What: Brief educational approaches including advice to gradually increase activity from a cognitive behavioral (CB) perspective.
Who: Patients in the acute phase of a painful episode.
Assurance That There Is No Serious Disease—Doesn’t Severe Pain Signify Serious Damage?
A powerful myth in modern back pain culture is that structural pathology is responsible for pain. Cartesian thinking promoted the view that pain is directly related to tissue damage or injury. However, Melzack and Wall’s gate control theory of pain led to the discovery that there are descending influences on the nociceptive pathways that directly influence pain perception.84,85
Pain not only is the result of ascending nociception but also is a result of a dynamic process of perception whereby some noxious stimuli are interpreted as potentially harmful and some are not. The Cartesian approach can be summed up in the adage “let pain be your guide.” This is now considered to be responsible for promoting unnecessary fear and functional limitations.
Most patients who have chronic back pain or are experiencing a stubborn acute episode have had some imaging of their spine. They usually come into our offices with their films and courageously bear their label of having a serious problem such as a herniated disc, spinal stenosis, or degenerative arthritis.59
They have found the cause of their pain and now they want us to “fix” them.
What they have usually not been told is that such structural pathology is present in an unusually large percentage of asymptomatic individuals (Fig. 14.1
Also, it does not even predict future problems when found in younger people.87
Therefore, it may be a coincidental finding.
Figure 14.1 False-positive rates for disc herniation with various imaging modalities. Imaging findings of disc abnormalities increase in frequency with age in patients without symptoms. (CT, computed tomography; DJD, degenerative joint disease; MRI, magnetic resonance imaging.) Reprinted with permission from Bigos S, Müller G. Primary care approach to acute and chronic back problems: definitions and care. In: Loeser JD, ed. Bonica’s Management of Pain. 3rd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2001.
Another important fact to note with McKenzie style exercises is that the phenomenon of centralization (the movement of symptoms up the leg and toward the back) doesn’t correlate with the severity of the disc lesion in people with sciatica.88
Whereas it is bad news that the cause of pain may still be a mystery, the good news is that surgery is likely NOT indicated and the long-term disabling potential of their condition is significantly lessened.
Imaging for Back Pain
Imaging is poorly correlated with symptoms, does not predict future problems, and in fact may be harmful. There is strong evidence to show that routine back imaging does not improve patient outcomes, exposes patients to unnecessary harms, and increases costs to the healthcare system. However, imaging practices remain inconsistent with evidence-based guidelines and its use continues to rise. Based on expert opinion, diagnostic imaging studies should only be performed in selected higher risk patients who have severe or progressive neurologic deficits or are suspected of having a serious or specific underlying condition.89
Imaging findings of debatable impact to the plan of patient care may actually have adverse effects on patients’ beliefs and behaviors regarding their health and ability to get better. In one randomized trial involving low-risk patients with back pain, those who underwent radiography reported worse pain and overall health at follow-up and incurred more physician visits compared with those who did not undergo radiography.89
In another study of lumbar magnetic resonance imaging (MRI), patients with acute back pain or sciatica were randomly assigned to receive their imaging results or not. Patients who received their imaging results reported less improvement in self-rated health over the subsequent year.90
With this in mind, it may actually be considered poor patient management to image those presenting with back pain.
Many imaging techniques have frequent false positive and negative results, limiting their ability to identify abnormalities that may be pain generators. Therefore, the primary utility of imaging lies in interventional and/or surgical planning or in determining the presence of serious medical conditions. For these purposes, lumbar MRI represents the most useful tool. However, routine ordering of imaging for LBP should be discouraged. In particular, imaging in acute LBP has not been shown to yield significant new findings or alter outcomes.91
If Pain Is Not Caused by Serious Disease, Then What Is Causing My Pain? (Doesn’t Severe Pain Signify Serious Damage?)
Most patients are reassured when told that structural pathology is more related to age—like graying hair or wrinkling skin—than to symptoms, or that people with pristine spines often have symptoms whereas some with objective signs of spinal degeneration are pain free! It is helpful to reassure them that the difference between people whose structural pathology is causing symptoms and those in whom it is not has to do with their ability to adapt to the changes, and this ability can be trained. Even in those with symptomatic intervertebral disc changes, discs often heal and remodel in response to conservative treatment.92
Therefore, instead of the negative message that they need to either learn to live with their problem by compromising their lifestyle or resort to surgery, patients learn that there are things that they can do to control the symptoms by modifying their activities and training to improve their fitness levels.
