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Push Through the Pain

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If you have chronic back pain, the best remedy is to rest and avoid strenuous exercise, right? Wrong. According to the team of experts at New England Baptist Hospital in Boston, MA, taking it easy is an outdated and ineffective approach.

With demonstrated effectiveness for improving function and work, exercise is a widely prescribed treatment for patients with acute, subacute or chronic low back pain. There is no evidence that exercise increases the risk of additional back problems or work disability and current studies demonstrate that exercise may reduce pain and disability.

"Years ago, bed rest was the common advice given to patients after an episode or exacerbation," said Kristine Kono, PT, clinical supervisor of the outpatient center at NEBH. "Now we are encouraging patients to move, stretch and even lift very light weights during these episodes."

One of the country's foremost experts on exercise and back pain, James Rainville, MD, is chief of physical medicine and rehabilitation at New England Baptist Hospital. Dr. Rainville and Lisa Childs, PT, senior physical therapist, founded The Spine Center at NEBH in 1997. Affectionately termed Back Boot Camp by patients, the program has widened its scope of patients from those with chronic back pain to a variety of spine dysfunctions.

Back Boot Camp
The fast-growing program is offered in two Boston sites-Chestnut Hill and Dedham. The Chestnut Hill site is a training ground for various medical providers who practice across the country.

In addition to the typical components of a physical therapy evaluation, the PTs issue each patient an Oswestry Disability Questionnaire, measure the patient's range of motion with an inclinometer and have the patient complete a back extension maximum strength test and lumbar and cervical maximum lift strength tests. The lumbar lift is performed as a floor-to-waist stoop lift. Following an evaluation, the patient is given an individualized program that focuses on improving overall flexibility, strength and function.

Treatment frequency and length of stay varies depending on patient availability. Patients generally attend treatment two times per week for six weeks. The initial 20 minutes of a session is a stretch class led by the primary physical therapist.

Patients may stretch on the floor or in a chair depending on their age, disability and fear level and are instructed and refined in the stretches that match the range of motion tested, Childs told ADVANCE. Patients who are able also participate in a 10-minute step-up class. 

"The purpose of the step-up class is to assist patients in restoring their agility, becoming more confident to take gym classes and/or returning to a previous recreational activity," Childs explained.

For the rest of the session-45 to 60 minutes-patients train in the gym. Under the direct supervision of a physical therapist, a physical therapist assistant and an aide, the patient completes a circuit of weight training equipment and lifting activities.

"It can be difficult to convince patients that although initially bending and lifting a weighted box from the floor may be painful, through desensitization, these activities will most likely become easier and more comfortable," Kono stated.   

Each patient has an individualized meeting with a physical therapist to assess pain, develop a long-term exercise plan, progress home or community function, set goals and meet educational needs. The treatment is team oriented under the leadership and direction of a physician and each team member has a defined role to allow for continuity of care, trust building and to ensure expected physical progression. The model offers patients a combination of group and individual treatment.

"The therapy team meets at the end of each session to review each patient," Childs said. "The therapists look for what needs to occur to assist each patient attain his maximal functional potential."

The PTs focus on reversing a patient's range of motion, strength and lift deficits. Deficit improvement is achieved through goal-oriented therapeutic exercise.

"Therapeutic exercise has been shown to decrease pain and is primarily used to provide the patient with the experience to safely and effectively function despite back pain," Childs said. "The treatment is successful when a patient makes the cognitive shift that his performance in physical therapy can be transformed into real life."

According to Childs, the ultimate goal of the program is long-term independent function and self management of the individual's back pain.

Overcoming Kinesiophobia
Many of the program's patients are kinesiophobic and/or demonstrate pain behaviors that present unique challenges for the PTs. To address kinesiophobia-fear of movement, (re)injury and/or pain-the PTs have discovered that placing patients in a group model often motivates them.

According to Kono, a 50-year-old marathon runner with a lumbar disc herniation may overcome his own fear by witnessing the progression of an 80-year-old man exercising beside him.

"The patient receives the benefit of a group milieu and group modeling, with the individualized attention needed to tailor his program to allow attainment of all goals," Childs explained.

Through published research and research conducted in the clinic, these PTs have learned that exercise is not harmful for many, if not all, types of spinal degeneration.

"As we know, the spine can begin degenerating as early as in our 20s and there is no evidence to suggest that exercise increases its rate," Kono explained. "The degree of spinal pathology, for example, does not necessarily correspond with the amount of pain or loss of function someone experiences, and we therefore encourage these patients to stretch and strengthen their spines aggressively."

