Restorative exercise for clinical low back pain. A prospective two-center study with 1-year follow-up.

STUDY DESIGN: A comparison of treatment of 412 patients with chronic back pain at two separate centers using the same treatment protocols and outcome measures. Outcome was defined by specific strength testing; Short Form-36 scores at intake, discharge, and 1-year follow-up; self-appraisal of improvement at discharge and in a 1-year follow-up; and reuse of health care services after discharge. OBJECTIVES: To investigate the efficacy of standardized treatment methods using isolated lumbar strength testing and strengthening based on progressive protocols using specific equipment. Comparison of results should clarify the effect of the treatment center versus the efficacy of standardized protocols. SUMMARY OF BACKGROUND DATA: There has been little support in the scientific literature for exercise programs based on standardized protocols. The use of specialized equipment to achieve intense specific exercise also has been poorly supported. Overall health benefit has not often been related to specific improvement in strength. METHODS: More than 400 individuals with chronic back pain were evaluated at the initiation of treatment, discharge, and 1 year after discharge. Measures of efficacy were based on Short Form-36 scores, self-appraisal of improvement, and reuse of health care services after discharge. Study participants were patients with chronic back pain consecutively referred to each treatment site and underwritten by a variety of payers, including workers' compensation, Medicare, and private insurance. RESULTS: Overall response during the course of the program and at 1-year follow-up was similar between the two centers. Similar proportions of participants at each site demonstrated improvement in SF-36 scores, self-appraisal of improvement, and reuse of health care services. CONCLUSIONS: Standardized protocols using specific strength and measurement equipment can achieve similar benefits at different sites.

Can spinal surgery be prevented by aggressive strengthening exercises? A prospective study of cervical and lumbar patients.

OBJECTIVE: To determine if patients recommended for spinal surgery can avoid the surgery through an aggressive strengthening program. SETTING: A privately owned clinic, staffed by physicians and physical therapists, that provides treatment for patients with neck and/or back pain. METHODS: Over a period of 2 1/2 years, consecutive patients referred to the clinic for evaluation and treatment were enrolled in the study if they (1) had a physician's recommendation for lumbar or cervical surgery, (2) had no medical condition preventing exercise, and (3) were willing to participate in the approximately 10-week outpatient program. Treatment consisted mainly of intensive, progressive resistance exercise of the isolated lumbar or cervical spine. Exercise was continued to failure, and patients were encouraged to work through their pain. Third-party payors in Minneapolis were surveyed for average costs. Average follow-up occurred 16 months after discharge. RESULTS: Forty-six of the 60 participants completed the program; 38 were available for follow-up and three required surgery after completing the program. DISCUSSION/CONCLUSIONS: Despite methodologic limitations, the results are intriguing. A large number of patients who had been told they needed surgery were able to avoid surgery in the short term by aggressive strengthening exercise. This study suggests the need to define precisely what constitutes "adequate conservative care."

Management of back pain in athletes.

Back pain affects millions of people. It affects 80% of the population and up to 52% at any given time. Back pain is not limited to sedentary individuals; it has significant effects on athletes as well. Depending upon the sport, incidence rates of back pain occur in athletes from 1.1% to as high as 30%. Athletes differ from the non-athletic population in that their incentives to return to activity are considerably different than non-athletes. The reasons may vary from the will to win through to significant financial considerations. Although reasons for recovery are different, the physiology and mechanics of repair of injured soft tissue in the athlete is the same as for the non-athlete. Proper management of the athlete requires ruling out emergent causes of back pain such as tumour, infection, acute fracture, progressive neurological deficit, visceral sources (e.g. pancreatitis, abdominal aortic aneurysm), and rheumatoid variants. Once a good history and physical is performed, a simple classification system can be utilised to manage the athlete presenting with back pain. This system can be expressed as: (a) regional back pain; (b) radicular leg pain; (c) radicular leg pain with progressive neurological deficit; and (d) cauda equina syndrome. Each of these categories needs to be managed in a specific manner and can provide the healthcare professional with simple, straightforward guidelines for handling the athlete with lower back pain. The key is to return the athlete to the field of play in a safe and timely manner.

The use and misuse of performance testing.

It is important to consider what performance testing can tell us and what it cannot. A performance test is a "snapshot" which says something about the ability of a patient to execute a specific task. This snapshot is reflective of only that moment in time. If there are no other available tests or there are no normative data from which to formulate a sound clinical plan, the test is at best misleading and at worst completely useless. The drive to utilize performance testing has resulted from an increased demand for accountability and objectivity. It is valuable to keep in mind, however, that if the correct questions are asked and the appropriate equipment and staff are available, performance testing can have an important place in rehabilitation of the spine.

Changes in isometric strength and range of motion of the isolated cervical spine after eight weeks of clinical rehabilitation.

There have been no reports in the literature objectively measuring changes in strength and range of motion in patients with non-spinal-cord injuries of the cervical spine. Ninety patients participated in an 8-week training study. Diagnostic groups included patients with the following: degenerative disc (n = 6), herniated disc (n = 14), and cervical strain (n = 70). Full-range isometric strength tests were performed at eight equidistant positions in a device that constrained all motion with the exception of cervical flexion and extension. Post tests were performed following training. Significant gains were seen in strength as well as range of motion. Perceived pain was significantly reduced. This kind of testing can potentially provide the clinician with objective findings to direct patient management more adequately.

Exercise tolerance and disease related measures in patients with rheumatoid arthritis and osteoarthritis.

One hundred and twenty patients with symptomatic rheumatoid arthritis (RA) or osteoarthritis (OA) in weight bearing joints (RA = 40; OA = 80) performed subjective maximal graded exercise tests on a motor driven treadmill. Disease related measures were also assessed. Findings from this sample indicated that people with arthritis were significantly impaired in exercise tolerance, flexibility and biomechanical efficiency. Significant differences between diagnoses appeared on a number of disease related measures; however, there was little correlation between disease related measures and exercise tolerance. Women demonstrated a greater aerobic impairment than men; and women with RA had a greater aerobic deficit than women with OA.

Wheelchair exercise testing: comparison of continuous and discontinuous exercise.

We have compared wheelchair exercise performed at submaximal levels in a continuous versus discontinuous format. There was a positive linear relationship between heart rate, systolic blood pressure, and VO2 with increasing workload. This was true for both modes of testing with no significant difference in heart rate, systolic blood pressure, VO2, Ve, or Ve/VO2. We conclude that clinical wheelchair exercise testing can be performed in a continuous format without sacrificing physiological data.

Clinical value of exercise testing in handicapped subjects.

This report describes the use of exercise testing in handicapped subjects to determine work capacity and the safety of exercise. Arm crank, bicycle, and wheelchair exercise studies are described by means of a few selected cases.

Wheelchair exercise: a review.

Not much is known concerning the physiological performance capabilities of wheelchair confined populations. Further, the instrumentation to collect physiological data has not been available until recently. It is in the area of work capacity measurement of the handicapped that the arm ergometer is of greatest interest (particularly for those who have a functional loss of one or both legs). In recent years, ther has been an attempt to develop instrumentation and investigate some of the physiological issues surrounding quantified exercise in wheelchair confined populations. The intent of this review is to provide the reader with an overview of the state of the art in wheelchair and wheelchair ergometric cardiorespiratory performance.