SECTION C: Physical Treatments for Pain

INTRODUCTION

The objectives of this chapter are to review the literature for articles about skilled therapy services applied to treat painful conditions; report primary outcomes of therapy participation (improved flexibility, strength, and endurance); and report secondary outcomes of therapy participation, including improved pain, disability, and quality of life. When the literature is informative, patient and provider attributes that guide patient selection for therapy are discussed. The terms “physical therapy for chronic pain” and “human,” were used to search the literature from January 1999 to January 2013. The search yielded 4940 articles, of which 200 were selected because they describe the application of licensed physical therapy¹ or the use of multidisciplinary programs² or functional restoration^3,4 as treatment for a painful disorder. That Cochrane reviews, systematic reviews, meta-analyses, randomized controlled trials (RCTs), and small series are included. Licensed physical therapy, as defined by the Centers for Medicare and Medicaid Services (CMS), is under the scope of PM&R and is a therapeutic activity funded by CMS and other payers in the United States. For articles not written in the United States, articles were selected that implied that a medical professional with an equivalent educational and licensing level of “licensed physical therapist” provided therapy services. Excluded were articles pertaining to exercise done at home or in a commercial gym, club, or spa, biofeedback, complementary and alternative medicine ([CAM]: homeopathy, acupuncture, hydrotherapy, massage), chiropractic manipulation, Tai Chi, Qi Gong, yoga, Pilates exercises, spas, balneotherapy (warm springs), mindfulness therapy, and cognitive-behavioral therapy (CBT) independent of a multidisciplinary program. Also excluded were articles that described exercise administered in nonmedical settings (commercial gyms or spas or home) and by trainers, instructors, certified trainers, “qualified lab personnel,” and kinesiologists. These exclusions were made because these activities, settings, or personnel do not fall under the scope of PM&R (e.g., CBT alone) or are activities that neither require medical prescription nor are reimbursed by medical insurance.⁵ (Fig. 96-1).

Discussions of rehabilitation applications for pain in the low back, knee, neck and pain caused by fibromyalgia and chronic regional pain syndrome, which were covered in the second edition chapter, are updated here. The current literature review permits a discussion of PM&R treatments for pain in the head and pelvic regions and for pain due to Achilles tendinopathy. The constructs of “back schools,” multidisciplinary programs, and functional restoration are also discussed.

BACKGROUND

The PM&R chapter in the second edition⁶ described the scope and philosophy of PM&R, explained the components of a detailed therapy script, and outlined basic prescriptions for various painful diagnoses. Simply put, PM&R focuses on function and performance and on restoring or compensating ability despite disease and impairment. The practice of PM&R spans the settings of home health, inpatient, outpatient, and community reentry. Our literature search confirms that most PM&R services that are accessed to treat pain are delivered in the outpatient setting.

The practice of PM&R has a long multidisciplinary tradition in which the physician works in concert with physical therapists (PTs), occupational therapists (OTs), and speech therapists, as well as social workers, nurses, pharmacists, psychologists, and recreational and vocational (or child life) specialists. Physical therapists help patients with gait or alternative mobility and trunk and lower limb strengthening, and OTs help patients with upper limb dexterity and strength, self-care, and activities of daily living. The literature search confirms that treatment of simple pain disorders may require only the physician and PT or OT; however, complex chronic pain disorders that cause severe disability and handicap may require treatment in a multidisciplinary program or a functional restoration program in which the services of a psychologist, nurse, or social worker are enlisted.

A physician writes a prescription to communicate the specifics of treatment to another allied health care provider, the medical record, and also the patient. There is no gold standard for what a therapy prescription should include, but Currie and Marberger⁷ suggest patient name and diagnosis, goals of treatment, discipline of the treating therapist (T, OT, speech therapist), precautions, and date of reevaluation. A physician familiar with options provided by a PT, OT, or speech therapist may elect specific types of exercise or treatments (Table 96-1). However, precautions, contraindications, or limitations to exercise are most important and should be discussed first.

A prudent physician pauses before prescribing a therapeutic moiety and, in the case of PM&R, considers any attribute of the patient that contraindicates participation in exercise or use of a thermal or electrical modality. It is second nature for a physician to ask about allergies prior to prescribing a medication. Exercise allergy is possible even when the antigen is unknown.⁸ Exercise mobilizes leukocytes and induces an initial inflammatory response; albeit rare, derangements of this inflammatory response, up to and including anaphylaxis, as well as exercise-induced asthma, and exercise-induced urticaria are possible.⁸ Medical and surgical conditions may limit, delay, or preclude exercising a patient. Writing about resistance exercises, Wai states that unstable medical or surgical conditions preclude participation.⁹ Wai cites the American Heart Association (AHA) article that recommends that persons with unstable ischemic, valvular, hypertensive, or arrhythmic conditions should not participate in resistance (strengthening) exercises¹⁰ (Table 96-2). Persons with these untreated or unstable diagnoses should not participate in aerobic,^11,12 aquatic, or flexibility exercises. Resources from the American College of Sports Medicine (ACSM) note other unstable medical conditions, including metabolic disorders (e.g., uncontrolled diabetes), hematologic disorders (e.g., acute deep venous thrombosis, severe anemia, coagulopathies, disorders of hemostasis), open wounds and certain skin eruptions, and unstable or untreated spinal or extremity fractures^11,12 (see Table 96-2). May notes that the exclusion criteria of studies may inform decisions about patients “felt to be unfit for physical therapy treatment,” for example, individuals with fracture, grade III or IV spondylolisthesis, malignancy, inflammatory arthropathies, pregnancy, significant neurologic loss, and prior spine surgery.¹³ In order to avoid burns, hot or cold modalities should never be used on insensate or vascularly compromised skin.⁶ In the United States, millions of people access PM&R services annually, but a complete history and physical examination are requisite to confirm diagnoses and conditions that limit, delay, or proscribe exercise participation. If there is a question regarding the patient's ability to participate in an exercise program or how to adjust an exercise program so that a patient may participate, consultation with a PM&R physician may be in order.

A physician familiar with the spectrum of treatments provided by a PT, OT, or speech therapist may elect to specify certain types of exercise or treatments (see Table 96-1). The goal of the second edition chapter was to familiarize physicians with exercise options. The ACSM guidelines are excellent resources for information about the medical prescription and monitoring of exercise and applied exercise physiology.^11,12

Stretch and flexibility are initial steps in an exercise program and prevent injury to soft tissue.⁶ Slow sustained stretch held for 60 seconds is optimal.⁶ The activity of stretching may not distend the myotendonous unit as much as increase tolerance of the activity. Discussing hamstring stretch, Halbertsma demonstrates no change in the length or elasticity of hamstrings with applied stretch; rather increased tolerance of stretching activity occurs.¹⁴ The presence of tubes, wires (new spinal stimulator implantation), and lines may limit participation. Stretching has been shown to relieve pain at least briefly. Lewitt studied patients with myalgic pain and found that stretch applied immediately after an isometric contraction gave immediate pain relief in 94% of patients.¹⁵

Strength refers to the ability of a muscle group to apply force.¹⁶ There are three types of muscle contractions and three types of strength training: isometric, isotonic, and isokinetic. The first type, isometric (“same length”) contraction occurs when the muscle is hardened, or “set,” and the length of the muscle does not change.⁶ The body builder posing with his elbows flexed and biceps contracted is an example of isometric contraction. In contrast to static isometric contraction, isotonic contraction has motion and contracts a muscle through all or part of its normal range of motion (ROM) while lifting a constant amount of weight. Lifting a dumbbell as the elbow moves from full extension to full flexion is an example of an isotonic contraction of the biceps. There are two types of isotonic contractions: shortening, that is, concentric contraction, and lengthening that is, eccentric contraction. Concentric strengthening creates power, but eccentric strengthening increases tendon tensile strength or lengthens tendon or the myotendonous junction.¹⁷ The third type, isokinetic contraction, occurs when the muscle contracts against a fixed torque. Club machines with cams and fixed axes or a heavy door on a hydraulic governor provide examples if one pulls against them. Strength training improves the force production of a group of muscles by any of the following mechanisms: an increase in the number of motor units activated, an increase in the rate of activation, an increase in the synchronization of motor units firing, or the hypertrophy of muscle fibers.¹⁶

Strengthening occurs as long as exercise continues to the point of fatigue. The various formulas for strength training involve lifting some percentage of the “one-repetition-maximum” that a muscle group can move and doing repetitions to the point of fatigue. For example, if the heaviest dumbbell an individual can lift (safely) with the biceps is 20 pounds, the one repetition maximum, then a strengthening strategy might be lifting 10 pounds for 10 repetitions and then 15 pounds for 10 repetitions or less if fatigue occurs. When weights are handled through a set of repetitions, additional weights can be added. For strengthening to be accomplished, strengthening regimens of each target muscle group must be performed to fatigue about three to five times per week.⁶

Contraindications and precautions for strength training exist.⁶ Strengthening exercise is contraindicated in the presence of fracture; the orthopedic surgeon should prescribe permitted activity and denote prohibited activity for a fractured limb and the contiguous joints.⁶ If this is not specified, the primary physician or health care provider should ask the orthopedist to determine allowed ROM, weight-bearing, and exercises permitted. Strengthening exercise acutely increases blood pressure, and this vital sign needs to be monitored in patients with hypertension.⁶ Persons should have a “spotter” or partner when performing strengthening exercises, especially with free weights.⁶ Strengthening exercises are contraindicated in the presence of acute or unstable cardiopulmonary disease.⁶

The last exercise type is endurance, also known as aerobics, which involves the rapid repeated motion of large muscle groups under low load, often to accomplish locomotion (jogging, swimming, biking) for a prolonged period. Endurance is the time that a person can maintain either a static force or a power level involving a combination of concentric and eccentric muscle actions.¹⁸ Endurance is “the ability to continue a prescribed task in the desired manner.”¹⁹ Although strengthening exercise increases muscle force, endurance exercise increases aerobic capacity, or maximal oxygen uptake (VO₂). As a result of endurance training, the number and size of mitochondria in muscle increase, the activity of mitochondrial enzymes increases, and blood flow to muscles increases because of increased numbers of capillaries and improved efficiency of blood flow shunting.¹⁸ Adaptations in the heart and vasculature include increased stroke volume, expanded blood volume, decreased resting heart rate, and decreased resting systolic and diastolic blood pressure.¹⁸ To achieve an endurance effect, the patient needs to participate in 15 to 60 minutes of continuous aerobic activity three to five times per week at sufficient intensity to raise heart rate to 60 to 90% of maximum.⁶ A maximal exertion exercise treadmill test can determine maximal heart rate; however, an easy approximation of maximal heart rate for a given age is arrived at by subtracting the patient's age from 220.

Howley writes about the classification of leisure and occupational activity in terms of aerobic and metabolic physiologic expenditures.²⁰ Patients often report that they get “plenty of exercise” in this manner. However the randomness of both the vector and intensity of work and leisure activity although it may expend calories, may not achieve strength, flexibility or cardiac endurance above the demand requirements the individual encounters and may expose the individual to risk and injury not inherent in isolated measured exercise.

To reiterate, this chapter is a review of the recent literature for articles pertaining to PM&R applications, that is, supervised exercise by a licensed therapist or multidisciplinary and functional restoration programs for the treatment of painful disorders, and to assess and report the effectiveness of these treatments. There are limitations for the review, and Mayer elegantly comments “that studies on therapeutic exercises often fail to provide details on the specific exercise techniques used and the exact exercise protocol that was prescribed or followed (e.g., dose, timing, intensity) and guidelines and systematic reviews frequently combine various forms of therapeutic exercise and ignore important differences among the types of exercise.”²¹ Exercise to relieve pain and applied at home or a commercial gym or the effectiveness of Eastern exercise and lifestyle traditions for the relief of pain is a different topic and not answered in this chapter.

NECK PAIN

In the second edition, a physical therapy prescription for neck pain that included corner stretches, cervical-thoracic stabilization exercises, and postural correction of head thrust position was described.⁶ The literature review for this edition supports that stretching for chronic neck pain is effective²² (Table 96-3). The literature finds that low-intensity postural neck exercise is not supported.^23,24 Deep cervical flexor (DCF) strengthening, which is believed to affect head and neck posture, does show correlations between improved electromyographic readings (a proxy for strength) decreased neck pain, and disability^25-29 (see Table 96-3). The review article by Ylinen reports that the effectiveness of long-term isotonic and isometric strengthening exercises of the neck and shoulders for chronic and recurring neck disorders was supported.²³ Pain and disability due to chronic neck pain are significantly improved not only by strengthening but also by endurance and coordination regimens³⁰ (see Table 96-3). The treatment of acute and chronic whiplash with exercise modalities continues to be problematic.^31-33 Only one study was found that evaluated the predictors of poor short-term and long-term outcomes for patients undergoing a rehabilitation program for chronic neck pain: Cecchi et al. concluded that poor outcome was predicted by pain-related medication intake in the short term and long term and by catastrophizing in the long-term.³⁴

A Cochrane review on applied exercise for mechanical neck disorders concludes that combinations of cervical and scapulothoracic stretching and strengthening for chronic neck pain improved function in the short and intermediate term.³⁵ However, chronic neck pain does not respond to upper extremity stretching and strengthening or a general exercise program.³⁵ Neck strengthening exercise in acute cervical radiculopathy relieves pain in the short term.³⁵ Many, but not all, studies analyzed in the Cochrane review describe the administration of an exercise program by a PT; however, some exercise regimens were self-administered or administered by a nonrehabilitation practitioner such as a chiropractor, which are applications outside the scope of PM&R.³⁵ The studies subsequently discussed are performed by a PT within a PM&R setting.