All patients want to know the cause of their pain. Fortunately, serious problems are easy to identify. Tumors and infections are extremely rare, and nerve root disorders occur less than 10% of the time (see Chapter 7
). Although most spinal pain is not serious, it is not always possible to pinpoint an exact cause of the pain. However, we can conclude that the problem is a simple, uncomplicated one, and reassure them that we do know what factors prolong pain (e.g., distress, deconditioning) and what treatments help resolve the problem.
Most patients are overly concerned with doing the wrong thing or doing too much. However, too little motion is just as deleterious as too much!93
One of the only factors that has been shown to predict future back problems is reduced endurance of the back muscles.94
One of the most potent predictors of recurrent back problems is atrophy of those same muscles that occurs when an acute episode strikes.56
Studies have shown that those who train the back muscles with gentle exercises reduce the likelihood of such recurrences.56
Similarly, neck pain patients after a whiplash or those with chronic headache have both been found to have a weakness of their deep anterior neck muscles.95
When these muscles are trained, improvement ensues.96,97
The most common cause for persistent pain is when external load repeatedly exceeds physical capacity or tolerance (Fig. 14.2
). This is typically caused by deconditioning or lack of fitness, NOT injury or structural pathology. Educating patients about the role and value of fitness for prevention or treatment of chronic symptoms is very simple. Evidence clearly shows the strong relationship between exercise and pain reduction. The same cannot be said for a relationship between most pathology and pain (see Chapter 4
Specific Reactivation Advice—“What Should and Shouldn’t I Do?”
Specific activity modification and reactivation advice is one of the most important aspects of patient education. Reactivation should be gradual. Pain is not a good guide because appropriate activities may be uncomfortable. Allowing pain to be a guide leads to activity avoidance and deconditioning. “No pain no gain” is also inappropriate and will lead to overstrain. Many patients who have trouble recovering either avoid activity entirely or jump back in too aggressively leading to a “boom or bust” cycle.98
Figure 14.2 Relationship between external demand and functional capacity.
Whereas some people catastrophize pain and avoid activities, others with positive moods may try to ignore pain and overexert.99
People use different “stop rules” with activities. The “as many as can” (AMAC) leads to persistence until the task is completed.7
The “feel like discontinuing” (FLD) leads to termination when the task is not enjoyable. Negative mood has different effects depending on a person’s stop rules. If AMAC, then negative mood leads to continuation; if FLD, then negative mood leads to stopping.
Instead of AMAC or FLD, the preferred approach incorporates pacing.100,101
This is a “quota-based” or “graded exposure” approach.100,101,102
The quota-based approach consists of the patient’s activity levels being gradually increased in a stepwise manner limited by quota, not pain. Graded exposure consists of the patient gradually encountering feared stimuli in a supervised setting involving safe, low-load maneuvers. The goal of these methods is to enhance the patient’s confidence or self-efficacy.
Reactivation advice is designed to assure patients of the safety and value of activity. The benefits of nourishing tissues through movement and the dangers of deconditioning are emphasized. Specific topics discussed include:
Benefits and risks of rest versus activity
Modifying daily activities to avoid flare-ups
The safety and benefit of light activity such as walking or swimming
Rest Versus Activity
Deyo performed a controlled clinical trial that compared 2 days of bed rest against 7 days of bed rest. Two days of bed rest was found to be as effective as 7 days of bed rest while limiting the negative effects of prolonged immobilization.103
A Cochrane collaboration review concluded that bed rest104
Has no positive effect for LBP.
May have slightly harmful effects.
Yields no improvement with 7 days compared with 2 to 3 days in LBP or sciatica.
A day or two of bed rest may be appropriate for acute LBP. However, it is important to reinforce that the rest is because of the pain not for the pain.105
The patient is resting because the pain is so severe that
they cannot do anything, but rest will only decondition them and as soon as possible they should start gentle movements (Fig. 14.3
Figure 14.3 Cat-camel.
