A common myth is that rehabilitation is merely strength or flexibility training.49 Put a gym and personal trainer in your office and learn basic sports/exercise science principles, and you can do rehab.As a result, many "so-called" rehabilitation programs focus on isotonic training-programs and stretching regimes. Adding a gym to a chiropractic office can help you market your practice to a more health-conscious public. But to maximize your practice's potential, you will need to provide a more clinical approach, one that identifies a patient's directional preference, fear-avoidance beliefs and motor-control deficits. This will enable you to distinguish your services not only from other DCs and PTs, but also from various yoga or Pilates centers.
Integrating this functionally oriented, self-care paradigm of care lies at the heart of both evidence-based and patient-centered musculoskeletal medicine. Rather than focusing merely on pathology and symptoms, the emphasis is on recovery and reactivation. This requires a shift from a traditional biomedical paradigm to a biopsychosocial one. The goal is return the patient to independent functioning by focusing on the biological (impairments), psychological (illness behavior/beliefs) and social (participation limitations) aspects of disability.49,50
Reactivation advice to resume near-normal activities is both safe and effective for acute low back pain (LBP) patients.35 Similarly, early activation has been found to be effective for neck pain following a whiplash injury.44 Deconditioning normally accompanies acute LBP, and its prevention has been shown to reduce recurrence rates.14,15 Active therapies involving such diverse exercise methods as simple reactivation advice, cognitive-behavioral graded-exposures training, stabilization exercise, and McKenzie methods have demonstrated their effectiveness for acute, subacute and chronic LBP.11,15,21,28,36,41
The Agency for Health Care Policy and Research (AHCPR) low back pain guidelines stated, "The main goal for treatment of back pain has shifted from treatment of pain to treatment of activity intolerances related to pain."1 Whereas my last article, "The Clinical Audit Process and Functional Reactivation," detailed how to prescribe and progress rehabilitation strategies in the office, this article will provide a brief overview of the foundations of rehabilitation, including the rationale (why), the candidates (who), the indications (when) and the types of rehab (what).
Why Active Care? The Rationale
Persistent pain reinforces negative attitudes about the relationship between activity and pain, as the patient takes on the "sick" role.34 Diagnostic tests that focus on pathoanatomy are frequently ordered to find the "cause" of the pain. Unfortunately, these tests have high false-positive rates for coincidental structural findings, such as degenerative joint disease or herniated discs, and thus reinforce the patient's self-image of having a "bad" back or needing to "learn to live with it."22,26,48 The result is further activity avoidance and deconditioning. Unfortunately, excessive immobilization interferes with the healing, coping and recovery processes. Thus, health care professionals are being urged by each successive international guideline on spinal disorders to first perform a diagnostic triage to rule out "red flags" of rare but serious disease, and then to reassure patients of the benign nature of their back pain and the safety and value of gradually resuming activities.1,5,6
Who and When? Clinical Indications Requiring Rehabilitation
Work at the University of Pittsburgh has convincingly shown that subclassification of the "nonspecific" group is possible with an evaluation consisting of a thorough history, disability questionnaires, and examination utilizing a battery of low-tech, yet reliable tests (e.g., sacroiliac, McKenzie).9 They have shown that treatment matched to the appropriate subclassification is superior to unmatched treatments. Furthermore, a recent, randomized clinical trial (RCT) has shown that treatment driven by subclassification is superior to the "generic" treatment recommended by the AHCPR for the broad "nonspecific" category.10 Outcomes included reduced disability and accelerated return to work. Patients were subdivided into the following treatment classifications: manipulation/mobilization; direction-preference exercise (e.g., McKenzie); and stabilization exercise groups. Here is a summary of the criteria for patient classification by treatment type:
- Directional-preference exercise - acute or chronic patents whose symptoms are aggravated by movement in one direction and improved by movement in an opposite direction.
- Manipulation - acute, uncomplicated back pain patients who do not meet the criteria for directional-preference exercise.