Cunha et al. found that stretching significantly reduces neck pain immediately and at 6 weeks.²²

Cunha et al. compared prolonged stretch (15 min) with manual therapy (pommage) versus conventional stretch after pommage, performed twice weekly for 6 weeks.²² Both were equally and significantly effective in reducing pain and improving the ROM and quality of life of women patients with chronic neck pain immediately after treatment (VAS 6.6 to 2, combination and 7.2 to 1.6 conventional stretch only, P > .000) and at a 6-week follow-up (VAS 3.2 combination, and 2.7 conventional stretch only)²² (see Table 96-3). The authors concluded that stretching exercises should be prescribed to chronic neck pain patients.²²

The literature review identified one active comparator trial²⁴ and one review article²³ regarding postural correction. The active comparator trial by Griffiths suggests that although posture exercises alone or combined with neck stabilization exercises (four sessions over 6 wk) may show a trend toward improving disability.²⁴ A significant finding in Griffiths's study is that neck stabilization groups were less likely to be taking pain medication at 6-week follow-up (P < .02).²⁴ Ylinen concludes that the effectiveness of postural and proprioceptive low-intensity exercise regimens for chronic neck pain is not supported.²³

Jull et al.²⁶ discuss imbalance or impaired function of the deep cervical flexors (DCF) associated with chronic neck pain. Impaired function of the DCF may allow extension in the upper cervical segments and flexion in the lower segments and a head-forward posture. Rudolfsson et al. studied sagittal movement of persons with chronic neck pain and reported reduced extension in the upper cervical levels and reduced flexion for the lower levels.²⁹ Additional altered ratios between ROM for the upper and lower levels was observed with less contribution of motion of lower cervical levels to the total sagittal ROM compared with pain-free controls, but the findings were not explained by greater forward head posture.²⁹ These sagittal changes may relate to DCF weakness. Strengthening the DCF results in improved pain rating²⁵ and neck disability scores^25,26 and in improved muscle strength as indicated by electromyographic proxy.^25-28

In an RCT of low-load exercises of the DCF, C-CF versus higher load neck flexion exercises, Jull et al.²⁶ report improved electromyographic (EMG) amplitude DCF after C-CF training as well as decreased EMG amplitude of the superficial flexors (scalenes and sternocleidomastoid). The relative latency between the activation of the deltoid and the DCF during rapid arm movement in the C-CF group shortened compared to the strength group (P < .05).²⁶ Average pain intensity (C-CF decreased 1.7+/−2.0 and strength group decreased 1.0 +/− 3.3, both P < .001)) and neck disability index score significantly decreased in both exercise groups (C-CF −5.0 +/− 4.2 (P < .05) and strengthening group −3.5 +/− 2.3, P < .001) (see Table 96-3). Baseline pain on a scale of 10 was 4.5 +/− 1.0 in the C-CF and 4.2 +/− 1.0 in the strength group while baseline disability on a 50 point scale was 11.0 +/− 2.7 and 9.6 +/− 3.1, respectively.²⁶ O'Leary evaluated change in pain (visual analog scale [VAS]) and change in pain pressure threshold (PPT) after a single performance of C-CF versus neck flexion exercises.²⁵ He found an immediate small but significant improvement in pain and in PPT (change on 10 cm VAS 0.42 cm vs. 0.11 cm, P < .04) (PPT increase of 21% (P < .001)) in the C-CF group.²⁵ Falla et al. undertook a prospective strengthening program for the DCF 14 subjects with supervision from a PT once a week for 6 weeks with home repetition twice a day.²⁸ The activation of the DCF increased (P < .0001) most in patients with the lowest amplitude of DCF EMG at baseline.²⁸ A significant (P < .05) relationship existed between initial pain intensity, change in pain level with training, and change in EMG amplitude for the DCF during C-CF.²⁸ Pain decreased with the exercise regimen from 4.1 +/− 1.7 to 2.3 +/− 2.3 (P < .01) VAS 0-10) and neck disability index (possible 50) decreased from 10.2 +/− 2.7 to 5.5 +/− 4.4, P < .001) (see Table 96-3). The baseline characteristics of some test subjects demonstrated only moderate pain and disability related to chronic neck pain, but for persons with similar symptomatology C-CF exercises demonstrated efficacy for reducing pain and disability.

Another controlled trial by Falla et al.²⁷ used C-CF low load exercises as a comparator versus a neck flexion endurance-strength regimen for the cervical flexors to evaluate if superficial cervical flexor muscle fatigue could be improved in patients with chronic nonsevere neck pain. Maximal voluntary contraction of the anterior scalenes and sternocleidomastoid was significantly improved in the endurance-strength group (10.1 +/− 17.3 N, baseline 75.5 +/− 17.9 N) versus the C-CF group (1.8 +/− 10.6 N, baseline 78.2 +/− 19.1 N) (P < .05)²⁷ Average intensity of pain about 1 point on a 10 point scale in each group (baseline ~4) and neck disability index score decreased about 3 points in both intervention groups (baseline ~10).²⁷ Falla et al. note that these changes although small are significant. This study underscores the specificity of exercise for both targeted muscle (in this study, the superficial flexors) and type of exercise; that is, strength-endurance regimens improved strength-endurance.²⁷ Pain improves regardless of the exercise regimen, and the authors draw no conclusions about the interaction or directionality of improved pain and improved strength endurance.²⁷

O'Leary et al. compare mobility, endurance, and coordination exercises showed training specific benefits with between-group comparisons revealed significantly greater gains in endurance (P < .02) by the endurance group, and significantly greater gains in coordination (P < .01) by the coordination training group. However, all three groups had improvement in pain (P < .01) and disability (P < .01) (see Table 96-3).³⁰ The authors comment that subjects with mild to moderate symptoms are recruited so that the study regimens can be completed but they hypothesize that patients with more severe symptoms might benefit.

A RCT to determine the dose or intensity of exercise required to decrease chronic neck pain was accomplished by Nikander.³⁶ Patients in the control group received baseline strength measurements and several days of instruction in stretching with a recommendation to complete aerobics activities three times a week. Patients in the two active groups were trained by a PT for 12 days in strength or endurance exercises and continued the exercise program at home for 1 year.³⁶ Strength and endurance training (compared to the control group) decreased perceived neck pain and disability.³⁶ Declines in neck pain and disability correlated positively with the amount of specific training, and specifically neck, shoulder, and upper-extremity training for more than 8.75 metabolic equivalent of task (MET)-hours per week was an effective training dose for decrease of neck pain.³⁶ One MET-hour of training per week accounted for a 0.8-mm decrease of neck pain on a VAS (100 range VAS) and a 0.5-mm decrease on a disability index.³⁶ Improvements in pain and disability occurred in both the strength and endurance-training groups. The pain and disability baselines in this study indicate a more symptomatic group.

Ylinen et al. studied isometric strengthening versus dynamic endurance training trained over four sessions with a PT and then carried over at home for 12 months. In the strength training and aerobic training groups the greatest gains in neck strength, as well as decrease in neck pain and disability, were achieved during the first 2 months, and improvements continued up to 12 months.³⁷ The isometric strengthening group achieved the greatest strength gains at all follow-ups, and change in neck pain and disability indices correlated with the isometric neck strength.³⁷ The baseline VAS of the subjects was 58 (VAS range 100) and at 12 months, the strength group improved 69%, the endurance group improved 61%, and the control group improved only 28% (P < .001)³⁷ (see Table 96-3). Ylinen et al. crossed the control group who had only minor changes in pain and functional measures in this study over high-intensity strength training.³⁸ Significant decreases in neck pain and disability indices occurred, and maximal isometric neck strength increased in flexion and rotation and extension at the 2-year follow-up.³⁸

Other PM&R strategies applied to treat neck pain include grade exercise, a multidisciplinary rehabilitation program, and a multidisciplinary or functional restoration type program with exercise and fear avoidance training. Pool et al.³⁹ studied behaviorally graded progressive exercises (BGA) versus manual therapy each applied by PT for the treatment of subacute (4-12-wk duration) neck pain. Pain and function were improved about 90% of the time.³⁹ The statistically significant overall effect was found on the NDI in favor of the BGA treatment.³⁹ An active comparator trial of multimodal group rehabilitation practicing stability, strengthening, and proprioceptive exercises with an educational program, 1 hour a week for 6 weeks, was compared to control group treated as deemed appropriate by their physiotherapist.⁴⁰ Both groups significantly improved in both function and pain scores (4.6 +/− 2.3 and 4.5 +/− 2.2, P <0.01). There was no significant difference in improvements in disability or pain between groups.⁴⁰ No comparison based on program cost or patient time expenditure or convenience was made. Taimela et al.⁴¹ compared a functional restoration type program to an active comparator of home exercise with two educational sessions to an inactive control group of education alone for the treatment of chronic neck pain. The exercise regimen for chronic neck pain, administered by a physiotherapist, which included 24 sessions of cervicothoracic stabilization, relaxation training to reduce unnecessary muscle tension, behavioral support to reduce anxiety and fear, and seated wobble-board training to improve postural control, yielded a significant reduction in neck symptoms and improvement in general health and self-reported working ability at 3 and 12 months.⁴¹ A trend of improved psychological well-being was observed at 3 and 12 months but was not significant.⁴¹

Little regarding modalities and neck pain was identified in our literature search. A study group in Hong Kong found that TENS (150 us square pulses at 80 Hz) applied over acupressure points for 30 minutes was as effective as strengthening exercise (twice a week for 6 weeks) compared to infrared radiation (heat lamp for 20 min) to improve disability, isometric neck muscle strength, and pain at 6 weeks and at the 6-month follow-up.⁴²

Lastly, the literature suggests that the neck disorder whiplash, both in acute and chronic states, has limited PM&R treatment options. Regardless of active or inactive treatment of acute whiplash Kongsted et al. showed 50% of subjects with pain at 1 year.³¹ The randomized parallel group trial for acute whiplash showed no differences among three treatment groups lasting 6 weeks. The treatment arms included immobilization with a neck collar for 2 weeks and then mobilization, “act-as-usual,” or mobilization, with weekly evaluation and instruction by a PT in ROM and exercise completed at home.³¹ The progressive mobilization was based on principles of mechanical diagnosis and therapy (MDT), which are based on repetitive movements directed by pain response. At 1 year, about one-half of subjects reported considerable neck pain and disability and one-seventh had not returned to work.³¹ A RCT for chronic whiplash demonstrated that exercise and advice was significantly more effective than advice alone to reduce pain intensity and pain annoyance and improve function at 6 weeks; however, the effect did not persist at 12 months.³² In the exercise group, activities included aerobic exercise (e.g., a walking or cycling program), stretches, functional activities, activities to build speed, endurance and coordination, and trunk and limb strengthening exercises, all performed with the PT two to three sessions per week for 6 weeks.³² Greater treatment effect was observed with patients with higher levels of initial pain or disability.³² A review of RCT and non-RCT analyzing the effect of defined physical therapy protocols or multidisciplinary programs on whiplash associated disorder (WAD) support the use of interdisciplinary interventions and chiropractic manipulation but not strongly.³³ Regarding exercise the review concluded that more effective regimens were supervised, and started earlier but aggressive subacute programs like work hardening could be counterproductive.³³

In considering PM&R treatments for neck pain, whiplash may be a distinct entity because of its less favorable outcome after these interventions. However for patients with moderate chronic neck pain and related disability, stretch, strengthening, endurance training, and deep neck flexor strengthening supervised in a PM&R setting have demonstrated significant improvement.

KNEE ARTHRITIS AND OTHER KNEE PAIN SYNDROMES

In the second edition, a physical therapy prescription was outlined including instruction in cane use and joint protection, hamstring stretch and progressive strengthening of the quadriceps, and low-impact or pool aerobics, as well as the use of TENS or ice for pain.⁶ The interim literature for the third edition chapter yielded five review articles (two on exercise,^42,43 two on TENS,^44,45 and one on bracing⁴⁶) and four controlled trials (two on exercise,^47,48 one on exercise with bracing,⁴⁹ and one on diathermy⁵⁰) for the treatment of knee pain, generally due to osteoarthritis but also anterior knee pain.⁴⁹ Strengthening and aerobic types of exercise improve pain and function,⁴² walking pain and locomotor function,⁴³ and pain and strength⁴⁷ in osteoarthritis. The Jessep study compared cost of individual supervised therapy to cost of activity and education administered at a community center with simple equipment and found no differences at 12 months in clinical outcomes (WOMAC pain and function, HADS anxiety and depression, and aggregated physical performance); however, there was significant (50%) cost savings with the community center approach⁴⁸ (Table 96-4). Regarding patient selection, only the Brakke review article noted that patient traits that predict a response to physical therapy include “milder disease (i.e., unilateral OA, symptoms for less than 1 year, and a 40-m self-paced walking test faster than 25.9 seconds)” and those who rate their pain 6 or greater on the numerical pain rating scale.⁴² Fatalism and fear that activity can worsen arthritis may bode work against a positive physical therapy outcome.⁴² Overall the interim literature does not support the use of TENS in knee arthritis.^42,45 Bracing may be helpful, but compliance after 6 months declines.⁴⁶

