Finding the Right Exercise Therapy for Back Pain
Strategies for using exercise therapy to improve outcomes in chronic low back pain reports there continues to be uncertainty about the most effective exercise approach in chronic low back pain. Two reviewers independently extracted data on exercise intervention characteristics. The study included 43 trials of 72 exercise treatments and 31 comparison groups, with the conclusion being exercise therapy, consisting of individually designed programs including stretching or strengthening delivered with supervision, may improve pain and function in chronic nonspecific low back pain (Hayden, Tulder, & Tomlinson, 2009).
A population-based survey of physical therapists conducted a study to describe the interventions used by physical therapists in the treatment of workers with acute or sub-acute low back pain, with or without radiating pain below the knee. The method used to obtain data included clinical management questionnaires for workers, without and with, radiation pain. 190 workers and 139 physical therapists returned them. For each treatment, therapists recorded treatment objectives, interventions, and education provided to two workers with LBP, one with radiation pain and one without radiation pain. Independent variables such as heat, massage, manual traction were administered. The results concluded physical therapists use an array of interventions with workers with LBP with the effectiveness of most interventions reported have not been well studied (Poitras, Blais, Swaine, & Rossignot, 2008).
Post-Intervention (follow-up) outcomes data were extracted from each included experimental study on the nature of exercise intervention, sample size in treatment arms and duration of follow-up periods. Outcome measure typically comprised data such as pain scales, return to work, or measures of function. However, given the similarity of effect sizes across studies during the follow-up periods, it could be argued that the nature of the exercise program is perhaps not as important as the message it provides, that is, to keep active (Smith, & Grimmer-Somers, 2010). Comparisons of isokinetic exercise versus standard exercise training in patients with chronic low back pain showed a comparison of both exercise groups in terms of parameters. At the end of the treatment and after the first month after treatment showed no significant difference. No statistically significant difference was found between the two programs (Sertpoyraz, Eyigor, Karapolat, Capaci, & Kirazli, 2009). Are physiotherapy (physical therapy) exercises effective in reducing chronic low back pain? No single exercise based treatment was consistently shown to be superior to other interventions.
This review found preliminary evidence that physiotherapy exercises are effective for the treatment of chronic low back pain, although no particular treatment modality was found to optimize therapy outcomes to a much greater extent than others (Lewis, Morris, & Walsh, 2008). An examination of the effectiveness of therapeutic aquatic exercise in the treatment of low back pain was also conducted. The result was therapeutic aquatic exercise appeared to have a beneficial effect, however, no better than other interventions. Summarily therapeutic aquatic exercise appears to be an effective treatment intervention for chronic and pregnancy-related low back pain (Waller, Lambeck, & Daly, 2009). Exercise therapy for nonspecific low back pain analyzed the effectiveness of exercise therapy in low back pain versus no treatment and other conservative treatments. It evaluated exercise therapy for adult nonspecific low back pain and measured pain, function, return to work or absenteeism, and global improvement outcomes. This literature suggests exercise therapy is as effective as either no treatment or other conservative treatment for acute low back pain (Hayden, Tulder, Malmivaara, & Koes, (2007).
Despite years of research and types of back pain interventions the literature suggests that over the long run one intervention or treatment is not superior to another and possibly equal to not adhering to any back pain program. The problem is core muscles of the body can remain in a state of partial spasm for long periods of time, even years. This muscle state is referred to as a chronically injured muscle: when the individual has some indication of discomfort at rest or during an activity. In medicine, this is often seen in individuals who continually push a significantly injured muscle and do not allow it to heal properly. Many individuals with significant injuries, due to something like a car accident, have reported over a year to heal the muscle and another three to four years to get the muscle feeling back to essentially normal. The asymptomatic chronically injured muscle (ACIM) behaves the same, except that the individual is completely unaware that there is a problem. Four T’s characterize this condition:
- Tightness to stretch.
- Tenderness to touch.
- Trigger points (A name for knots in the muscle that are especially tender).
- Transition of stretch to pain is shortened.
To the individual, the muscle is asymptomatic and usually seems to function about the same as it used to, prior to the injury. However, the muscle is extremely susceptible to re-injury and recurrent strains. These asymptomatic chronically injured muscles (ACIMs) are more noticeable in the upper back and neck muscles because the core muscles involved are quite superficial. Frequently, these muscles do not completely heal when treated by normal physical therapy treatment. In the 1960’s, Dr. Janet Travell who was the personal physician to Presidents Kennedy and Johnson, first demonstrated that trigger points could be injected with various medications. This promoted healing in many individuals. However, in some individuals the symptom would simply resolve for two weeks and then return. Healing any type of chronically injured muscle remains a difficult task in medicine.
Once this extremely common problem is detected, many have devised their own way to tone, strengthen and condition the muscles. Once accomplished, this partially injured muscle appears to be no more susceptible to injury than any other muscle. Unfortunately, there has not system that has helped everyone. The asymptomatic chronically injured muscle not only constitutes the major risk factor for recurrent back pain, but also is something that can be eliminated.
The U.S. Preventive Services Task Force answered the question: Do educational programs (i.e., back schools) help to prevent low back pain? A recent systematic review assessed the effects of back schools for patients with nonspecific low back pain. The authors reviewed 15 RCTs that reported on back schools for the treatment and secondary prevention of nonspecific low back pain. A qualitative review was performed using 11 preset internal validity criteria with 6 or more positive scores denoting “high quality.”
Using these criteria, only three trials were considered to be of high quality. Their results showed moderate evidence that back schools have better short-term effects than other intervention for the treatment and secondary prevention of low back pain in occupational settings. There was only moderate evidence that back schools are effective in the secondary prevention of back pain in occupational settings. The review concluded that back schools may be effective in preventing further back injury for individual with recurrent and chronic low back pain, but their cost-effectiveness is not well known.