- Stabilization - recurrent or persistent pain patients with or without fear-avoidance beliefs who do not meet the criteria for directional-preference exercise.
What? Appropriate Goals of Rehabilitation
Most novices to rehab feel strength and flexibility training are the cornerstones of adding this to the practice. However, an evidence-based approach requires that motor control, muscle balance and cognitive-behavioral goals be our main focus.
Abnormal Motor Control. Coordination of "core" muscles has been found to be correlated to back pain. Researchers at Yale University have shown that a specific motor-control signature of delayed agonist-antagonist muscle activation predicts which asymptomatic people will later develop low back pain.4 In particular, the researchers found longer muscle response latencies to perturbation in the "at-risk" group than in healthy control subjects. A delayed activation of the transverse abdominus muscle during arm or leg movements has been found to distinguish LBP patients from asymptomatic individuals.17,18 A rehabilitation program designed to improve this dysfunction has been shown to be effective for chronic LBP patients.41
Coordination of hip flexion as in an active straight-leg raise (ASLR) test has been shown to be associated with postpartum sacroiliac (SI) pain.38 The test involves lifting one leg 5 cm up from a relaxed supine position. It has been shown that altered kinematics of the diaphragm and pelvic floor are present in those with a positive test.42
Balance deficits (e.g., excessive anterior to posterior body sway on an unstable surface or poor single-leg-standing balance ability) have been demonstrated to be related to LBP.3,40,46 Poor balance also was prospectively correlated with future LBP by Takala.46
Craniocervical flexion (CCF) coordination can differentiate both chronic headache and chronic neck pain post-whiplash patients from asymptomatic individuals.23,24 Individuals with mild or moderate/severe pain and disability had significant overactivity of the superficial neck muscles (sternocleidomastoid), during CCF.45 Treatment directed at improving CCF recently has been shown to achieve lasting results, both in terms of improved function and reduced symptoms.25
Muscle Balance. A reduced ratio of trunk extensor-to-flexor strength/endurance discriminates between LBP patients and control subjects. The normal ratio is approximately 1.3:1, with the extensors being stronger.37 Decreased endurance of the trunk extensors has been shown to predict recurrences (Biering-Sorensen), as well as first-time onset of LBP in healthy individuals.19,33
Cognitive-Behavioral Components. Fear-avoidance beliefs (FAB) and distress have been shown to account for approximately 50 percent of the variation in self-rated disability (Oswestry Disability Index) in acute and chronic LBP patients.12 Fritz, et al., have confirmed that initial fear-avoidance beliefs were significant predictors of subacute status at four weeks, independent of pain intensity, physical impairment, disability or therapy received.8
Rehabilitation is traditionally viewed as exercise. Thus, its application is usually focused on voluntary strength training. Unfortunately, voluntary exercise often perpetuates faulty movement patterns or abnormal motor control. Therefore, rehabilitation should emphasize motor control when attempting to build stability.
Reactivation Advice. Information and advice emphasizing the value of fitness and the safety of resuming activities achieved superior outcomes to advice reinforcing rest, activity restrictions and the notion that the spine was injured or damaged (arthritis, herniated disc).2,31 Reassurance, coupled with encouraging resumption of ordinary activities, was found to be superior to medication, bed rest or mobilization exercises.35
McKenzie Method. The McKenzie method was shown to be at least as effective as an isotonic strengthening program in a randomized, controlled trial of subacute and chronic patients (pain duration of at least eight weeks).43 And in a study of McKenzie's matched directional-preference exercise prescription vs. evidence-based care (EBC) for chronic LBP patients, the following results were achieved:32
- Fifty-six percent of the EBC group reported no improvement or worsening of symptoms.
- Forty-four percent of the EBC group reported improvement in symptoms.
- Ninety-five percent of the matched group reported improvement in symptoms.
- Only five percent of the matched group reported no improvement in symptoms.