Patients are informed that prolonged rest reduces blood supply and thus slows healing and recovery. The HCP’s role is therefore to assure patients that early, gradual reactivation is both safe and effective and to instruct the patient in how to accomplish this. Additionally, a very “hot” low back may require a stronger pain management approach guided by patient preferences (manipulation, modalities, medication) to enable the patient to resume near-normal activities sooner.
If one does rest for severe, acute LBP, resting in a semi-traction position is often pain relieving (Fig. 14.4
Avoiding Flare-ups Although rest is not best, neither is continuing to engage in activities that are avoidable and likely to cause a flare-up. As Karel Lewit says, “the first advice is to teach the patient how to avoid what harms him.” Of course, activities that harm one client may help another, so the determination of which activities to avoid should be based on a thorough history and many considerations specific to the individual.
Figure 14.4 (A and B) Semi-traction position for severe, acute low back pain.
People with chronic LBP can also demonstrate impairments in body awareness. For instance a study done by Dankaerts et al in 2006 showed that people who are sensitized to flexion actually sit in flexion whereas people who are sensitized to extension actually sit in extension!106
Some common postures or movements that are easily modified include sitting, bending, and lifting. In each case, the practitioner should help the client identify problematic tasks and explore different ways to perform them, so the client can find better alternatives. This will help avoid flare-ups, build confidence in the ability to continue with necessary activities, and introduce greater variability into the movement repertoires.
When one thinks about activities “bad” for the back, strenuous things such as bending, lifting, twisting (BLT) or certain sports that combine all three usually come to mind. However, prolonged static postures such as in sitting in any one static posture are potential sensitizers to the back. Too little or too much strain is harmful (Fig. 14.5
). Stauber reported that the keys to preventing repetitive strain injuries are appropriate rest times, job rotation, and self-pacing.83
Prolonged sitting is known to be a common aggravating factor for those with flexion intolerant back pain. After only 3 minutes of full flexion of the spine, ligamentous creep or laxity occurs that persists even after 30 minutes of rest!81,107
Even if the static posture is not strenuous, if just 4% of maximum voluntary contraction (MVC) ability is encountered, a negative metabolic state is established.108,109
Other researchers have found that very low levels of muscle contractions during static workloads involving the neck resulted in fatigue and pain.110,111,112
Jensen et al suggested that any sustained static work load of more than 10 minutes should not exceed 2% of MVC.111
Figure 14.5 Relationship between activity history and injury. Reprinted with permission from Abenheim L, Rossignol M, Valat JP, et al. The role of activity in the therapeutic management of back pain: report of the International Paris Task Force on Back Pain. Spine. 2000;25(4 suppl):1S-33S.
Adams et al113
believe that prolonged full flexion renders the spine susceptible to flexion overload during lifting. According to Bogduk and Twomney,114
“After prolonged strain ligaments, capsules, and IV discs of the lumbar spine may creep, and they may be liable to injury if sudden forces are unexpectedly applied during the vulnerable recovery phase.” Once a tissue is strained, it has difficulty returning to its original length. The energy lost after prolonged or repetitive loading is called hysteresis and is represented by the difference between the new and old stress/strain curves (Fig. 14.6
Wilder showed that the motor control signature associated with LBP involves a slow reaction time, decreased peak torque output (power), and increased discharges when irregular load is handled (sustained elevated muscle tension).115
Prolonged sitting was shown to further disturb these variables and a brief walking break was shown to improve them again.
Solomonow et al have demonstrated that the creep reaction may be much more stubborn than previously believed.82
Creep develops in ligaments after just 10 minutes of static flexion. Reduced muscle activity with spasms was found during static flexion periods during a 7-hour recovery period. Multifidus spasm and acute inflammation of ligaments were noted. The dysfunction was reported to outlast the period over which strain occurred by 60 times. The chief three components of cumulative trauma disorders noted were:
Magnitude of load
Duration of load
Frequency of such loads
Figure 14.6 Stress-strain curve illustrating hysteresis. When unloaded, a structure regains shape at a rate different to that at which it deformed. Any difference between the initial and final shape is the “set.” Reprinted from Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2nd ed. Melbourne, Australia: Churchill Livingstone; 1991. © 1991 Elsevier. With permission.