Exercise continues to be a primary PM&R treatment for knee arthritis, and Brakke et al.⁴² conclude that “strength training, aquatic therapy, and balance and perturbation therapy were the most beneficial with respect to reducing pain and improving function.” Bennell and Hinman⁴³ reviewed application of exercise for primarily knee osteoarthritis across the spectrum of self-administered to therapist-supervised scenarios and reported that strengthening improves strength, pain, and physical function while aerobic exercise benefits pain, joint tenderness, functional status, and respiratory capacity. Bennell and Hinman also caution that the literature does not clarify the optimal exercise modality and dosage for osteoarthritis of the knee and the existing literature has not compared exercise regimens on the basis of exercise modality, intensity, duration, and/or frequency.⁴³ Specific to therapist administered exercise, Bennell and Hinman cite an 8-week program that led to significantly greater improvements in locomotor function and walking pain long-term at 12 months. Bennell and Hinman also report a smaller treatment effect with regimens fewer than 12 sessions but 12 or more supervised sessions having a moderate effect.⁴³ One study comparing types of exercise showed isokinetic exercise to improve strength and pain better than isometric exercise of the knee.⁴⁷ Hernandez-Rosa et al. compared 8 weeks of isometric to isokinetic strengthening applied every third day.⁴⁷ Isokinetic exercises had greater effectiveness for strength gains and pain relief (see Table 96-4), but ROM was similar.⁴⁷ The Jessep article highlights cost-efficiency in the delivery of skilled therapy services.⁴⁸ The community-based ESCAPE program starts with patient education and group discussions and instruction and supervision in the performance of an exercise set with the PT.⁴⁸ Over time the ESCAPE patients become independent with the carryover of the regimen. Patients in the ESCAPE paradigm were compared with patients receiving individualized therapy.⁴⁸ Although the authors use inconsistent terms to describe the number of visits, the authors suggest that the ESCAPE patients had about twice as many (8, presumed median) visits for strengthening exercise as the individualized therapy group (median 4) at about one-half the cost, £583 (currency expressed as pounds) per subject for the individualized group versus £320 for an ESCAPE subject.⁴⁸ Outcomes on the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain and function indices, the Hospital Anxiety and Depression Scale (HADS), and the aggregated functional performance time (AFPT) for four tasks were similar between groups.⁴⁸ In sum, aerobic and strengthening (preferably isotonic or isokinetic) exercises improve pain and function related to symptomatic knee arthritis. Twelve or more visits may have a more substantial dose effect than fewer than 12 visits for this diagnosis. The setting in which supervised therapy is delivered did not affect outcome, and paradigms for economical therapy service delivery exist.

In addition to osteoarthritis other painful conditions of this joint exist. For refractory anterior knee pain, Schneider⁴⁹ described a study comparing 8 weeks of proprioceptive neuromuscular facilitation with 16 exercises to a training program using a special resistance-controlled knee splint for 15 minutes three times daily. Increased electromyographic activity in the vastus medialis muscle increased in both groups but a significant improvement in pain was observed only in those treated by knee splint.⁴⁹

A Cochrane review in 2000 reported that TENS and acupuncture-like TENS were more effective than placebo for the relief of pain and stiffness due to knee osteoarthritis.⁴⁴ However the updated review in 2009 of interim smaller studies of questionable quality did not confirm that TENS is effective for pain relief.⁴⁵ Brakke also concludes that electrical stimulation likely has little impact for knee osteoarthritis and also that evidence regarding manual therapy is equivocal.⁴²

A modality for knee osteoarthritis includes diathermy (433.92 MHz microwave), and Giombini et al. showed that the modality reduces pain and improves physical function in patients with moderate knee arthritis symptoms when applied 30 minutes three times a week for 4 weeks and compared to sham treatment.⁵⁰ The last review article of physical therapy interventions for knee pain due to unicompartmental arthritis reported that patellar taping reduces pain and knee unloader braces improve symptoms; however, about one-half of patients discontinue brace use within 6 months.⁴⁶

ACHILLES TENDINOPATHY

Achilles tendinopathy is one of the most common foot and ankle complaints related to sports and overuse injuries. A discussion of the exercise treatment of Achilles tendinopathy is included because the clinical complaint is common and the regimen is simple. In contrast to other painful diagnoses discussed in this chapter, Achilles tendinopathy and its treatment fall in the realm of sports medicine, in which a primary goal of intervention is the expedient return of the athlete to his or her sport, whether at the level of a professional athlete or as a tenacious weekend warrior. Unlike patients with chronic pain who may need supervision and education to overcome fear avoidance and kinesiophobia, athletes may require supervision and education to allow adequate healing and to improve techniques to prevent reinjury and safe return to play.

Eccentric training for chronic Achilles tendinopathy is described in the literature. After initial supervised instruction with a PT, the exercises can be performed independently. Petersen et al. demonstrate the technique that compared eccentric stretching to an ankle bracing device to both treatments.⁵¹ Eccentric training can be done with the patient standing on tiptoe, that is, the foot plantar flexed, on a step edge and slowly lowering the heel to achieve maximal dorsiflexion at the ankle.⁵¹ Petersen et al. reported that Air Heel brace was as effective as eccentric exercise for pain relief, but no synergistic effect with a combination of bracing and exercise was observed.⁵¹

Eccentric stretching has not been found to be harmful, and one study demonstrated improved microcirculatory tendon levels without any evidence of adverse effects in both midportion and insertional Achilles tendinopathy.⁵² A review of the literature on eccentric stretch for Achilles tendinopathy by Kingma et al. concluded that because of the methodologic limitations of the trials, the effects of eccentric overload training are inconclusive but promising.⁵³

Verrall et al. studied athletes with chronic Achilles tendinopathy and reported that after 6 weeks of stretching, pain significantly decreased (VNS 7.2 to 2.9, P <.01).⁵⁴ Patient satisfaction was rated as excellent for 80% of athletes, and average time to return to premorbid activity was 10 weeks.⁵⁴ However, long-term results may be limited. In a 5-year follow-up of Alfredson heel drop exercises, about 40% of patients were pain-free; however, about 50% of patients had elected other therapies.⁵⁵ Subjects were average age 50 years, and about 70% engaged in sports or recreational activities. Additional PM&R treatments for Achilles tendinopathy include supportive night splints, but no recent literature was located on this topic.

CHRONIC REGIONAL PAIN SYNDROME

In the second edition, a physical therapy prescription for chronic regional pain syndrome (CRPS) included instruction in pacing activity and admonitions to withhold therapy if vasomotor sudomotor instability worsened.⁶ Passive and active ROM and stretch were recommended.⁶ Four review articles or treatment guidelines^56,59 summarize older PMR as well as medical strategies to treat CRPS and introduce newer therapy strategies.^58,59 A Canadian review summarized medications and injection therapies as well as physical therapeutics for CRPS.⁵⁶ Contrast baths and stress loading are older techniques and are discussed in a review by Li et al.⁵⁷ Stress loading has patients do “scrubbing” and “carrying.”⁵⁷ A recent review of therapy techniques used in the treatment of CRPS include graded exposure to activity, movements, and light touch; pain-adapted exercises and desensitization activities, exercise with stretching and active ROM, water therapy, stress loading, and mirror visual feedback.⁵⁸ British guidelines for the treatment of CRPS recommend referral to PT and integrated interdisciplinary treatment and the use of newer therapy paradigms such as graded motor imagery and mirror therapy.⁵⁹ Articles are reviewed for current treatment strategies with motor imagery programs or graded motor imaging, mirror therapies, pain exposure physical therapy (PEPT), and interdisciplinary programs for adults and children.

Motor imagery program (MIP) described by Moseley⁶⁰ is an exacting technique and uses 2 weeks each of recognition of hand laterality with pictures and then imagined and then mirrored movements.⁶⁰ This specific order of the component treatments needs to be maintained in order to improve pain and disability as was shown in later research with sequence changes that were unsuccessful.⁶¹ Moseley compared the MIP technique to a control group who received twice to three times weekly active and passive mobilization of the limb, systematic desensitization, and hydrotherapy in a department of physical therapy.⁶⁰ Compared to conventionally treated subjects, the MIP group reported significantly less pain and the neuropathic pain scale (NPS) (Table 96-5), finger circumference and response time to recognize the affected hand significantly improved (P < .01), and the beneficial effects of treatment were replicated when the conventionally treated controls were crossed over to the MIP group.⁶⁰ No improvement was noted in the control group while they were receiving conventional therapy. Twelve weeks after the study four patients in the initial MIP group and two patients in the crossover MIP group no longer fulfilled the criteria for CRPS.⁶⁰ Moseley concludes that response to MIP supports the hypothesis that cortical abnormalities are involved in the development of this disorder.⁶⁰ Because a specific sequence of activity is required, Moseley postulated that a sequential activation of cortical motor networks may occur.⁶¹ However, motor graded imagery (GMI) did not show improvement in pain outcomes in a prospective clinical audit of “real world” patients with CRPS treated in physical therapy clinics.⁶² Average pain intensities did not change from pre- to posttreatment, and 3 of 32 patients reported that pain had decreased by at least one-half.⁶² However, a secondary outcome of pain interference with activities of daily life was significantly improved at one center.⁶²

Moseley et al. studied mirror therapies to evaluate if tactile training resulted in improvement in tactile acuity (as determined by two-point discrimination[TPD]); when patients watched the reflected image of their unaffected limb in a mirror during training, they looked toward the stimulated (CRPS) body part and could see the skin of the opposite body part in the mirror.⁶³ TPD was 8 mm less 2 days after training compared with before training ([95% CI = 1.5-14.3 mm], P < .001).⁶³ Reduction in pain and change in TPD over the session were strongly related (R = .83, P < .001). However the effect is short-lived and there was no residual effect on pain at 2-day follow-up.⁶³

Van de Meent et al. explain pain exposure physical therapy (PEPT) as “treatment for patients with chronic regional pain syndrome type 1 (CRPS-1) that consists of a progressive-loading exercise program and management of pain-avoidance behavior without the use of specific CRPS-1 medication or analgesics.”⁶⁴ Ek et al.⁶⁵ studied an application of physical therapy of the affected CRPS limb that ignored or neglected pain and was directed at functional improvement only and normal use of the limb despite pain.⁶⁵ The authors emphasize that extensive explanation and disclosure is required with this methodology. Additionally, the subjects included were considered “end stage” and had failed multiple prior treatments and had symptoms of CRPS longer than 9 months. Activities included traction and translation of the stiff joints, assisted or active movement of the joint combined with passive stretching of contiguous muscles, and manual friction of tender points if needed. The patients underwent about four treatments over 3 months with encouragement to use the limb normally between sessions. It should be noted that the authors did not obtain institutional review board review prior to performing this study, rationalizing that the patients had already failed all available treatments. The function of the affected arm or leg improved in 95 patients and full functional recovery (defined outcome) was experienced in 49 (18 upper limb and 31 lower limb) (46%).⁶⁵ However, functional improvement did not imply a reduction in pain, and in 23 patients functional recovery but pain also increased.⁶⁵ Seventy-six patients had a significant reduction in pain.⁶⁵ At completion pain increased in 14 patients and did not change in 12. Four patients dropped out of the study related to pain increase.⁶⁵ No harm or injury from this therapy regimen is reported. Van de Meent et al.⁶⁴ studied the safety of PEPT in 20 patients and found that the physical signs of CRPS did not worsen (edema, color change, temperature, and joint mobility). The mean and mode for the number of sessions was five, and the maximum number allowed was six. Pain, upper and lower limb disability and function, and quality of life improved significantly at 12 months. Visual analog scale (57% decrease at 12 months from baseline, P < .001), pain intensity (48%), muscle strength (Newton) (improved 52% (upper limb) and 59% (lower limb) of the difference at baseline between affected and normal limb), arm/shoulder/hand disability (improved 36%, 71.7 +/− 16.2 at baseline 5.7 +/− 18.2, P < .001) (disability of arm, shoulder, and hand [DASH] measure), 10-meter walking speed (improved 29%), pain disability index (improved 60% 37.8 +/− 9.4 improved to 15.3 +/− 13.7 at 12 months (P < .001), kinesiophobia (18%) (Tampa Scale of Kinesiophobia), and the domains of perceived health change in the SF-36 survey (26.9% [corrected]) improved. Three patients initially showed increased vegetative signs but improved. Two patients had increased edema that resolved.⁶⁴ No injuries were reported.

The frequently cited Oerleman article is a RCT of PT versus OT versus a control group (social service interview) on 135 subjects with upper limb CRPS of less than 1 year's duration.⁶⁶ Therapy regimens and frequencies were individualized for the patient, but the goals of PT were increasing pain control and optimizing coping and extinguishing the source of the ongoing pain and improving skills while the goals for OT were reducing symptoms of inflammation and/or protecting and supporting the hand in the most functional and comfortable position and normalizing sensibility and improving functional abilities of the hand and improving independence in activities of daily living.⁶⁶ Outcome measures were ROM and pain evaluation with VAS and the McGill pain questionnaire (MPQ). Results indicated that PT improved VAS pain scores somewhat faster than OT and significantly faster than the control group.⁶⁶ PT significantly improved scores on the McGill pain questionnaire (MPQ) compared with OT and the control group at 1 year.⁶⁶ Raw scores are not provided. Physical therapy or pursuit of the treatment goals assigned to that discipline in this study's methodology (increasing pain control, optimizing coping, extinguishing the source of the ongoing pain, and improving skills) improved the symptomatology of upper limb CRPS more than OT or pursuit of its assigned treatment goals.

