Basis, indications and risk: Basis, indications and risk

Treatments Basis, indications and risk Patient information Postural hygiene Exercise Maintaining level of Activity Bed rest Pharmacological therapy Neuroreflexotherapy (NRT) Spinal column surgery Surgery for Pain and Pain Clinics Vertebral manipulation Behavioral treatment Epidural injections Facet joint infections Trigger point and ligament infections Rhizotomy Corsets and lumbar belts Traction Physical therapy/physiotherapy Electromyografic Feedback TENS: Transcutaneous electrical Nerve Stimulation Shoe insoles and shoe lifts Acupunture Recommended treatments

Exercise

Objetive

To develop the muscles for support of the spine.

Theoretical base

A strong and balanced musculature improves spinal stability and performance, decreases risks of intervertebral disc injury and improves mobility. Also, it improves the unconscious coordination of muscles, reducing the risk of overload and injury to muscles or ligaments

In fact, it is proven that the risk of onset or recurrence of back pain episodes is influenced by:

1. General physical fitness: It has been proven that sedentary individuals with poor physical endurance are at higher risk for suffering back pain than those who exercise on a regular basis, even with activities as generic as walking or swimming, which are not specific to the strengthening of back muscles.
2. The status of back muscles: Pain is more frequent and lasts longer in people with weak back and abdonimal musculature. Inversely, specific physical training, adapted to personal characteristics, is also efficient in diminishing the risk of back pain.

Whenever there is or has been back pain

1. 1. At an early recovery phase, or whenever possible during a pain episode, the prescription of some type of light aerobic physical exercise may be indicated to recover muscle tone, especially if the patient has had bed rest. Some of the existing recommendations based on scientific evidence advise:
   1. To start with activities like walking or swimming in order to avoid weakening from inactivity.
   2. Gradually increase the intensity of aerobic exercise. Usually, after two weeks patients may do 20 to 30 minutes daily of gentle aerobic exercise. Although this type of exercise may temporarily and mildly increase pain, it is beneficial at midpoint if pain is well tolerated. In case of poor pain tolerance, exercise should be modified or interrupted.
2. During a second phase, a specific individualized exercise program may be initiated in accordance with the patients' characteristics. Some of the existing recommendations based on scientific evidence advise that this not be done during acute pain, since it will produce a greater strain on the back muscles.

Recommended exercises

There are many standard exercise programs for chronic back pain patients. The most used are the Williams or McKenzie programs. The Williams program essentially consists of abdominal muscle exercises, with spinal flexion (bending forward). On the contrary, the McKenzie program encourages postures and exercises with spinal extension (bending backward). This latter one is the only one indicated for specific acute patients, according to some of the existing recommendations based on scientific evidence.

Scientific studies to evaluate the effect of one or the other program show that there is no general plan that has proven useful for all patients. With the Williams exercises, as with McKenzie's, some patients improve and others worsen. Physical exercise may be useless, or even harmful if the same exercises are prescribed to all patients.

It is necessary to individualize exercises and training for each patient, according to factors such as prior physical fitness, spinal characteristics or other existing disorders.

To determine which exercises are most suitable, patients must be individually evaluated. There are two ways:

1. A detailed physical examination, directed at determining the strength of the different muscle groups, possible muscle shortening or tension, and if muscle activation causes pain. The outcome of this physical examination will enable establishing the most convenient exercises as well as those to be avoided by a particular patient.
2. Although exercises may have been properly prescribed, they may prove useless or harmful if not done correctly. This is why it would be wise to have patients perform prescribed exercises under supervision. Once patients are trained, they may perform exercises by themselves, and return to physical therapists or coaches to check whether they are being done correctly, or to their physician to ensure that the prescribed exercises are still the most suitable.
3. 3. Some authors defend the need to use sophisticated technology to determine the mass and strength of the different muscle groups, to identify the muscles to be developed and to prescribe the necessary exercises. Some authors defend the use of computed devices to precisely measure the strength of each individual muscle group. Others use a real-time sonogram, to enable patients to visualize the contractions of the muscle they must work on, to ensure their effort is specifically directed at the muscle to be strengthened.
4. 4. The problem is that this type of rehabilitation is expensive. It requires sophisticated technology and lots of time, since each patient will be individually using the device, occupying it during a long period of time. Moreover, there are no studies showing the superiority of these methods in comparison with those based on a physical examination and the performance of exercises by well trained patients.

Evidence of efficacy

The existing recommendations based on scientific evidence take into account the results of scientific studies that suggest exercise efficacy in chronic patients, especially for improving pain, mobility and autonomy.

Risks and contraindications

In the presence of inflammation and muscle contracture, exercise may increase the contracture and exacerbate pain. That is why exercise is contraindicated in acute pain. For acute pain patients, only some of the existing recommendations based on scientific evidence advise mild exercise plans, selecting the patients for whom it should be prescribed by means of the McKenzie criteria.

Poorly prescribed or performed exercises may aggravate patients' muscular instability. This is why not all patients should follow the same exercise plan: what may be indicated for one patient may be counter-productive for another.

Exercises that elicit pain or increase existing pain must not be performed. Exercise during acute pain is harmful, except in those cases of back pain radiating leg or arm pain where radiated pain improves or disappears, although back pain may increase with exercise.

Indications

Physical exercise is indicated for the healthy general population, to decrease risk of back pain; and in chronic patients, to improve their autonomy, speed their recovery and diminish the risk of recurrent painful episodes.

The existing recommendations based on scientific evidence suggest starting with general exercises and beginning muscle strengthening six weeks after the onset of pain.