities including; “core” strengthening, conditioning, spinal manipulation, motor control, flexibility and mobility exercises (Tagliaferri et al., 2020). Results of these studies have shown favourable outcomes in low back pain (Escriche-Escuder et al., 2020; Tagliaferri et al., 2020; Tjøsvoll et al., 2020). However, there is no collective agreement on which exercise best aids in the resolve of this specific back pain disorder (Holmberg et al., 2012). Thus, the question arises can barbell deadlift only based interventions be efficacious in treatment of low back pain?

This review will examine the neuromusculoskeletal mechanisms and adaptations as a result of the barbell deadlift in back pain rehabilitation interventions to determine the pathophysiology and outcome. Several systematic reviews were found on the topic of exercise interventions in low back pain, motor control exercises in treatment of low back pain, trunk strengthening and multiple modalities of exercise on low back pain treatment. However, barbell deadlift training only in treatment of low back pain was an area that merits further investigation. Articles for this literature review were retrieved using Google scholar, Pubmed, National Centre for Biotechnology Information, Kinesiology Publications, Scopus, Web of Science and Western University searchable database. Although more than fifty articles on related topics were found, only four were relevant to the topic and met the inclusion and exclusion criteria for this paper. The main inclusion criteria had to be a barbell deadlift only intervention, implemented for the treatment of low back pain. The publication should further reference a proposed mechanism to indicate the result or adaptation of deadlift training and its outcome. The measured outcomes had to evaluate pain intensity, movement screening, functional status, disability, or some type of valid and reliable qualitative metric that could indicate a statistically significant change. Furthermore, the back pain needed to be classified as chronic non-specific or mechanical nociceptive in origin, with participants between the ages of eighteen to seventy.

For the purpose of this literature review, exclusion criteria, including research and data that included multiple exercises, alternative treatment modalities, or deadlifts that were performed with a resistance band were excluded. Back pain associated with any type factor beyond chronic non-specific back pain or nociceptive mechanical. Several different research approaches and methods were examined for the purposes of this literature review; randomized control trial (n=1)(Aasa et al., 2015), randomized control trial with 24 month follow-up (n=1)(Michaelson et al., 2016), a randomized control trial secondary analysis (n=1) (Berglund et al., 2015), and a pilot study; single subject experimental design with 15 month follow-up (n=1) (Holmberg et al., 2012).Commonalities across the literature indicate that barbell deadlift only interventions can be beneficial in rehabilitation interventions in low back pain. Holmberg et al., (2012) proposes the deadlift causes high compressive forces of the spine and during axial loading, which is thought to be beneficial in disc regeneration as fluid diffusion and the transfer of metabolites occurs during compression-decompression phases of the lift (Adams & Hutton, 1986). The stimulus of compressive forces on the spine are theorized to enhance cartilage regenerative properties (Jung et al., 2008 as cited by Holmberg et al., 2012). This adaptation occurs over a duration of time but may explain the improvement observed in the study. However, this proposed mechanism has yet to be verified (Holmberg et al., 2012). Furthermore, Holmberg and colleagues (2012) state the additional improvements in low back pain can be attributed to enhancement of neuromuscular activation of the extensor muscles of the back and increases in strength of participants combined with the hypertrophy of type II muscle fibers. Further research supports that individuals with low back pain also have weakness in the spinal erectors and musculature of the trunk (Hultman et al., 1993) and the lower extremities (de Sousa et al., 2019).

Aasa et al. (2015) state that low back pain is associated with altered postural and maladaptive movement patterns. As a result, alteration of normal biomechanics leads to tissue stress which is the cause of non-specific or pain related to mechanical factors. Interventions therefore have been targeted at motor control exercises to improve muscle recruitment patterns as this been shown to be a contributor to low back pain (Hodges & Richardson, 1999). In addition, treatment of low back pain motor interventions has also been focused on improvement of muscular co-ordination while maintaining neutral spinal alignment. Aasa et al. (2015) suggest the deadlift accomplishes these components in a single exercise as compared to multiple exercises.