The Lee⁶⁷ pediatric CRPS article is often cited to indicate the frequency of therapies for CRPS.⁸ Twenty children with lower limb CRPS received physical therapy once a week for 6 weeks or three times a week for 6 weeks and both groups received six sessions of CBT.⁸ All patients were treated with transcutaneous electrical nerve stimulation (TENS), progressive weight-bearing, tactile desensitization, massage, and contrast baths.⁶⁷ All measures of pain and function improved significantly in both groups after treatment: VAS pain improved from 6.4 to 0.6; VAS effect improved from 5.4 to 0.6; allodynia (7-point Likert scale) improved from 5 to 7 (7 is anchored to no allodynia, 1 is anchored to extreme allodynia); stair climbing impairment score and gait impairment score also improved.⁶⁷ Sustained benefit was observed in most patients at long-term follow-up (average 66 weeks), but was not permanent as the authors note that recurrent episodes of CRPS were reported in one-half of subjects and about one-third eventually received sympathetic blockade.⁶⁷ The possibility of recurrence is noted in a review article by Bialocerkowski and Daly.⁶⁸ The review of the treatment of CRPS in children with PT or OT concluded that “low volume and poor to fair quality evidence which suggests that physiotherapy prescribed with other interventions may lead to short-term improvement in the signs and symptoms of CRPS-1 or functional ability in children with CRPS and relapse rate may be moderately high.”⁶⁸

Additional treatment strategies for children with CRPS include an interdisciplinary day hospital program.⁶⁹ The day hospital program described by Logan et al. demonstrated clinically and statistically significant improvements from admission to discharge in pain intensity (P <.001), functional disability (P <.001), subjective report of limb function (P <.001), timed running (P <.001), occupational performance (P <.001), medication use (P < .01), use of assistive devices (P <.001), and emotional functioning (anxiety, P < .001; depression, P < .01), and functional gains were maintained or further improved at follow-up (range 2-24 mo).⁶⁹ Treatment consisted of intensive daily physical, occupational, and psychological therapies 8 hours a day, 5 days a week for an average of 3 weeks.⁶⁹

Singh et al.⁷⁰ reported on a prospective study of 4 weeks of interdisciplinary management for adult patients with CRPS. The treatment consisted of 20 sessions of PT, 20 sessions of OT, 12 sessions of water therapy, 20 sessions of group psychotherapy, stellate ganglion blocks, and drug therapy that resulted in significantly improved upper limb function for weight tolerance and fine and gross motor skills and physical activity evaluated as maximum isometric force and endurance.⁷⁰ The MPQ was administered but does not appear to have been an outcome measure.⁷⁰ Results seem to be largely observational. After 2 years, 11 of 12 subjects could be contacted and 9 were employed, 8 had the same or less pain, 4 reported the spread of pain, and 5 reported using opioids.⁵

CRPS remains a difficult pain disorder to treat. Old treatment strategies like desensitization, contrast baths, and stress loading are still referred to in the literature. Newer treatment paradigms such as motor imagery program (MIP) which requires exact sequencing of therapy stages have had significant results in the laboratory but have not translated into real world practice. Mirror therapy alters sensory discrimination but has only short-lived effects on pain. It appears that PEPT significantly improves pain and function in patients with upper and lower limb CRPS and have not been shown to cause harm; however, it is indicated only for end stage patients who have failed available treatments. Children with CRPS show significant response to physical therapy given one or three times per week, but improvement may not be lasting and recurrence of CRPS happens one-half the time and one-third of patients opt for interventional treatment.

PRIMARY FIBROMYALGIA SYNDROME

In the second edition, a physical therapy prescription for primary fibromyalgia syndrome (PFS) included generalized upper and lower limb flexibility and aerobic activity to a heart rate of over 70% predicted maximum.⁶ A review of exercise for fibromyalgia by Busch et al.⁷¹ catalogs the self-administered, community-based, and skilled-therapy exercise for fibromyalgia. Exercise regimens applied to treat PFS include stretch, stretching in a warm pool, Pilates, lifestyle exercise, Tai Chi, yoga, aquatic breathing, Nordic walking, vibration boards, aerobics, strengthening combinations of flexibility, aerobics, strengthening, aquatics, and multidisciplinary programs.⁷¹ Nijs recommends “primary care physical therapy” for patients with FMS that includes education, aerobic exercise, and strengthening exercise.⁷² Nijs recommends against passive treatments, activity management, and relaxation, citing less evidence supporting use as primary treatment.⁷² The search strategy used for this chapter yielded few examples^73-75 of physician-prescribed and physical therapy-supervised exercise for the treatment of fibromyalgia; a secondary literature search of references from the Busch article⁷¹ and others was also undertaken, but few additional examples of PT-supervised exercise for PFS were identified.

Although the descriptions of exercise to treat fibromyalgia in the literature are frequent, the specific trials of skilled PT within the prescriptive authority of a physician are not. It is not clear why skilled therapy does not seem to be used as often, or at least reported in the literature as often, with PFS patients compared to patients with other pain disorders. It is possible that the patients do not select skilled therapy services. The Valencia group commenting on their dropout rate during a stretching trial (25%) postulate that “sometimes, an fibromyalgia patient's idea of how a rehabilitation program should be, or how it is going to affect their pathology, is often a wishful thinking; and their expectations are poorly satisfied.”⁷⁶ It is possible that the straightforward regimens described, for example walking 45 minutes three times a week or cycling for 60 minutes, do not require the skilled and more expensive attention of a PT. Busch et al.⁷¹ have observed that for patients with PFS, exercises with self-selected intensity appear well tolerated; by contrast, Busch et al. also note that PFS symptoms, like stiffness, may increase or new symptoms, like plantar pain, may emerge if the patient adheres to vigorous and even moderate-intensity exercise.⁷¹ They recommend “supervised programs encouraging PFS participants to perform short bouts of self-selected physical activity” as an initial exercise endeavor, but they then encourage progression to “self-efficacy,” “mastery,” and “modeling” of exercise for the ongoing management of PFS symptoms through instruction and practiced behavioral techniques.⁷¹ The recent review⁷¹ and Cochrane review⁷⁷ by Busch et al are recommended for the physician seeking a detailed discussion of exercise applications for PFS, and caveats for the exercise of PFS patients are provided. If the physician prescribes physical therapy for the treatment of fibromyalgia, aerobic, strengthening, and flexibility exercises may be specified; however, it is best to proceed slowly, to rest and repeat, and to advance weight, duration, or speed of exercise in a slower manner than might be expected for the patient's age. Education about pacing and about carrying over exercise, and discrimination of old symptoms (tender points) from new ones (e.g., plantar fasciitis) or from postexertional myalgia, and about self-treatment with ice or heat should be reviewed. Patients who wish to pursue alternatives like Tai Chi, Nordic walking, yoga, and aquatic- or gym-based offerings do not require prescription and may not be reimbursed by medical insurance, but advice about pacing, proper athletic and foot wear, and exertional myalgia can be offered as counsel.

Valencia et al. evaluated stretching regimens to treat fibromyalgia.⁷⁶ Patients were randomized to a program of kinesiotherapy and active muscular stretching (self-administered) or to techniques of Meziere's Global Myofascial Physiotherapy⁷⁶ (global stretching postures and manual myofascial and articular mobilization in relation to the patient's respiratory dynamics).⁷⁸ Both treatment arms were twice weekly for 150 minutes per week for 12 weeks; with 20 total participants whose average duration of symptoms was 7 years, one-fourth dropped out (3 from control and 2 from Meziere). Both groups achieved a statistically significant reduction in the severity of the disease as measured by fibromyalgia impact questionnaire (FIQ) (Table 96-6) during treatment but then significantly worsened in the follow-up period.⁷⁶ Regarding tender points, while both groups showed improved counts, only the control group's change was significant; both groups returned to baseline at follow-up (see Table 96-6).⁷⁶ Significant improvement in flexibility was demonstrated in both groups during treatment, and significant improvements remained in the Meziere group at follow-up (see Table 96-6).⁷⁶ Stretching in either form yielded short-term improvement for number of tender points and disease impact with a notable return to baseline in the intermediate term while short- and intermediate-term effects were noted for flexibility.

Aerobic exercise improves cardiovascular fitness, pain, tender points, function, depression, and quality of life in patients with PFS. Articles about aerobic exercise to treat fibromyalgia largely describe exercise programs administered by trainers or fitness instructors; these personnel are outside the scope of skilled therapy and PM&R. The Hauser meta-analysis of aerobic exercise for fibromyalgia describes 35 studies and notes that aerobic exercise was supervised by a “trainer” in 32 studies.⁷⁹ McCain⁸⁰ describes cycling three times per week for 60 minutes for 20 weeks to an intensity to sustain elevated heart rate, supervised by “medical fitness instructors,” improved pain thresholds of tender points, and improved cardiovascular fitness. Busch et al. conclude that aerobic exercise interventions reduce pain and improve physical fitness, as in the McCain article, and also reduce fatigue and depression and improve health-related quality of life.⁷¹ Thomas similarly concludes that there is moderate evidence that aerobic exercise for the treatment of fibromyalgia improves physical function and possibly improves tender points and pain and benefits the management of PFS.⁸¹ Busch cautions that the dropout rate for subjects in the aerobic exercise arm of studies is double (22% vs. 10%) the drop-out rate of control subjects.⁷¹ However, Lemos et al. report that PFS patients who complete an aerobic program can tolerate and be trained within the anaerobic threshold at 75% to 85% of predicted maximum heart rate and predicted using either (208 – [0.7 × age]) or (220 – age).⁸² In this study, PFS patients were enrolled in a walking program 45 minutes three times weekly for 20 weeks. No patient drop-out was described.⁸² The same work group led by Valim⁸³ compared the aerobic walking program to a stretching control. Valim et al.⁸³ reported a drop-out rate of 16 of 76 subjects (20%). Attributes of subjects who dropped out of the study included a higher pain score (29.86 +/− 15.71 drop-out versus 23.5 _+/− 8.57 completing study, P < .03) and significantly higher vitality and mental health (MH) on the SF-36 in the dropout group (vitality 48.46 +/− 24.36 dropout vs. 31.18 =/− 18.95 completing study, P <.007; MH 56 +/− 23.26 dropout vs. 42.83 +/− 19.19).⁸³ The aerobic group was superior to stretching for improvement of aerobic capacity, function, depression, pain, and emotional and mental health domains of the SF-36.⁸³ Aerobic exercise is superior to stretching to improve pain and function in persons with PFS. Patients who do not drop out of an aerobic excise program can be exercised to a target heart rate of 75% of (220 − age). The supervision of a PT is not warranted for the participation in a basic regimen such as timed walking or cycling.

The effect of resistance exercises on fibromyalgia was evaluated by Kingsley in a prospective controlled trial administered in a rheumatology department research.⁸⁴ Thirty-minute training sessions twice weekly involved resistance, that is, weight training, of the upper and lower body at an initial intensity set at 50% to 60% of 1RM (one repetition maximum) in weeks 1 to 8 and progressing to 75% to 85% of the 1RM in weeks 8 to 12.⁸⁴ Both the control and fibromyalgia women had significant increases in maximal strength (P < .05) after strength training. In the fibromyalgia subjects, the number of active tender points, myalgic score, and FIQ score were significantly decreased (P < .05)⁸⁴ (Table 96-6). Hakkinen studied strength training in premenopausal women with fibromyalgia at an initial intensity of 40% to 60% of 1RM (one repetition maximum) and progressing to 70% to 80% of the 1RM over 21 weeks.⁸⁵ Subjects with PFS increased maximal and explosive strength and EMG activity as much as healthy controls, and there were significant immediate benefits on subjectively perceived fatigue, depression, and neck pain of training patients with FM.⁸⁵ The study does not indicate that the strengthening program was administered in a therapy setting. A study of similar design of elderly subjects (average 59 yr) showed that older women with fibromyalgia also benefited from strength training.⁸⁶ Significant increases in maximal isometric and concentric forces, muscle cross-sectional area, and EMG activity were observied.⁸⁶ The strengthening group also reported a significant decrease (16–14) in the number of tender points after strength training but pain, sleep quality, fatigue, and general wellbeing only showed a tendency toward but not a significant decrease.⁸⁶ The study does not indicate that the strengthening program was administered in a therapy setting although exercise was “supervised.” Strengthening exercise improves pain, tender points, depression, and function in persons with PFS, and the patients can be exercised intensively enough to gain strength. The supervision of a physical examination may not be warranted for the participation in weight-training program.

Sanudo compared and “supervised” a combined aerobic, flexibility and strengthening program (15 min aerobic exercise to HR 70% maximum plus strengthening of 8 muscle groups, 10 repetitions of 1-3 kg weights) to aerobic exercise (45 min at HR of 60 to 80% maximum) to no exercise.⁸⁷ Dropout was 4, 4, and 1 respectively, in groups of 22, 21, and 21 subjects. Improvements in more individual SF-36 domains were observed after the combined intervention with significant improvements in SF-36 Physical Functioning (P < .003) and Bodily Pain (P < .003) domains and Vitality (P < .002) and Mental Health (P < .04) domains.⁸⁷ Compared to inactive controls, combined exercise and aerobic-only exercise significantly improved total FIQ score from baseline (about 15 5%; P < .02) and Beck depression inventory (BDI) scores decreased significantly (P < .001, aerobic 8.5 decrease and combined 6.5).⁸⁷

Suman reported on a 3-week intensive residential multidisciplinary treatment program for fibromyalgia patients whose symptoms before treatment were constant.⁷⁴ At 1 year subjects still demonstrated improved pain area and intensity and aerobic fitness.⁷⁴ The authors’ perception is that physical exercise was adopted as a coping strategy for chronic pain acceptance.⁷⁴ An outpatient multidisciplinary program by Carbonell-Baeza et al.⁷⁵ studied 75 women with fibromyalgia who participated in a 3-month (3 times/week) multidisciplinary (pool, land-based, and psychological session) (n = 41) or to a usual care group (n = 34). Post hoc analysis revealed significant improvements in total score of FIQ (P < .001), fatigue (P < .001), stiffness (P < .001), anxiety (P < .011), depression (P < .008), physical role (P < .002), bodily pain (P < .001), vitality (P < .001), and social functioning (P < .001) in the multidisciplinary group.⁷⁵ The control group showed significant worsening in the subscale depression (P < .006) and social functioning (P < .019).⁷⁵ Compared to no treatment, patients in a multidisciplinary treatment show decrease in pain and other symptoms, anxiety and depression, and functioning whereas the control group worsens for mood and function.