Stabilization Exercise. Australian research has shown that if acute LBP patients perform specific spinal-stabilization exercises, multifidus muscle atrophy can be prevented.16 The training also has a secondary preventive effect of reducing future recurrences.15 Specific spine-stabilization exercises achieved superior outcomes to isotonic exercises in chronic patients with spondylolysthesis.41 One study that compared McGill's "general" stabilization exercise approach to the Australian "deep" local stabilization training demonstrated that the "general" approach was superior.27
Graded-Exposures Training (GET). This involves exercises perceived as threatening by the patient. GET is also commonly called quota-based exercise because the exercises are performed for a specific duration or frequency, independent of symptoms.7,13,29,30 Two studies found that either lay-led or professional-led instruction in self-care and worry-reduction were successful in reducing back-related worry, fear-avoidance beliefs, pain severity and activity intolerances.39,47 A long-term follow-up study led by Indahl focused on education designed to reduce fear.20,21 Patients were informed that light activity would not injure the disc, but instead speed recovery. The return-to-work rate was double that of the control group.
- Agency for Health Care Policy and Research (AHCPR). Acute Low-Back Problems in Adults. Clinical Practice Guideline Number 14. Washington DC: U.S. Government Printing, 1994.
- Burton K, Waddell G. Information and advice to patients w/ back pain can have a positive effect. Spine, 1999;24:2484-91.
- Byl NN, Sinnot PL. Variations in balance and body sway. Spine, 1991;16:325-330.
- Cholewicki J, Silfies SP, Shah RA, et al. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine, Dec. 1 2005;30(23):2614-20.
- Manniche C, et al. Low Back Pain: Frequency Management and Prevention From an HAD Perspective. Danish Health Technology Assessment (DIHTA), 1999.
- Preliminary Draft: European Guidelines for the Management of Acute Nonspecific Low Back Pain in Primary Care. www.backpaineurope.org.
- Fordyce WE, Brochway JA, Bergman JA, et al. Acute back pain: a control-group comparison of behavioral vs. traditional management methods. J Behav Med, 1986;9:127.
- Fritz JM, George SZ, Delitto A. The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain, 2001;94:7-15.
- Fritz JM. George S. The use of a classification approach to identify subgroups of patients with acute low back pain. Spine, 2000;1:106-14.
- Fritz JM, Delitto A Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine, 2003;28:1363-71.
- Frost H, Lamb SE, Shackleton CH. A functional restoration programme for chronic low back pain: a prospective outcome study. Physiotherapy, 2000;86(6):285-93.
- Grotle M, Vollestad NK, Veierod MB, Ivar Brox J. Fear-avoidance beliefs and distress in relation to disability in acute and chronic low back pain. Pain, 2004;112:343-52.
- Hagen EM, Eriksen HR, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine, 2000;25:1973-6.
- Hides JA, Stokes MJ, Saide M, et al. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine, 1994;19(2):165-72.
- Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine, 2001;26:e243-8.
- Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode of low back pain. Spine, 1996;21(23):2763-9.
- Hodges PW, Richardson CA. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Arch Phys Med Rehabil, 1999;80(9):1005-12.
- Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. J Spinal Disord, 1998;11(1):46-56.
- Holm SM, Dickenson AL. A comparison of two isometric back endurance tests and their predictability of first-time back pain: a pilot study. Journal of the Neuromusculoskeletal System, 2001;9(2):46-53.
- Indahl A. Velund L, Reikeraas O. Good prognosis for low back pain when left untampered: a randomized clinical trial. Spine, 1995;20:473-7.
- Indahl A, Haldorsen EH, Holm S, et al. Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain. Spine, 1998;23:2625-30.
- Jensel MC, Brant-Zawadzki MN, Obuchowki N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med, 1994;2:69.
- Jull GA. Deep cervical flexor muscle dysfunction in whiplash. Journal of Musculoskeletal Pain, 2000;8:143-54.
- Jull G, Barret C, Magee R, Ho P. Further clinical clarification of the muscle dysfunction in cervical headache. Cephalgia, 1999;19:179-85.