Berglund et al., (2015) further examines the deadlift in a secondary analysis in low back pain interventions, in which they found that the deadlift is an effective intervention in low back pain. Their research indicates that the deadlift elicited proper activation of musculature, commonly cited as dysfunctional in low back pain, and that associated pain is thought to cause motor disturbances in movement patterns causing increased stress on tissues due to maladaptive compensation patterns, which ultimately causes the pain and dysfunction. The deadlift, when executed properly has been cited as an exercise that facilitates motor learning and motor unit synchronization (Hales, 2010).

In a 24-month follow-up study to Aasa et al., (2015) by Michaelson et al., (2016), they claim that the deadlift intervention is an effective treatment even in long-term applications. The researchers state that mechanisms were found to be similar throughout literature on this topic, these mechanisms included activation of stabilizing musculature of the trunk and retraining of the lumbar erector spinae. In addition, the authors state high intensity exercises such as the deadlift, increase motor unit synchronization and enhance motor control and co-ordination during dynamic movement; activating stabilizing musculature while simultaneously maintaining a neutral spine while concurrent dynamic movement occurs in the lower extremities (Michaelson et al., 2016). Thus, reinforcing proper motor control and co-ordination in contrast to dysfunctional motor patterns which is associated with low back pain (Aasa et al., 2015). Michaelson et al. (2016) further state the potential hypertrophy and increase of the cross sectional area of the multifidus is stimulated by stabilization exercises which may be a potential mechanism for the improvement of low back pain, as this was found to be a contributor in the alleviation of low back pain in cricket players with lumbar associated pain (Hides et al., 2008).

One of the major limitations of this research (Holmberg et al., 2012; Berglund et al., 2015; Aasa et al; 2015; Michaelson et al., 2016) is the lack of quantitative data extraction such as EMGs, Biomechanical 3D analysis and MRIs throughout the interventions as the researchers explicitly state (Holmberg et al., 2012; Michaelson et al., 2016). Many of the physiological adaptions and mechanisms elicited by the deadlift in improving pain and function of low back pain were cross-referenced and theorized but valid. Collecting quantitative data on a qualitative outcome may be a difficult task as pain perception is a subjective experience in non-pathological back bain. This presents a challenge as there is a lack of validity in which diagnostic tests can evaluate back pain (Holmberg et al., 2012) and based upon radiologic pathological findings, back pain may still be classified as un-specific (O’sullivan et al., 2005). However, there is also a significant amount of correlational data across the literature, which indicates consistencies in which neuromusculoskeletal components of low back pain are the root cause. Therefore, measuring these components might also be accomplished quantitatively. Additionally, another limitation within this particular body of literature and research is that one publication was a pilot study (Holmberg et al., 2012) and the other (Berglund et al., 2015) a secondary analysis. Furthermore, Aasa et al., (2015) study was then followed-up by Michaelson et al., (2016) using the same participants at 24 months, however despite this limitation, this was indicative of long-term safety and efficacy. Future directions to consider, would to be implement EMGs, MRIs and 3D biomechanical analysis in randomized control trials with much larger populations. The strength of this literature is the specificity of the treatment interventions, which evaluate the efficacy of the deadlift, reduce confounding variables, and was also the rationale for the selection of these studies and research. Furthermore, the long-term follow up and evaluation of participants is of importance as motor re-learning, hypertrophy, muscular activation and co-ordination, and cartilage regenerative processes occur over of a duration of long-term implementation. Short duration interventions may not provide the appropriate amount of time for these adaptations to occur. Through maladaptive motor re-learning, motor-unit synchronization, muscular co-ordination and activation, trunk stabilization, muscular hypertrophy, cartilage regeneration and the enhancement of spinal nourishment, the barbell deadlift seemingly may aid in improvement of pain, disability, dysfunction and strength associated with chronic low back pain. Although, much more research is required before any conclusions can be inferred.

Table 1: Study Characteristics in the review of Deadlift Interventions in Low Back Pain

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