Lastly, Mannerkorpi et al. studied of the effects of pool therapy on PFS.⁷³ One hundred and thirty-four women with fibromyalgia and 32 with chronic widespread pain were randomized to a 20-session pool exercise program supervised by a PT and a six-session education program or to a control group undertaking the same education program.⁷³ Patients who had participated in at least 60% of the exercise sessions showed significantly improvement (P < .05) for the FIQ total and FIQ pain and the 6-minute walk test. Analyses within the subgroups showed that patients with milder stress, pain, or depression improved most by treatment on the FIQ total (effect size >.50, P < .05) compared with controls.⁷³

In sum, stretching yields short-term improvement for number of tender points and disease impact and intermediate-term improvements to flexibility. Aerobic exercise is superior to stretching to improve pain and function in persons with PFS. Patients who do not drop out of an aerobic excise program can be exercised to a target heart rate of 75% of (220 – age). The supervision of a PT is not warranted for the participation in simple aerobic programs. Strengthening exercise improves pain, tender points, depression and function in persons with PFS, and the patients can be exercised intensively enough to gain strength. The supervision of a physical examination may not be warranted for the participation in weight training program. Variations on the basic exercise types, including combination programs, aquatic version, and multidisciplinary programs, improve pain, function, and mental health.

PELVIC PAIN

Myofascial physical therapy (MPT) for pelvic pain targets internal (pelvic) and external trigger point work, focusing on the muscles and connective tissues of the pelvic floor, hip girdle, and abdomen.⁸⁸ Sacroiliac dysfunction (hypermobility) and transverse abdominal muscle weakness may contribute to pelvic floor dysfunction and may be targets of physical therapy interventions.⁸⁹ Doggweiler and Stewart⁹⁰ review the evaluation and available treatments for chronic pelvic pain. Kavvadias et al.⁹¹ review neurostimulation, physical therapy, oral agents and hydrodistension, and intravesical instillations for the treatment of females with pelvic pain. Cox and Neville⁹² detail the physical therapy strategies for vulvodynia:

“Myofascial release and connective tissue massage performed on the inner thighs, labia majora, perineum, superficial genital muscles, and associated trunk, abdominal, and hip muscles;

Trigger point release performed on the levator ani, superficial genital muscles, and obturator internus muscles intravaginally or intrarectally and on associated trunk, abdominal, and hip muscles;

Visceral mobilization Improve mobility and motility of bladder and urethra and neural mobilization to improve mobility of the pudendal nerve at Alcock canal.”

PTs who do pelvic myofascial work may seek a certificate of achievement as well as postgraduate offerings in this specific therapy application.

Patients who seek physical therapy treatment for pelvic floor dysfunction are primarily were female (92%), younger than 65 years of age, and with symptoms present longer than 90 days.⁹³ Urinary problems were reported two-thirds of the time, 25% had bowel problems, and 39% had pelvic pain.⁹³ Bladder and bowel problems included leakage and constipation.⁹³ About one-third had the constellation of all three problems (bowel, bladder, and pain).⁹³

FitzGerald et al. studied 47 patients (23 men, 24 women) with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) or interstitial cystitis/painful bladder syndrome (IC/PBS) who were randomized to global therapeutic massage (GTM) or myofascial physical therapy (MPT). Forty-four patients (94%) completed the study.⁸⁸ MPT treatment targets internal (pelvic) and external trigger point work, focusing on the muscles and connective tissues of the pelvic floor, hip girdle, and abdomen whereas GTM is a nonspecific somatic treatment with full-body Western massage and was included as a comparison treatment arm.⁸⁸ Patients were scheduled for 10 weekly treatments of 1 hour each; 87% of patients received at least 7 treatments. For home practice, the patients were instructed in a double voiding maneuver to improve pelvic proprioceptive awareness and drop the pelvic floor. The main outcome measure, global response assessment (markedly or moderately improved), was significantly higher (57%, 13 subjects) in the myofascial physical therapy group than the rate of 21% (5 subjects) in the global therapeutic massage treatment group (P < .03).⁸⁸ Five (21%) patients in the GTM group and 12 (52%) patients in the MPT group reported adverse events, primarily increased pain by 14 (30%) subject.⁸⁶ Three adverse events for pain were rated as severe (1 in GTM group and 2 in MPT group).⁸⁸ Other adverse events were arrhythmia, infection, and constitutional symptom.⁸⁶ Of note a significant difference of response to GTM was noted between the IC/PBS group and CP/CPPS group since many patients with CP/CPPS responded to GTM with improved domains of pain, quality of life, and ICSI (O'Leary-Sant IC Symptom Index) (P < .05).⁸⁸ One IC/PBS patient responded to GTM. In the IC/PBS group, pain, urinary urgency and frequency MPT significantly decreased (all 11 point scales) on average from about 7 +/−2.0 to 4 +/− 2.5. The IC symptom index, IC problem index, and female sexual health index also significantly improved.⁸⁸ Different pain and urinary symptom scales were used in the CP/CPPS group (21-point pain scale and 10-point urinary scale from NIH-CPSI), but pain decreased from 14 +/− 2.5 to 8 +/− 5.7 and the urinary scale decreased from 8.9 +/−1.4 to 5 +/− 2.8.⁸⁸ (Table 96-7) Tenderness of the anterior and posterior levator, and obturator internus but not the urogenital diaphragm was significantly decreased by MPT but not by GTM in both IC and CP patients.⁸⁸ The appendix of exclusion criteria for this study is extensive and includes pregnancy, active infection including prostatitis or urinary, calculi, painful lower abdominal scars, unilateral orchialgia, pelvic mass or suspicious prostate, etc.

Anderson et al. used a different study design to evaluate the effectiveness of MPT for pelvic pain in 200 men who had had pain for an average of 4.8 years, average age 47 years.⁹⁴ Male urologic pain syndromes include interstitial cystitis, isolated testicular pain, pudendal neuralgia, and levator ani syndrome.⁹⁴ Male subjects who had failed traditional therapies for chronic pelvic pain were recruited for a 6-day intensive (immersion) treatment protocol including training of participants in self-treatment of intrapelvic and extrapelvic myofascial trigger point release therapy, and training in paradoxical relaxation including some cognitive behavioral methods.⁹⁴ The therapy method was detailed:

“For 5 consecutive days the same PT performed myofascial trigger point release and trained patients in the self-administration of the method. This consisted of placing the patient in a semilateral, prone position with pillows under the abdomen after external abdominal and pelvic muscles had been examined. Using a gloved finger the sphincter ani, internal posterior and anterior pelvic muscles were examined, turning the patient as necessary. A traditional palpation force of approximately 4 kg/cm2 for tender points (recommended for examination of fibromyalgia) was used for the assessment of pain. The therapist treated individual muscle groups and released TrPs with applied pressure (details have been previously described). Therapy was delivered in 30 to 60-minute sessions each day, and patients were also instructed how to stretch and enhance relief of muscle tension.”⁹⁴

Outcome measures were National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), global response assessment, and a psychological query.⁹⁴ At 6 months 116 patients (about 60% of 200 self-referrals) were included in the data assessment. Global response assessment (the same primary outcome as the Fitzgerald trial⁸⁸) showed that 60% reported marked to moderate improvement.⁹⁴ Symptom index scores decreased by 30% (average score 26 +/− 4 decreased to 19 +/− 6, maximal possible score 43) (P < .001) at follow-up. (see Table 96-7) For comparison in the FitzGerald trial⁸⁸ NIH-CPSI decreased on average from 33.5 +/− 4.3 to 19 +/− 11.1 (P < .003). Domains of pain (decreased from 12 to 9), urinary dysfunction (decreased from 4 to 2), and quality of life showed significant improvement (P < .001).⁹⁴

Patients with urologic chronic pelvic pain syndrome (UCPPS) who referred themselves for an intensive 6-day PT and relaxation therapy program were invited to participate in a study to evaluate the safety of a personal wand that enables a patient's self-treatment of internal myofascial trigger points in the pelvic floor.⁹⁵ The Anderson group is from the same facility; the patients may overlap from the preceding study: Enrollment in the preceding study was from 2004 to 2009⁹⁴ and, in this study, 2008 to 2009.⁹⁵ The average age of patients was 41 years, and 93% were men.⁹⁵ Baseline median sensitivity VAS score (1 to 10, 10 = most sensitive) was 7.5 and decreased significantly at 6 months to 4 (P < .001).⁹⁵ Most patients (95.5%) reported the wand as very or moderately effective in alleviating pain.⁹⁵ No serious adverse events occurred; 44 of 157 patients withdrew from the study but not because of adverse events.⁹⁵

Pelvic floor physical therapy has also been shown in provoked vestibulodynia (PVD), the most common form of chronic vulvar pain, to significantly increase vestibular pain thresholds and significantly lower pain ratings during the gynecologic examination and during intercourse.⁹⁶ Goldfinger⁹⁶ studied 13 patients with PVD. The treatment protocol describes eight treatment sessions of 60 to 75 minutes each. The sessions began with a discussion of interim pain and exercise adherence, followed by a series of intravaginal manual techniques (e.g., trigger point release, massage) carried out by the PT that progressed over the course of the treatment program (e.g., progressed from one to two fingers, more pressure applied), and then biofeedback with practiced exercises, and progressive dilation occurred.⁹⁶ The subjects’ mental health did not improve significantly; however, pain catastrophizing and pain-related anxiety significantly decreased.⁹⁶ Vestibular pain significantly decreased from 5.23 +/− 2.05 to 2.06 +/− 1.67, (P < .01) and point tenderness significantly decreased⁹⁶ (see Table 96-7).

The use of devices at home or during therapy in the treatment of pelvic pain is described above. Additionally, a trial of TENS on 24 patients with chronic prostatitis revealed a significant effect of TENS on chronic prostatitis pain (P < .05).⁹⁷

Male and female patients with chronic pelvic pain respond moderately to markedly to MPT over half the time, and pain, tenderness, and urinary symptoms significantly decreased; a thorough review of systems should occur prior to prescribing this therapy to determine there are no contraindications. Devices and techniques to use at home are available.

TEMPOROMANDIBULAR JOINT DYSFUNCTION AND HEADACHE PAIN

PM&R strategies have been described to treat temporomandibular joint pain, tension headache, and myofascial facial pain. Treatment regimens utilize oral appliances, stretching and relaxing exercises, and thermal modalities.

Cuccia et al.⁹⁸ compared osteopathic manipulation to conventional physical therapy for the treatment of temporo-mandibular joint dysfunction (TMJD). One group was treated with specific manipulative procedures performed by an osteopath, and a second group with conventional treatment by a physiotherapist with an oral appliance, physical therapy (gentle muscle stretching and relaxing exercises), thermal therapies such as hot or cold packs (or both), and TENS.⁹⁸ Patients were treated every 2 weeks for 24 weeks. After treatment the use of medication was greater in the conventional therapy group (14 using medication) than in the osteopathic group (6 using medication); however, both treatments led to significantly decreased pain. The osteopathic treatment significantly increased mouth opening range.⁹⁸ The authors concluded that both osteopathic manipulation and conventional physical therapy stretching, relaxation, and modalities improved TMJD symptoms during the 6-month trial.⁹⁸

Soderberg et al. compared strength training for neck flexion, shoulder elevation, arm row, arm extension, and latissimus pull down to acupuncture with specified insertions to relaxation training to improve central nervous system symptoms (e.g., tranquility, self-confidence, mental fatigue, concentration, and quality of sleep) in chronic tension headache in 90 patients.⁹⁹ Sessions were conducted weekly for 8 to 10 weeks.⁹⁹ The outcome measure was the minor symptom evaluation profile (MSEP), which was significantly improved in the physical training group compared with the acupuncture group at 2 months (P < .036).⁹⁹ No significant difference was found among the three treatment groups at baseline or immediately after treatment. At 3-month follow-up the physical training group had significantly better MSEP score that the acupuncture and relaxation group, and improvement continued to 6-month follow-up.⁹⁹ On specific subscales of vitality and sleep both were significantly better at 6 months in the relaxation group compared to the acupuncture and exercise groups (P < .04). The authors conclude that moderate physical training has a long-lasting positive effect on collective central nervous system symptoms of chronic tension headache; however, relaxation training specifically affords long-term improvement in vitality and sleep in patients with chronic tension headache.

Doepel et al. concluded that effectiveness of the prefabricated appliance is similar to that of the stabilization appliance in the long term in treating patients with myofascial pain.¹⁰⁰

The use of prefabricated or stabilization oral appliances is effective in the treatment of myofascial facial pain. Eighty-one percent of patients with a prefabricated appliance improved to “better” to “symptom-free” and 64% in the group with stabilization appliances.¹⁰⁰ At the 12-month follow-up, graded chronic pain, functional limitation of the jaw, nonspecific physical symptoms, and depression showed statistically significant reduction at 12-month follow-up in both groups.¹⁰⁰

BACK PAIN

In the second edition,⁶ sample physical therapy prescriptions were suggested for:

• Axial low back pain (LBP) (back education, flexibility, flexion bias, e.g., “crunch” strengthening)

• Spondylolisthesis (similar)

• Radicular LBP (back education, flexion or extension bias exercise to centralize pain)

• Exercise after laminotomy (exercise regimens discussed began 1 year after surgery)

• Discectomy (variable, from no restrictions, to walking and passive ROM, to leg strengthening)

• Osteoporotic compression fracture (education, bracing as needed, thoracic extension, and scapular stabilization).

