Active Rehabilitation of Low Back Pain

Over the last few years, a consensus has emerged in the medical literature that active treatment of back pain is more successful than passive approaches, such as bed rest and medications.

This is yet another study that compares the two different approaches. Active rehabilitation in this case was defined as, "educational, psychological, and social components along with therapeutic exercises;" the regimen included 24 (1^1/2 hour) exercise sessions over 12 weeks, with encouragement to perform at home. The purpose of the plan was to improve mobility and teach coordination of the spine. The passive treatment was a non-exercise-based controlled treatment designed for minor efficacy, and included thermal therapy and massage once a week for a month. 30 LBP patients were enrolled in the active group, and 24 in the passive. The authors assessed patient's pain, self-experienced disability, and lumbar fatigability. Subjects were evaluated immediately before and after treatment, at six months, and one year after treatment.

At the baseline, pain intensity and disability was the same in both groups. The self-reports indicated moderate to severe intensity, but minor disability caused by low back pain. At follow-up assessment reductions in back pain intensity and disability were larger in the active group than in the passive control.
An aspect of this study focused on lumbar endurance. The authors utilized a complex test, which provided objective measure of endurance both before and after treatment. They found:

"Active rehabilitation was effective in improving objectively assessed lumbar paraspinal muscle endurance, at least in the short term. However, the change tended to diminish during the follow-up, one year after the rehabilitation."

Furthermore, the results also showed that improved lumbar endurance correlated to lessened intensity. This finding was significant since it allowed the practitioners to monitor patient progress objectively and individually during the active treatment program.

Kankaanpaa M, Taimela S, Airaksinen O, Hanninen O. The efficacy of active rehabilitation in chronic low back pain. Spine 1999;24(10):1034-1042.

Disappearing Herniated Disc

This interesting report details the case of a 48-year-old woman who developed right-sided scapular pain after some heavy lifting. MRI showed loss of normal cervical lordosis, degeneration between C5-6 and C6-7, as well as disc herniations at C3-4, C5-6, and C6-7. The C6-7 herniation was large and was compressing the spinal cord. She was scheduled for surgery two weeks after the initial MRI scan.

On the day of her scheduled surgery, she reported that her symptoms had resolved and she declined surgery; two years later, complaining of intermittent scapular pain, she was given another MRI. "Follow-up MR imaging again demonstrated loss of normal cervical lordosis; however, the C6-7 disc herniation had resolved dramatically and, to a lesser extent, so had the herniations at the C3-4 and C5-6 levels."

The authors (neurosurgeons) conclude, "We do not advocate conservative management of a large herniated cervical disc that becomes symptomatic with myelopathy; however, this case illustrates the potential for the spontaneous regression of even significantly sized herniated cervical discs."

Westmark RM, Westmark KD, Sonntag VKH. Disappearing cervical disc: case report. Journal of Neurosurgery 1997;86:289-290.

Influence of MRIs on Low Back and Leg Pain

This study compared the clinical features of low back and leg pain patients at the time of requesting a lumbar spine MRI to the subsequent pain management plan.

72 Patients were reffered for MRI. In 65 of the cases, leg pain emerged as the main symptom. 40 Patients showed no evidence of nerve compression, but in 28 patients nerve compression was evident. Interestingly, patients planned for surgery dropped from 48 to 30, while the conservative treatment plans rose 35% after the MRI. Overall, 50% of patients' diagnoses were altered after the MRI.

MRI is typically used in the medical setting to support surgical intervention, as the physician can pinpoint the area that is to be operated on. Ironically, this study found that the real effect of MRI is to move patients to the conservative treatment.

Rankine JJ, Gill KP, Hutchinson CE, Ross ER, Williamson JB. The therapeutic impact of lumbar spine MRI on patients with low back and leg pain. Clinical Radiology 1998;53(9):688-93.

Informative Approach to Low Back Pain

This study tested the long-term effects of a light mobilization program and informative approach to low back pain (LBP). The authors compared 245 patients in an intervention group to 244 patients in a control group, to gauge the benefits of such a program, and to determine the factors that would indicate eventual return to work.

The intervention included an exam and clinical advice, and 3 hours of a "Mini Back School." The information covered the basics of coping with LBP amidst everyday living, discussed the link between pain and emotions, and stressed the importance of continuing normal activity. The program attempted to heighten awareness, rather than ordering instructions.
198 (81%) of the patients in the intervention group returned to work within five years; 160 (65%) in the control group. The control group patients were nearly twice as likely to end up permanently disabled.