Acute patients should not sit for more than 20 minutes without taking a “micro-break.” The slouched posture leads to overload in the neck, mid back, and lower back, as well as negatively affecting respiration (Fig. 14.7
). Regular “micro-breaks” help to centrate the overall posture for better gravity tolerance. The Brügger relief position (Fig. 14.8A and B
) is performed
by relaxing the arms at the side, supinating the forearms fully, abducting the fingers fully, and then exhaling actively as if trying to make a candle flame flicker but not go out. The standing overhead arm reach (Fig. 14.8C and D
) is performed by reaching the arms overhead gently, taking a big breathe in and holding it, then reaching the arms up all the way and holding.
Figure 14.7 Cog wheel model of joint centration in upright posture. Reproduced with permission from Brügger A. Lehrbuch der funktionellen Störungen des Bewegungssystems. Zollikon/Benglen: Brügger-Verlag; 2000:150.
Erect sitting involves disc pressures significantly higher than that of normal standing. Sitting slumped forward (anterior sitting) increases disc pressure even more, whereas slumping backward (posterior sitting) increases pressure the most.116,117
Using a lumbar support or back rest reduces disc pressures.118
Adjusting the seat backrest angle to 95 to 105 degrees reduces both erector spinae electromyographic activity and disc pressure compared to normal sitting.118,119
Figure 14.8 (A and B) Brügger relief position. (C and D) Standing overhead arm reach.
The chair seat should have certain characteristics to provide a stable base and yet not be too constraining.120
The height of the chair is very important. Too low a seat height will place too much strain on the
ischial tuberosities. Too high a seat will increase pressure on the thighs. Chairs lacking variable height adjustments may need to be complemented by a footrest. The seat edge should not press into the popliteal fossa or this will lead to too rigid a sitting posture. A slight depression for the buttocks is beneficial for stability. A concave seat increases weight bearing through the greater trochanters and internally rotates the femur again restricting movement of the legs. A saddle type seat is thus preferred. Seat angle is controversial, although it is apparent that a forward-sloping seat will increase lumbar lordosis during sitting and maintain the erect sitting position.
Figure 14.9 Typical slouched desk posture.
Figure 14.10 (A-C) Correct desk posture.
The proper desk height is normally approximately 27 to 30 cm above the seat.121
The shoulders should be able to relax with the elbows bent 90 degrees and the hands relaxed on the desk surface. A slanted desk (10-20 degrees) and/or arm rests may also be helpful for reducing neck and shoulder girdle strain. Figures 14.9
show correct and incorrect sitting positions and workstations. Table 14.2
is an ergonomic checklist that can be given to patients or used during the history/evaluation.
It must be stated that there is no one best seated position for all people with LBP. In essence, movement variety and variability is what is needed to help curb the pain some people associate with
prolonged sitting. In recent years, sit-stand desks have been incorporated into workstations to help provide the movement variability needed while still allowing workers the ability to complete their job-related duties. Daved et al found that posture-altering workstation interventions, specifically sitstand tables, were effective in introducing posture variability and that postural variability appeared to be linked to decreased short-term discomfort at the end of the day without a negative impact on worker productivity.122
In special populations, such as those who are overweight or obese, these recommendations should still be fostered. Thorp et al found that transitioning from a seated to a standing work posture every 30 minutes across the workday, relative to seated work, led to a significant reduction in fatigue levels and lower back discomfort in overweight/obese office workers, while maintaining work productivity.123
Figure 14.11 Incorrect desk posture caused by chair too low or desk too high.
Table 14.2 Workstation Ergonomic Checklist
Seat height adjustable
Feet should be on floor and knees no higher than hips
Good lumbar support
Seat back should be able to recline (95-105 degrees)
Tiltable seat pan
Tilt seat forward for desk work
Tilt seat backward for reclining work
Center of monitor nose level
No glare on monitor
Keyboard height so that wrists are not bent, elbows at a 90-degree angle, and shoulders relaxed (not shrugged)
Overall, micro-breaks are an essential component to breaking up the pain cycle that can occur when any singular position is taken to for too long. Even altering positions while seated can help absolve back stiffness in a population of patients with LBP. It has been shown that in chair exercise programs, such as pelvic tilt, gluteal muscle contractions and weight shifts from side to side done on a regular basis help reduce perceived back stiffness in office workers.124
In summary, there is no one perfect posture for everyone and ergonomic recommendations must be made on the basis of the individual characteristics of each unique patient presentation.