The search strategy for this chapter identified 100 articles concerning PM&R and physical therapy applications for LBP. There is no therapy regimen, temporal phase, or specific diagnosis in the catchment of LBP that is the agreed upon gold standard comparator in clinical trials.¹⁰¹ Comprehensive reviews, PM&R applications, and LBP include Cochrane reviews of exercise for LBP,¹⁰² back schools,¹⁰³ multidisciplinary programs for LBP,¹⁰⁴ exercise after lumbar surgery,¹⁰⁵ and TENS for LBP;¹⁰⁶ review articles of lumbar stabilization exercises,¹⁰⁷ general physical activity and other life style modifications,⁹ lumbar extension,²¹ McKenzie exercises,¹³ and TENS and other modalities;¹⁰⁸ and reviews of the treatment of LBP¹⁰⁹ by the Philadelphia panel.¹¹⁰

A number of exercise techniques have been proffered and trialed in the literature for the treatment of LBP.²¹

• Activity as usual (sometimes a control group)

• Community-based commercial offerings (e.g., Pilates, Tai Chi)

• Aerobic (repetitive movement of large muscle groups to achieve locomotion usually to a target heart rate)

• Aquatic (pool activities to achieve unweighting of painful limbs, resistance with “buoyant weights” or difficult end-of-range motion aided by buoyancy)

• Directional preference (e.g., McKenzie)

• Flexibility (e.g., yoga)

• Proprioceptive/coordination (e.g., wobble board, stability ball)

• Stabilization (e.g., low-load isometric or restricted ROM exercise targeting abdominal and spinal trunk muscles)

• Strengthening (e.g., lifting weights or progressive resistive exercises)

• Lumbar extensor strengthening (e.g., “Roman chairs” targeting the lumbar erector spinae and multifidus)

• Back school and multidisciplinary programs.

The European guidelines for the management of nonspecific CLBP note that the “active ingredient” of exercise programs is unknown;¹¹¹ however, the guidelines recommend supervised exercise and back schools as well as brief educational interventions and multidisciplinary (biopsychosocial) treatment for the condition of nonspecific chronic low back pain (CLBP).¹¹¹ Van Middelkoop et al. commented that no type of exercise has been shown to be more effective than others and subtypes of LBP or patients with specific attributes may respond differently to various exercise therapies, but the correct match of patient with exercise is not known.¹¹² Van Middelkoop et al. observe that adherence to exercise prescription is usually poor, so supervision by a therapist is recommended.”¹¹² This said, therapy cannot and should not continue indefinitely. The goal of a therapy program should be transition to a home exercise program.

Therapy benefits should not be squandered; in 2012 in the Unites States, CMS capped outpatient therapy services at $1880 per annum; this equates to probably 10 to 14 visits to achieve specified therapeutic goals for your patient.¹¹³ Useful information regarding costs and coverage as well as benefits and harms of physical activity for LBP were found.^{3,9,13,21,107,108,114} Uniquely, this series of articles in The Spine Journal discusses coding and reimbursement for the skilled-therapy exercise programs and this information may be useful when discussing options with patients.

Quality reviews about nonspecific exercise programs for LBP and their outcomes were found. A Cochrane review concludes that exercise chronic LBP is slightly effective for reducing pain and increasing function and that in subacute back pain there is some evidence of effectiveness of graded-activity exercises.¹⁰² In acute LBP, exercise was not better than no treatment or other conservative measures.¹⁰² More positively, the Wai review⁹ reported moderate benefit for aerobic, strengthening, or water exercise versus no activity to reduce disability, and improve pain in low back conditions.⁹ Wai et al. reported limited evidence supporting home aerobics to improve worst pain, medication use, work status, and mood.⁹ No harm of exercise was found.⁹

The Spine Journal series of articles on lumbar extension exercise,²¹ McKenzie method,¹³ and lumbar stabilization¹⁰⁷ provide an opportunity to compare the features, outcomes, and risks of these different exercise methods and are highly recommended for perusal. Specific studies of lumbar extension exercises with both active and wait listed controls demonstrated significant benefits in the short term (3–6 mo) for endpoints including lumbar extensor strength and cross sectional area, pain, disability, physical impairment, and psychosocial function.²¹ The cited literature demonstrates no clear benefit of lumbar extensor strengthening exercises compared with other exercise programs.²¹ Potential harms of extension exercises include delayed onset muscle soreness, and rare complications such as fracture or disc herniation.²¹ May's article in The Spine Journal reviews the McKenzie method is an approach to CLBP that includes an assessment and an intervention component.¹³ The assessment component of the McKenzie method, also called mechanical diagnosis and therapy (MDT), attempts the assessment of a pattern of pain response called ‘‘centralization,’’ which refers to the decrease or eradication of radiating symptoms of a back pain complaint in response to a single direction—“directional preference”—of repeated movements or sustained postures.¹³ Side effects or adverse events to the McKenzie method have not been documented, but May et al. note that, as a clinical assessment method, failure to alter symptom distribution (non-centralization) predicts negative outcomes and poor behavioral responses to back pain.¹³ The Standaert article¹⁰⁷ on lumbar stabilization exercises, also called core stabilization, motor control exercises, or segmental stabilization, has a therapeutic goal of improving the neuromuscular control, strength, and endurance of muscles central to maintaining dynamic spinal and trunk stability, including the transversus abdominis (TrA), lumbar multifidi, and regional musculature from the diaphragm to pelvis and paraspinals to abdominals. Andrusaitis¹¹⁵ explains that the term ‘‘stabilization,” based on co-contraction of the abdominal and multifidus muscles, is a generalization describing any type of exercise that challenges the stability of the spine while training muscle activity patterns in a variety of positions and postures that ensure sufficient stability without unnecessarily overloading tissue. Standaert et al. note trials comparing general exercise to lumbar stabilization; both yield significant improvements in function, pain, and quality of life over baseline, and there were no significant differences between groups and no additional benefit of lumbar stabilization.¹⁰⁷ No serious harms result from lumbar stabilization exercise, but the authors are careful to note that exclusion criteria in studies listed patients “felt to be unfit for physical therapy treatment” including subjects with fracture, Grade III or IV spondylolisthesis, malignancy, inflammatory arthropathies, pregnancy, significant neurological loss,” and other unstable medical conditions and prior spine surgery.¹⁰⁷ A review of exercise to evaluate the duration of benefit found that trials which reported on pain scales at 6-month follow-up found significant differences in favor of exercise.¹¹⁶

The Cochrane reviews and The Spine Journal articles on back schools,^103,114 functional restoration,³ and multidisciplinary programs¹⁰⁴ provide an opportunity to compare the features, outcomes, and risks and are highly recommended for perusal. Back school is a Swedish concept from 1969 that initially instructed participants how to protect spinal structures in daily activities but later added exercises for the back.^103,114 Back school involves group education about fear-avoidance and kinesiophobia and exercise, delivered in an occupational setting or as part of a multidisciplinary rehabilitation program.¹¹⁴ The Cochrane review on back school¹⁰³ concluded that moderate evidence suggests that back schools, in an occupational setting and when compared with exercises, passive therapies, or wait list, improve function and return to work for patients with chronic and recurrent LBP status in the short and intermediate term. Brox et al. concluded evidence for back school was too conflicted to recommend it as an intervention.¹¹⁴ While back school started as an educational strategy that evolved to add an exercise component, multidisciplinary programs consist of a physician consultation as well as at least one additional psychosocial or vocational evaluation and intervention. A Cochrane review of multidisciplinary programs¹⁰⁴ concluded that moderate evidence of positive effectiveness of multidisciplinary rehabilitation for subacute LBP exists and that a workplace visit increases the effectiveness. The same Cochrane review characterized multidisciplinary programs as an inpatient or outpatient rehabilitation program that consisted of a physician's consultation plus either a psychological, social, or vocational intervention or a combination of these.¹⁰⁴ Functional restoration is a more complex treatment that addresses the biopsychosocial complexity of chronic LBP that is disabling. Functional restoration that is metric and outcome focused distinguishes itself from back school, which is on the surface task-defined, and multidisciplinary programs which on the surface are personnel defined. Developed and described by Gatchel and Mayer in the 1990s, components of functional restoration include:

1. “formal, repeated quantification of physical deficits to guide, individualize, and monitor physical training progress;

2. psychosocial and socioeconomic assessment to guide, individualize, and monitor pain, disability, behavior and outcomes;

3. multimodal disability management programs using cognitive-behavioral therapy approaches;

4. psychopharmacological interventions for any required detoxification and psychosocial management;

5. ongoing outcome assessment using standardized outcome criteria and objective data collection through structured interviews; and

6. interdisciplinary, medically directed team approach with formal staff meetings and frequent conferences.”³

Differing from other treatment approaches, functional restoration has been shown to prevent chronic disability for persons with LBP compared to usual treatment and also to have a long-term effect that other interventions lack. Bendix et al.¹¹⁷ note “functional restoration” programs for the treatment of LBP may have a full-day schedule lasting 3 to 6 weeks. Bendix et al.¹¹⁷ explain that personnel are multidisciplinary and patients are treated in groups with “intensive physical and ergonomic training, psychological pain management, back school, and instruction in social- and work-related issues,” including “acceptance of the pain, activity, and self-responsibility,” and quantitative functional evaluation “to make participants aware of physical improvement.” Gatchel et al.³ report patients with acute LBP at risk for chronicity were enrolled in a functional restoration program (FRP) and, compared to “usual treatment,” (UT) at one year were significantly more likely to return to work (91% vs. 69%, P 0.027), utilized about half as much health care (12 visits vs. 25, P < .004) and medication (27% vs. 43%, P < .02), and had less self-reported pain (VAS 26 vs. 43, P < .001).”¹¹⁸ If lost wages related to sick days ($7K FRP vs. $18.9 K UT) are included in costs, FRP treatment (program $3.8K plus health care and medication and lost wages = $12.7K) is about 60% of the cost of no treatment ($21.8K).

Systematic reviews of therapeutic modalities for the treatment of pain were reviewed. For treatment of CLBP a recent Cochrane review concluded the evidence was conflicting about whether TENS was beneficial in reducing back pain intensity.¹⁰⁶ TENS was not shown to improve back-specific functional status, work status, or the use of medical or the Sickness Impact Profile.¹⁰⁶ The Poitras article in The Spine Journal also concluded there is little evidence to support the use of TENS in LBP.¹⁰⁸ He concluded TENS does not appear to have an impact on perceived disability or long-term pain.¹⁰⁸ Skin irritation and even burns are possible with TENS with inappropriate electrode placement.¹⁰⁸

STRETCH

Stretch and flexibility are the first steps in an exercise program and prevent injury to soft tissue.⁶ Slow sustained stretch held 60 seconds is optimal.⁶ The new implantation of subcutaneous portions of stimulators or implanted pumps may be a contraindication for a time specified by the implanting physician. No peer reviewed literature was found regarding activity restriction after the implantation of spinal cord stimulators. Recommendations to avoid lifting, bending, and twisting for 6 to 8 weeks after implantation to allow the tract site to scar down was found searching the internet for “patient information” or “restrictions” after the procedure.¹¹⁹

The conservative treatment includes flexibility exercises, especially of the hamstrings. The rationale is that hamstring tightness during tasks of lumbar flexion restricts motion and introduces shear among the vertebral segments and risk for injury.¹²⁰ Johnson et al. evaluated hamstring flexibility and hip and lumbar joint excursions during forward-bending tasks in persons with LBP compared to persons recovered from LBP, but no significant correlation was found.¹²⁰ The authors conclude that hamstring flexibility is not strongly related to the amount of lumbar flexion used to perform forward-reaching tasks in participants who have chronic LBP or who have recovered from LBP.¹²⁰ Halbertsma's work demonstrates no change in the length or elasticity of hamstrings occurs with applied stretch but stretching increases tolerance of the activity.¹⁴ Stretching has been shown to reduce pain at least briefly.¹⁵ However, how stretching helps pain is not clear and seems to be more complex than the presumed rationale of tissue distension or improved lumbar mechanics.

WALKING AND AEROBIC EXERCISE

Walking is a basic human ability requiring no equipment other than appropriate clothing and comfortable footwear. It does not require the supervision of a physiotherapist. Unless performed briskly enough to elevate heart rate to 70% of maximal predicted heart rate, it does not constitute aerobic exercise. However, even at a slow pace, if continued for 30 minutes five times per week aerobic exercise has shown benefits to bone density.¹²¹ Walking is simple and in the spectrum of treatments for the individual suffering with LBP, walking (similar to stretch) has been shown to lessen pain following the activity and in combination with other treatments.¹²² Hendrick et al.¹²² systematically reviewed the literature comparing walking to exercise or physiotherapy for the relief of back pain and cited four articles comparing preferred speed walking to fast walking, vertical traction (VT) alone to VT plus walking, exercise versus thermal modalities, and traction versus walking and core stabilization versus supported walking. Hendrick et al. report that preferred walking speed significantly relieved pain (P < .02) and fast walking did not; VT plus walking and VT alone relieved pain but the combined program was significantly better, but in the other three-arm study with an exercise arm and a traction and modalities arm, both relieve pain significantly better compared to walking. Lastly stabilization exercise with supported walking had a notable dropout rate at 45% but pain decreased in 50% of patients completing the study and function improved in 80%. No study found walking to be detrimental, but it is probably complementary at best.¹²² Compared to interventions with higher costs or burdens of travel, expense, or personnel, walking may not be as effective at relieving pain; however, for its simplicity, walking as a start in the spectrum of treatments for LBP has an initial economical and uncomplicated place.