After the five-year study, the researchers went back to determine the predictors of return or nonreturn to work. Nonreturners had more children, less income, and feelings of no control or power over their health status.

The authors conclude with the benefits of the program:

"The thorough examination coupled with the assurance that the patient's situation was not serious, gave the patient the confidence needed to follow the advice and resume light normal activity. Lasting behavioral modification is achieved only through experience. It is believed that it was the patient's positive experience that resulted in the favorable long-term effect. The outcome supports the view that a substantial part of LBP may be a functional disturbance, and that light normal activity may restore normal function."

Indahl A, Haldorsen E, 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(23):2625-2630.

Massage Therapy for Low Back Pain

According to medical experts, low back pain is the second most common reason why people visit their physician, only after visits for cold and flu. If you've ever suffered a backache, you know how difficult life can be when simple things like chores, sitting at a desk or even finding a comfortable sleeping position seem impossible. Unfortunately, conventional treatments are not always helpful.

A doctor may prescribe pain medications and anti-inflammatory drugs for your lower back pain or even recommend invasive surgery. Other treatments may involve physical therapy or weight reduction as many cases of lower back pain are attributed to excessive abdominal weight and improper compensation when bending or lifting. It's imperative that you learn proper lifting methods and perform exercises to strengthen the abdominals thereby reducing the stress on your lower back.

However, even with the proper care and prevention, some people continue to suffer from pain and their quality of life quickly diminishes. Fortunately, massage therapy has been found to be an extremely effective method for dealing with lower back pain. A study published in the International Journal of Neuroscience concluded that "lower back pain is reduced and range of motion was increased after massage therapy" in a group of lower back pain sufferers.¹ The group was compared to a group of similar patients that underwent progressive muscle relaxation.

The group that underwent 30-minute massage therapy sessions twice a week for five weeks reported less pain, depression, anxiety and improvements in sleep. Greater trunk movement was reported and their serotonin and dopamine levels were higher. Serotonin and dopamine are responsible for feelings of calm and euphoria.

For more information on how massage therapy can reduce your lower back pain and improve the quality of YOUR life, please give our office a call.

1. Hernandez-Reif M, Field T, Krasnegor J, Theakston H. Lower back pain is reduced and range of motion increased after massage therapy. International Journal of Neuroscience 2001;106(3-4):131-145.

Muscle Relaxants Ineffective for Acute Low Back Pain

Low back pain is a common condition in the US. A current study from the journal Spine sums up the scope of the problem:

“[Low back pain] accounts for 15 million physician visits per year and an estimated cost of $192 million in 1990. Low back problems are the second most common cause for office visits to primary care physicians, and back pain is the most common reason for office visits to orthopedic surgeons, neurosurgeons, and occupational medicine physicians. It ranks third among indications for surgery. The content of the care provided by these allopathic physicians consists of evaluation, reassurance, advice regarding activities, physical methods, medications, and surgery.”

The goal of this study was to evaluate the effectiveness of muscle relaxant use in patients with acute low back pain. The authors prospectively collected data on 1,633 patients from a wide range of health care providers: primary care, chiropractic, orthopedic, and HMO patients.

The individual practitioners treated the study subjects as they would treat any other patient. Each subject was given the Roland-Morris survey to assess loss of function. The authors of the study then contacted the patients at 2, 4, 8, 12 and 24 weeks after the baseline interview to see if they were “completely better.”

• The patients taking muscle relaxants had higher Roland-Morris scores.
• 49% of the patients received muscle relaxants at some point during the study.
• The researchers found that patients receiving muscle relaxants had a significantly longer recovery period than did those who did not receive the drugs:

“[The findings] indicate that patients taking muscle relaxants, after controlling for baseline status, return to self-assessed ability to perform their daily activities more slowly than patients who do not take muscle relaxants.”

The authors then wondered if perhaps the delayed recovery was due to an initially higher score on the Roland test. The authors then looked at just those patients with Roland scores higher than 12. The authors found that the high-scoring patients who were prescribed muscle relaxants took 19% longer to reach functional recovery than patients who were not given muscle relaxants.

An additional area of concern is the adverse affects that can be experienced with these medications:

“Muscle relaxants can be sedating, may increase fall risk, and impair the ability to drive automobiles or operate machinery. There is also some concern relating to possible risk of dependency for benzodiazepine medications.”

The authors conclude:

“This large cohort study showed no evidence of benefit and even a delay in functional recovery for severely affected patients who take muscle relaxants in the setting of acute back pain.”

Bernstein E, Carey TS, Garrett JM. The use of muscle relaxant medications in acute low back pain. Spine 2004;29(12):1346-1351.