When resting or sleeping, it is advisable to sleep with pillows under or between the knees (Fig. 14.12
). The neck can be easily irritated by improper sleep positions. Maintaining cervical lordosis is a key. Either too firm or too soft a pillow is to be avoided (Fig. 14.13
Figure 14.12 (A and B) Spine-sparing sleep postures.
Figure 14.13 Pillows and the neck: (A) ideal, (B) too thin or soft, or (C) too hard or firm.
The problems of prolonged flexion are not limited to sitting and are particularly magnified in the morning. The morning is recognized as a more vulnerable time for the spine. Reilly et al showed that 54% of the loss of disc height (water content) occurs in the first 30 minutes after arising.125
Disc bending stresses are increased by 300% and ligaments by 80% in the morning.113
Avoidance of early morning flexion has been shown to be a wise strategy when recovering from acute LBP.27
Therefore, avoidance of high-risk activities (BLT) early in the morning, after sitting, or stooping in full flexion is crucial to injury prevention.
Figure 14.14 (A-C) Rising from bed.
When rising from bed, simply rolling onto the side and then pushing the body upward from a side lying position, avoiding spine twisting or bending motions is preferable to sitting straight up to get out of bed (Fig. 14.14
Many daily activities involve bending, potentially aggravating the sensitized spine—for instance, getting in and out of a chair, car, or bed. It is important to spare the spine by hinging with the hips instead of the spine. This entails maintaining mild lordosis—the position of “static elastic equilibrium”—when getting in/out of chairs; lifting and bending; squatting, stooping, or kneeling; and stretches (e.g., hamstring).
To perform the hip hinge while rising up from a chair or sitting back down (Fig. 14.15
Start by perching at the edge of a chair.
Stand up and then return to perch position.
This can be progressed by using the seat of a normal height chair.
Key errors to watch for are:
Use a high bench, bar stool, arm rest of a chair or couch, or top of the backrest on a chair turned backward (Fig. 14.16
Use a dowel to demonstrate to the patient the difference between squatting with a hip hinge versus squatting with a stooped posture (Fig. 14.17
Common daily activities can often overload the spine and perpetuate painful syndromes. Simple biomechanical corrections can reduce spine load considerably. Low back strain when brushing teeth can be reduced by placing a hand on the counter top or by using a foot stool (Fig. 14.18
). Strain is increased by bending forward from the waist.
Figure 14.15 Rising from a chair: (A) incorrect and (B and C) correct.
Figure 14.16 Learning to squat with a hip hinge.
Figure 14.17 Hip hinge: (A) correct and (B) incorrect.
Figure 14.18 Brushing teeth: (A) incorrect and (B and C) correct.
When washing one’s face, it is important to squat by hinging from the hips instead of stooping forward from the waist (Fig. 14.19
When putting on socks or tying shoes, it is ideal to bring the foot up to a higher surface and then hinge from the hips. If the foot cannot be raised, it is still possible to hip hinge rather than rounding the back by scooting to the edge of a stool or chair (Fig. 14.20
When changing a baby, the most important thing is to have a changing area of proper height. If it is too low, stooping will be unavoidable (Fig. 14.21
When carrying objects, always hold them as close to the chest as possible to reduce the moment arm (Fig. 14.22
). When picking up a bag with a handle, avoid shrugging your shoulder and leaning to side by allowing your gripping muscles in the fingers to hold the bag (Fig. 14.23
). This will reduce neck, shoulder, and lower back strain.
Pushing a stroller or cart can lead to lower back, upper back, or neck strain if the handles are too low (Fig. 14.24
When moving an object on wheels like a cart, it is easier to maintain a good upright spine posture and generate power when pushing rather than when pulling (Fig. 14.25
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