The PTs do not promise their patients that the pain will go away completely, but often through desensitizing the pain-producing tissues, not only does the pain diminish but also function improves. "This leads to a more active lifestyle, often decreasing the amount of depression, anxiety and kinesiophobia," Kono explained.

"With the doctor's assurance, it is acceptable to work through modest amounts of pain and with our watchful eye and encouragement, I have witnessed so many people transform their lives," Kono said. "Within six weeks, many are dancing, running and simply smiling."

Patient Limitations
Patients frequently complain of pain or difficulty bending to don their socks and shoes, standing and preparing meals, carrying groceries/children, sleeping at night, walking in the community, tolerating yoga/aerobic classes, running, etc., Kono told ADVANCE. To address these concerns, the PTs at NEBH evaluate each patient's trunk range of motion, flexibility and core strength as they progress through the program.

"The most common limitations toward progress include a limited understanding of one's diagnosis or pain exacerbation," Childs said. "When patients have concerns related to their diagnosis, additional education is provided by the physical therapist or physician."

When a patient experiences a pain exacerbation, the patient is assessed to see if the pain is safe to continue treatment. If the patient is not in need of medical intervention, the patient continues treatment at a lower intensity for a few days, and then resumes the expected exercise progression. The exercise prescription may be temporarily altered to allow the patient to tolerate continued strengthening.

Patients are given a specific home exercise program and are encouraged to join a gym to maximize their efforts and achieve their goals. If this is not feasible, the PTs modify the patient's program to be performed completely at home.

"Since having worked at the NEBH spine clinic, I have seen hundreds of debilitated patients walk into the exam room in tears," Kono explained. "[Being] unable to work, care for their families or themselves [made] many of them give up hope."

To alleviate fear and illustrate the program's approach to patients, Kono draws a parallel to the first time one walks barefoot outdoors following a long winter. In this scenario, the patient's feet are initially sensitive but within a short while, he is running around comfortably. Kono explained that the bottoms of our feet become desensitized, as can spinal nerves and muscles.

"Perhaps some of what is happening is placebo with the power of persuasion; most of it I believe stems from desensitization," Kono said. "Irritate something repeatedly and the brain begins to ignore the pain."

Patients are generally focused on decreasing their pain, which they believe must occur before they can regain their function, according to Childs. Patients do not recognize that they can progress their function in the state they arrive.

"The exercise experience has the greatest effect on helping patients overcome their fear of movement," Childs stated. "The goal-oriented program gives the patient needed confidence to begin resuming normal movement."

Dance the Pain Away
Karen Stewart Amber, a 58-year-old social worker, spent 25 years of her life in pain. She unsuccessfully tried surgery, acupuncture and traction to overcome excruciating back pain. After reading about the Back Boot Camp program offered at The Spine Center at New England Baptist Hospital in Boston, MA, Amber enrolled even though she had to travel for weeks at a time from her home in Michigan.

Amber had to adjust mentally and physically to the aggressive approach of the program. "I did things on this program that were exactly what my doctors at home told me not to do," she said. "Like twisting and rotating my hips and doing back extensions."

Doctors and physical therapists traditionally have told patients with back pain to avoid movements or activities that are painful. Kinesiophobia-fear of movement and pain-has prevented many patients from performing what many consider simple tasks.

"Many of our patients have had previous traditional hands-on physical therapy, chiropractic, acupuncture, injections or multiple surgeries," said Kristine Kono, PT, clinical supervisor of the outpatient center at NEBH. "With time, fear of movement had caused their everyday lives to become less functional as they were told by many practitioners to avoid activities that increased their pain."

Amber was focused on regaining functional use of her back and resuming daily activities. At NEBH, Amber was most impressed by the PTs' dedication to helping her achieve her personal goals.

"They kept asking what I wanted to get out of the program, and I said I didn't want to be a jock, I just wanted to be able to pick up my future grandchildren, lift water bottles at Costco and dance at my daughter's wedding," she said.

At least one of her wishes has been granted. Her daughter was married last July and Amber danced every song at the wedding.

"I still have some pain, but this program gave me the confidence to know I can do physical activities without hurting myself," Amber said. "In the past, I would have stopped short, but now I have a whole different mind-set about what I'm able to do."

Amber finished the program in August and joined a gym where she works out for 90 minutes twice a week. She supplements the gym workouts with stretching exercises and riding a stationary bike at home.

Rebecca Mayer is regional editor at ADVANCE. She can be reached at rmayer@merion.com




 
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