- Jull G, Trott P, Potter H, et al. A randomised control trial of physiotherapy management of cervicogenic headache. Spine, 2002;27:1835-43.
- Kendrick D, Fielding K, Bentler E, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ, 2001;322:400-5.
- Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle stabilization training versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Phys Ther, 2005:85:209-25.
- Lindstrom A, Ohlund C, Eek C, et al. Activation of subacute low back patients. Phys Ther, 1992;4:279-93.
- Linton SL, Hellsing AL, Andersson D. A controlled study of the effects of an early active intervention on acute musculoskeletal pain problems. Pain, 1993;54:353-9.
- Linton SJ, Andersson T. Can chronic disability be prevented? A randomized trial of a cognitive-behavioral intervention for spinal pain patients. Spine, 2000;25:2825-31.
- Little P, Roberts L, Blowers H, et al. Should we give detailed advice and information booklets to patients with back pain? A randomized controlled factorial trial of a self-management booklet and doctor advice to take exercise for back pain. Spine, 2001;26:2065-72.
- Long A, Donelson R, Fung T. Does it matter which exercise? Spine, 2004;29:2593-2602.
- Luoto S, Heliovaara M, Hurri H, Alaranta H. Static back endurance and the risk of low-back pain. Clin Biomech, 1995;10:323-4.
- Main CJ, Watson PJ. Psychological aspects of pain. Manual Therapy, 1999;4:203-15.
- Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain - bed rest, exercises, or ordinary activity? N Engl J Med, 1995; 332:351-5.
- Manniche C, Lundberg E, Christensen I, et al. Intensive dynamic back exercises for chronic low back pain. Pain, 1991;47:53-63.
- Mayer TG, Smith S, Keeley J, Mooney V. Quantification of lumbar function part 2: sagittal plane trunk strength in chronic low back patients. Spine, 1985;10:765-72.
- Mens JM, Vleeming A, Snijders CJ, et al. The active straight-leg-raising test and mobility of the pelvic joints. Eur Spine J, 1999;8:468-74.
- Moore JE, Von Korff M, Cherkin D,et al. A randomized trial of a cognitive-behavioral program for enhancing back pain self-care in a primary care setting. Pain, 2000;88:145-53.
- Mok NW, Brauer S, Hodges PW. Hip strategy for balance control in quiet standing is reduced in people with low back pain. Spine, 2004;29:E107-12.
- O'Sullivan P, Twomey L, Allison G. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolysthesis. Spine, 1997;24:2959-67.
- O'Sullivan PB, Beales DJ, Beetham JA, et al. Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine, 2002;27:E1-8.
- Petersen T, Kryger P, Ekdahl C, et al. The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: a randomized clinical trial. Spine, 2002;27:1702-9.
- Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine, 2000;25(14):1782-7.
- Sterling M, Jull G, Vicenzino B, et al. Development of motor system dysfunction following whiplash injury. Pain, 2003;103:65-73.
- Takala EP, Vikari-Juntura E. Do functional tests predict low back pain? Spine, 2000;25(16):2126-32.
- Vlaeyen JWS, De Jong J, Geilen M, et al. Graded exposure in the treatment of pain-related fear: a replicated single case experimental design in four patients with chronic low back pain. Behav Res Ther, 2001;39:151-66.
- Wiesel SE, Tsourmans N, Feffer HL, et al. A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine, 1984;9:549.
- Waddell G, Burton AK. Current concepts of rehabilitation for the management of low back pain. Best Practice & Research Clinical Rheumatology, 2005;19:655-70.
- World Health Organization. International Classification of Human Functioning, Disability and Health: ICF. Geneva: WHO, 2001.
Editor's note: To read Dr. Liebenson's previous article on rehabilitation strategies ("The Clinical Audit Process and Functional Reactivation"), visit www.chiroweb.com/archives/25/08/09.html.
Click here for previous articles by Craig Liebenson, DC.