One study, Chan et al.,¹²³ found aerobic exercise to be administered under the supervision of a PT, that is, within the context of PM&R. Other studies were found in which subjects performed aerobic exercise in a fitness center or individually, but these settings are outside this chapter's inclusion criteria. Compared to conventional physiotherapy (modalities, mobilization, stabilization exercise, and education for 8 weeks), the addition of aerobic exercise (starting at 40% of predicted heart rate and progressing to 85% over 8 weeks) to conventional treatment shows a significant decrease in pain and disability at 2 and 12 months in both groups, with no significant difference between groups.¹²³ Conventional therapy alone and aerobic plus conventional therapy both significantly improve pain reports.¹²³ For clinical applications, if the individual patient has specific aerobic conditioning goals, an aerobic prescription might be added to the usual prescription for strengthening and education but will not further improve pain.

CORE STABILIZATION, MOTOR CONTROL EXERCISES, SEGMENTAL STABILIZATION, AND LUMBAR STABILIZATION

Core stabilization, as a strengthening strategy, is known by a variety of terms and targets the transversus abdominis, and multifidi as well as abdominal muscles, paraspinals and pelvic girdle muscles. The deepest abdominal muscle, transversus abdominis, interacting with the lumbar fascia is believed to contribute to lumbar stability and vertebral constraint.¹²⁴ Altered timing and changes in muscle contraction thickness and slide in the deep abdominal muscles has been found in LBP patients.¹²⁴ The significance and contribution of the excursion and timing of the transversus abdominis in dynamic tasks in patients with LBP is debated.^125,126

Some studies have found that improvement in these measurements after core stabilization exercise parallels improved pain reports in patients with LBP. Unsgaard-Tondel et al.¹²⁴ report that transversus abdominis lateral slide (excursion of the muscle border between rest and contraction as determined on ultrasonography) that was low at baseline improves after an 8-week exercise program and is associated with a VAS improvement of 2 or greater (“clinically important pain reduction”) through 1 year follow-up compared to participants with small baseline slide and no improvement in slide. They did not find a correlation with muscle thickness, which was also measured, but Ferriera et al did.¹²⁶

Ferreira et al. compared three supervised therapy regimens, motor control (core stabilization exercise versus general exercise versus manipulative therapy, found that subjects with chronic LBP who received motor control exercise had a greater improvement in recruitment (as measured by increased thickness on ultrasonography) of transversus abdominis (7.8%) than participants receiving general exercise (4.9% reduction) or spinal manipulative therapy (3.7% reduction).¹²⁶ Similar to Unsgaard-Tondel in which poor performers who improved had better pain relief, Ferreira et al. observed that the effect on pain reduction was greater in motor-control participants who had a poor ability to recruit transversus abdominis at baseline.¹²⁶ There was a significant, moderate correlation between improved recruitment of transversus abdominis and a reduction in disability.¹²⁶ A third study showed no correlation with deep abdominal muscle function (as measured by thickness on ultrasound) and exercise although subjects improved clinically.¹²⁷ Mannion et al. observe that although significant improvements in pain and disability occurred after a 9-week physiotherapy program of stabilization exercises (once a week with therapist and daily home exercise), neither baseline transversus abdominis (TrA) muscle function nor its improvement after the exercise intervention was a statistical predictor of a good clinical outcome.¹²⁷

Improved outcome measures include a decreased disability (Roland Morris, RM) score from 8.9 ± 4.7 to 6.7 ± 4.3 (P < .01), and decreased pain from 4.7 ± 1.7 to 3.5 ± 2.3 (P < .01), increased voluntary activation of the TrA by 4.5% (P < .045).¹²⁷ The authors report, but not available in tablature, that changes only, presumably improvements, in catastrophizing (P < .003) and in fingertip-to-floor distance (P < .006) explain the variance in the improved RM scores.¹²⁷

While excursion and thickness of the deep abdominal muscles may show a relation to pain, the onset of firing of the muscle group during standardized dynamic tasks does not. Additionally, although exercise shows an ability to improve “muscle slide” and thickness, exercise does not affect the onset of firing relative to other muscles during a standardized task. Vasselgen et al.¹²⁸ used arm swing as a proxy for testing lumbar stability dynamically. Comparing low-load core strengthening to high-load sling exercise and to general exercise, the group reports that abdominal muscle onset in coordination with an arm swing task was largely unaffected by any 8-week strengthening program, and there was no association between change in faster or slower onset of firing of the transversus abdominis and arm movement and LBP.¹²⁸

The multifidi are believed to be strengthened both by core strengthening and by lumbar extension strengthening strategies. Chan et al.¹²⁹ have observed that the multifidus, as measured by ultrasonography methods, is stiffer, smaller, and possesses higher fat content in chronic LBP patients compared to asymptomatic controls. Different multifidus cross-sectional area were identified in relation to upright compared to lumbar flexed postures in both normals and subjects with LBP having smaller cross-sectional areas in all positions.¹²⁹ Beneck et al. report that even active persons with LBP when compared to active pain-free controls showed considerable localized, bilateral multifidus atrophy.¹³⁰ The authors hypothesize that impaired size of the multifidus reduces its capacity to control intersegmental motion and increases susceptibility to further injury.¹³⁰ A poor ability to contract multifidus was related to poor transversus abdominis contraction.¹³¹ Changes in the firing pattern of other muscles in persons with LBP has been noted. Higher activation of global and lower activation of local abdominal muscles in patients with CLBP has been noted, and the authors interpret this as a pain-related change to neuromuscular control, with the increased activity of extensor muscles during trunk flexion contributing to stability and controlling flexion.¹³²

Andrusaitis et al.¹¹⁷ studied the effect of stabilization exercises versus general strengthening of the abdominals and pelvic and back muscles or versus normal volunteers assessed at baseline for 40-minute sessions three times weekly for 5 weeks. The stabilization group demonstrated significant reductions in both pain intensity (VAS decreased from 5.08 to 0.23, P < .043) and pain frequency (VAS decreased from 6.19 to 2.09, P < .043) and disability (measured by the Oswestry Disability Questionnaire [ODQ], decreased from 11.8 to 3.4) (P < .05) after the treatment while the strengthening group did not show any significant changes (pain intensity 4.83 decreased to 3.59, intensity from 8.74 to 5.31, and Oswestry 19.8 decreased to 18.2, P > .05).¹¹⁷ Kumar et al.¹³³ compared stabilization exercises versus general strengthening and had similar results showing certain functional activities and pain were significantly (P < .01) improved with stabilization more than with strength training, and rate of improvement was significantly (P < .01) higher in the stabilization group. Franca et al. evaluated 30-minute sessions twice weekly for 6 weeks, showing similar results.¹³⁴ Franca et al.¹³⁴ compared segmental stabilization, with exercises targeting the transversus abdominis and lumbar multifidus muscles, versus superficial strengthening, with exercises targeting the rectus abdominis, abdominus obliquus internus, abdominus obliquus externus, and erector spinae. Outcome measures included pain (VAS and MPQ), functional disability, ODQ, and transversus abdominis muscle activation capacity (pressure biofeedback unit [PBU]). Both treatments were effective in relieving pain and improving disability (P < .001), but the segmental stabilization group had significant gains for all variables when compared to the standard exercise group (P < .001).¹³⁴ From a perspective of not only efficacy but also cost, Critchley et al.¹³⁵ compared stabilization exercises versus general strengthening versus PT-led pain management education were found to significantly reduce disability [Roland Disability Questionnaire score improved from 11.1 (9.6–12.6) to 6.9 (5.3–8.4) with usual outpatient physiotherapy, 12.8 (11.4–14.2) to 6.8 (4.9–8.6) with spinal stabilization, and 11.5 (9.8–13.1) and to 6.5 (4.5–8.6) following pain management classes]; and also reduce pain and time off work, improve quality of life.¹³⁵ In this cost analysis study, PT-led pain management was the most cost effective intervention (£165 [British pounds]); the stabilization was just over twice as expensive (£379), and the individual strengthening physiotherapy almost three times as expensive (£474).¹³⁵

Compared to graded exercise, motor control (stabilization) exercises showed no significant difference at 2, 6, and 12 months for pain over the previous week (numeric rating scale) and function (Patient-Specific Functional Scale) or disability (24-item Roland-Morris Disability Questionnaire), global impression of change (Global Perceived Effect Scale), and quality of life (36-Item Short-Form Health Survey questionnaire [SF-36] in a study by Macedo.¹³⁶ The outcome measures improved in both treatment groups: Pain Numeric rating decreased from 6.1 to 3.7 in both groups at 12 months; function (Patient-Specific Functional Scale) improved from about 3.6 to about 6.0 in both groups; and disability (Roland Morris Disability Questionnaire (RMDQ) decreased from about 11.3 to 8.0 in the Graded exercise group and 7.4 in the motor control group.¹³⁶ Additionally the authors provide a useful comparison of the two exercise approaches.¹³⁶ The authors explain graded activity as time contingent, paced progressive exercises that aim to reduce pain and disability by addressing pain-related fear, kinesiophobia, and unhelpful beliefs and behaviors about back pain while correcting physical impairments such as reduced endurance, muscle strength, or balance, whereas motor control exercises are general and focal strengthening exercises focused on correcting the activation of muscles and motor patterns and on the correction of posture and coordination.¹³⁶ Adverse effects included temporary exacerbation of pain (27 of 176), increased pain of preexisting musculoskeletal condition such as knee arthritis (n = 7), development of shin splints (n = 1), and hip bursitis.¹³⁶

Compared with an educational booklet or manual therapy, stabilization exercises have been shown to be significantly better at improving pain and dysfunction at 6 months and, at 1 year, reduction in medication usage, dysfunction, and disability (Oswestry).¹³⁷ Another study comparing sham modalities to motor control exercises demonstrated improved activity and patient's global impression of recovery in the motor control group, but this did not clearly reduce pain at 2 months.¹³⁸

Motor control or core stabilization exercises are believed to strengthen, and increase excursion and hypertrophy deep abdominal flexors including the transversus abdominis and multifidus through low load, limited excursion strengthening exercises of the trunk. Pain and disability have variably been shown to correlate with improvements in these physiologic outcomes. Studies have not clearly shown a relationship with pain or dynamic coordination with other muscle groups in studies of arm swing. Motor control core stabilization exercises have been shown in several studies to be superior to general exercise regimens for pain and disability outcomes and on a par in one study. Motor control exercises were as effective as graded exercise to improve function, pain, and disability and superior to written educational materials or manual therapy alone. Adverse effects are not reported for the most part but when reported seem to be minor.

GENERAL EXERCISE AND STRENGTHENING REGIMENS

Nassif et al.¹³⁹ evaluated assembly line workers with chronic LBP doing 60-minute sessions of muscle strengthening, flexibility, and endurance training with a physiotherapist in an occupational environment performed three times per week during 2 months. A significant beneficial effect (P < .025) for the experimental group at 2 months (program end) was observed in pain parameters (numerical rating scale (NRS) decreased from 4.54 to 2.76, P < .001), specific flexibility tests, and back function and disability (Tampa Scale of Kinesiology decreased from 46.71 to 41.59, P < .001; RMDQ decreased from 13.91 to 9.75, P < .001; Quebec Back Pain Disability Questionnaire decreased from 40.85 to 26.5, P < .001) subscales of the Dallas Pain Questionnaire significantly improved); the effect persisted at 6-month follow up.¹³⁹ No changes were noted in the control group at 2 months except a change in persons engaged in physical activity.¹³⁹ Significant improvement at 6 months in the control group (education or seek aid on own) was observed for NRS (4.92 decreased to 3.53, P < .01), anterior flexion, flexibility of quadriceps, and Dallas Pain Questionnaire's work recreational score.¹³⁹ The authors concluded that multiple health benefits of physical activity and physical therapy modalities in the workplace exist for employees with chronic LBP.¹³⁹

Smeets compared general aerobic and strengthening exercise versus cognitive behavioral training or a combination versus “wait list” and observed significantly reduced functional limitations, reduced “patient's main complaints” and decreased pain intensity for all three active treatments.¹⁴⁰ Self-rated treatment effectiveness and satisfaction was higher in the three active treatments.¹⁴⁰ The two active treatments with an exercise intervention, but not CBT, significantly improved physical performance tasks of walking and stair climbing.¹⁴⁰ The authors conclude that either active program is effective, arguing against a more expensive combination program.¹⁴⁰

Isokinetic strengthening compared to usual strengthening, flexibility, and endurance training by a physiotherapist was found to improve significantly the VAS fingertip-to-floor test, disability (Modified ODQ), and BDI scores compared to the baseline, which persisted through the end of the study (7 weeks) (P < .05).¹⁴¹ Exercises were done 10 times a day for 1 month.¹⁴¹

The most beneficial dose, frequency, and duration of exercise have not been elucidated in the literature. Kell et al.¹⁴² attempted to discern the optimal frequency of a strengthening program. Patients were randomly assigned to groups receiving exercise 4 days per week, 3 days per week, 2 days per week, or no training with an exercise program that progressively overloaded muscle groups for 16 weeks.¹⁴² The 4 days per week training volume significantly (P < .05) outperformed all other training volumes by weeks 9 and 13 on the relief of pain, Oswestry Disability Index, and SF-36, although all groups improved.¹⁴² All training volumes made significant (P < .05) improvements in strength, but the 4-day training pattern consistently demonstrated the largest effect size.¹⁴² Limke et al.¹⁴³ assessed the benefit of one versus two sets of progressive resistive exercises (PRE). Exercises on various equipment were performed twice weekly for 6 weeks for about 1 hour, one or two sets of PRE.¹⁴³ At discharge there was no statistical difference between the group completing one set and the group completing two sets of PRE for pain, disability, or strength measures, which suggests that there is no additional benefit to completing a second set of PRE in patients with LBP.¹⁴³ A review article on strengthening exercise for LBP arrived at similar conclusions to this section.¹⁴⁴ Trunk strengthening appears effective compared with no exercise, but compared with aerobics or McKenzie exercises is not shown to be better.¹⁴⁴ Increasing exercise intensity, which differs from increasing the number of sets or times per week, and adding motivation increase treatment effects.¹⁴⁴

MCKENZIE METHOD

McKenzie is a methodology to “centralize” peripheral pain and exercise the patient in the “direction” that accomplishes that goal. Al-Obaidi evaluated patients in a physical therapy setting using the McKenzie method, and outcomes measures for pain-related disability and fear beliefs, as well as time to complete various mobility tasks were obtained.¹⁴⁵ Patients were then treated with McKenzie intervention for 12 visits at a minimum frequency of three per week.¹⁴⁵ Patients showed significant (P < .001) improvement in pain and related fear and disability beliefs and functional task completion at the end of the treatment and throughout the 10-week follow up period.¹⁴⁵ McKenzie exercises perform similarly to a back school paradigm for improvement of pain and disability. Garcia compared four sessions of back school versus four sessions of McKenzie directional preference exercises that showed improvements in pain intensity and disability.¹⁴⁶ The results of the two groups do not seem to have been considered separately, but patients regardless of the treatment arm improved; pain intensity (0–10) decreased from 6.4 to 4 (P < .005) and RMDQ decreased from 13 to 7.8 (P < .001).¹⁴⁶ Paatelma compared six sessions of McKenzie exercise to six sessions of manual therapy to one advice-education session.¹⁴⁷ At 3 months there was no significant difference in any group for leg or back pain, but at 6 months back pain (P < .009), leg pain (P < .03) and disability (P < .003) were significantly improved in the McKenzie group compared with the advice group, and disability continued to be significantly improved in the McKenzie group compared with the advice group at 12 months (P < .028).¹⁴⁷ The manual therapy group trended toward improved leg pain over the advice group at 6 months (P < .075) and disability trended toward improved at 12 months in the manual therapy group compared to advice (P < .068).¹⁴⁷ The authors note there was no significant difference between the McKenzie and manual therapy groups.¹⁴⁷ The authors concluded that the McKenzie method is only marginally better than advice¹⁴⁷ but the McKenzie regimen appeared to perform significantly better in the long term (6–12 months). A meta-analysis of outcomes subsequent to the McKenzie method and intervention by Machado et al.¹⁴⁸ echoed Paatelma's conclusions. Machado et al.¹⁴⁸ conclude that “some evidence that the McKenzie method is more effective than passive therapy for acute LBP exist; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic LBP.”¹⁴⁸

LUMBAR EXTENSION

Progressive resistive exercise in extension demonstrated significant reductions in pain and improved muscle strength, endurance, and joint mobility in patients with LBP.¹⁴⁹ The optimal frequency and duration of the various exercise regimens to treat LBP has not been determined. One study of lumbar extension exercise evaluated the difference in outcomes between one and two sessions per week supervised by a therapist.¹⁵⁰ The results (pre vs. post) showed significant increases in maximal strength and ROM and reductions in pain for both training groups, and Bruce-Low et al. concluded that one lumbar extension training session per week is sufficient for strength gains and reductions in pain in LBP in CLBP patients.¹⁵⁰ Investigators have also tried to discern whether high load or low load extension exercises are more therapeutic. Harts et al.¹⁵¹ evaluated whether 8 weeks of high-intensity strengthening (10 sessions, 10 to 15 repetitions, start 50% maximal extensor strength and add 2.5 kg if able to complete 20 repetitions) of the isolated lumbar extensors was more effective than low-intensity strengthening (fixed 20% maximal extensor strength) or no strengthening. Of interest, while the SF-36 was 7% better and the self-assessed decrease of back symptoms was on average 39% in the high intensity group, no other differences were found at the 8-week conclusion or 24-week follow-up, and the authors concluded that the results of this study of high-intensity strengthening program of the isolated lumbar extensor muscles do not clearly support the generally claimed beneficial influence of lumbar extension exercise for chronic nonspecific LBP at any intensity.¹⁵¹ Review of the tabulated data show a RMDQ baseline in the high intensity of 6.2 (similar in the low-intensity group and wait list controls) with improvement at 8 weeks to 3.4. The range on the RMDQ is 24; other studies have enrolled patients with “more” disability. The exercise program may show weak effect due to patients with low disability being enrolled in the first place. Harts comments on this as a limitation of “voluntary” recruitment and bias.¹⁵¹

GRADED EXERCISE

Graded activity exercises were developed based on studies suggesting that counterproductive belief systems delayed recovery from back pain and increased levels of disability in patients with chronic pain. Therefore, graded activity exercises address pain-related fear, kinesiophobia, and unhelpful beliefs and behaviors about back pain while increasing strength and endurance.¹³⁶ Graded activity programs target activities the patient does not feel he or she can do, having the patient perform submaximal exercises while the supervisor ignores illness behaviors and reinforces wellness behaviors.¹³⁶ In a systematic review Bunzli et al. reviewed 15 trials that included over 3700 subjects and found moderate evidence supporting the application of graded (physiotherapist-provided operant conditioning) for the treatment of LBP.¹⁵² Graded exercise was not inferior to any comparators in reducing disability, and there was moderate evidence that graded exercise is more effective than other behavioral interventions in reducing long-term disability in chronic LBP.¹⁵² In subacute LBP the authors found moderate evidence that operant exercise may be more effective than other treatments in reducing posttreatment fear avoidance beliefs and more effective than a placebo intervention in reducing short-term pain.¹⁵²

Macedo et al. compared graded exercise and motor control (core stabilization) exercise for the treatment of LBP and found no significant difference between treatments for outcomes of average pain over the previous week and function or disability, global impression of change and quality of life.¹³⁶ Rasmussen-Barr et al.¹⁵³ compared weekly supervised graded core stabilization exercise with an education component to daily 30-minute walks and education about the benefits of walking. The primary outcome was perceived disability and pain at 12-month follow-up, but secondary outcomes included physical health, fear-avoidance, and self-efficacy beliefs.¹⁵³ Perceived disability (P < .01), pain (P < .001), and physical health improved significantly in both groups (P < .001), but fear-avoidance and self-efficacy beliefs improved significantly only in the exercise group (P < .001).¹⁵³ Significant differences in favor of the exercise group for perceived disability at 6-, 12-, and 36-month follow-up were found.¹⁵³ Pain showed greater reduction for the exercise group after the intervention.¹⁵³

Smeets et al.¹⁵⁴ compared graded exercise plus problem solving training to active physical training (lumbar extension strengthening) or a combination of graded exercise and physical training for 10 weeks. Their objective was to determine any long-term benefits at 1 year follow-up. None of the treatments showed a clinically relevant reduction of pain and depression or improvement of performance tasks at 1 year.¹⁵⁴ They found that there were no significant differences between each single treatment and the combination treatment on disability and pain, depression, and task performance at 1 year.¹⁵⁴ Graded exercise and active physical training, compared with the combination, showed a higher, but both statistically and clinically insignificant, reduction of disability.¹⁵⁴ Smeets et al. did not endorse a combination treatment.¹⁵⁴

Graded exercise compared to graded exposure was included the 3- to 5-week, seven-hour-a-day interdisciplinary treatment of patients with chronic LBP in a study by George et al.¹⁵⁵ In the graded exercise process the PT first determined tolerance to a particular exercise and determined the baseline target intensity and increased the exercise based on a quota system with positive reinforcement if the quota was met or additional education if the quota was not met.¹⁵⁵ The graded exposure process was described as determining the exercise and activity that were fearful to the patient and was determined using the Fear of Daily Activities Questionnaire.¹⁵⁵ Two feared activities were then incorporated into the patient's exercise regime, initially at a nonthreatening level and progressed with positive reinforcement and increase of intensity or education and maintenance of intensity, depending on the patient's ability to complete the task.¹⁵⁵ Statistically significant (P < .01) improvements were observed for pain intensity and disability at discharge in both goups.¹⁵⁵ Interestingly, Tampa Scale of Kinesiophobia scores did not change significantly in either group. Change in depressive symptoms was associated with change in pain intensity, while change in pain catastrophizing was associated with change in disability.¹⁵⁵

Graded exercise is as effective to reduce pain and disability as lumbar stabilization exercise. However, in a comparison to general exercise, either treatment was found to be clinically significant. Effects on fear avoidance and kinesiophobia, which this treatment theoretically targets, are mixed.

BACK SCHOOL

Back school started as an education intervention in the late 1960s and then an exercise component was added. A systematic review by van Middelkoop et al.¹⁵⁶ concluded that there are insufficient data to draw firm conclusions on the clinical effect of back schools. Brox et al.¹¹⁴ reviewed the literature on back school, brief education, and fear avoidance training and concluded that evidence supporting back school as treatment for LBP was conflicting and back school as a treatment was not recommended.

The literature cited in this section reviews back school compared to general physical therapy, and suggests patient attributes that may improve patient selection for this therapy.

Van der Roer et al.¹⁵⁷ compared exercise with operant conditioning (graded exercise) combined with back school education (10 individual and 20 group sessions) to guideline-driven therapy treatment (session frequency and number determined by therapist) for the treatment of patient with LBP that had lasted over 12 weeks. Multilevel analysis did not show significant differences between the treatment groups on any outcome measures in the intermediate (26-weeks) or long term (52 weeks) except that the operant conditioning back school group showed more reduction in pain intensity (NRS decreased from 6.2 to 4.1 vs. 5.9 to 4.8 in the comparator group) at 26 weeks.¹⁵⁷ Other outcome measures show trends in improvement, but some return to or toward baseline occurs at 1 year.¹⁵⁷ Functional status as measured by Roland Morris Disability Questionnaire (RMDQ) decreases from 11.6 to 6.7 in the operant conditioning back school group while the guideline group decreases for 12.1 to 7.1; however fear avoidance as measured by Tampa Scale of Kinesiophobia at baseline was 37.9 with a nadir of 35.6 at 13 weeks and return to 37.9 at 52 weeks in the operant conditioning back school group; the control group values have a similar shape.¹⁵⁷ The authors note that the differences in groups are small and insignificant at 1 year but the operant back school group “tended to be more effective in reducing pain, coping and self-efficacy” and perceived improvement (45%) than the guideline-driven group in which 32% perceived improvement.¹⁵⁷ They note that at the level of the individual patient 48% of the operant back school group (vs. 375 in control group) achieved a clinically significant decrease in pain (change of 2 points on NRS) and 57% achieved a clinically significant improvement in RMDQ (30% change) compared to 48% in the control group.¹⁵⁷ In the balance the program was noted to be more expensive than the guideline-driven comparator and the authors’ overall conclusion is that this specific program is not recommended to be implemented in primary care physical therapy.¹⁵⁷

Sahin et al.¹⁵⁸ compared physical therapy alone (TENS, hot packs, flexion and extension exercise, and stretching, twice weekly for 5 weeks) to back school (twice weekly education for 2 weeks) combined with therapy and found that VAS and ODQ were significantly reduced at the conclusion of therapy (P < .01) in both groups.¹⁵⁸ However, between groups, there was significantly greater improvement in VAS (P < .01 posttreatment, and P < .002 at 3 months) and ODQ in the back school group (VAS baseline 5.69 +/− 2.14 decreased to 4.9 +/− 0.11 decreased to 3.6 +/− 0.15; ODQ baseline 54.50 +/− 14.13 decreased to 41.01 +/− .59 decreased to 36.13 +/− 0.69) compared with the control group (VAS baseline 6.52 +/− 1.12 decreased to 5.35 +/− 0.11 decreased to 4.31 +/− 0.15; ODQ baseline 55.65+/− 11.80 decreased to 44.76 +/− .59 decreased to 39.93 +/− 0.69) at the end of therapy and 3 months posttreatment (P < .001 for both time frames).¹⁵⁸ Sahin et al.¹⁵⁸ concluded that the addition of back school was more effective than physical therapy and exercises alone for patients with chronic LBP.

Yang et al.¹⁵⁹ reported on a 4-week back school program with typical educational topics and core strengthening exercise and concluded that less use of relaxation (odds ratio _ 2.11. 95%, P _.001) and more use of exercise and stretching (odds ratio _ 2.39, P _.001) as coping strategies were significantly predictive of the success of back school programs. Based on the scores of the Oswestry Disability Index patients were subclassified as very improved, somewhat improved, or not improved (change <6 points) and compared.¹⁵⁹ As a group, participants improved, pretreatment to posttreatment, significantly in terms of back-specific disability (P < .005), worst pain (P < .001), and mean pain (P < .005), SF36 subscales bodily pain (P < .001), mental health (P < .005), vitality (P < .001), and social functioning (P < .001).¹⁵⁹ In long-term follow-up, the much-improved group showed significant improvement in chronic pain coping inventory (CPCI 9) scores for relaxation, task persistence, and exercise; however, the coping strategies of those in the somewhat improved and not improved groups did not change significantly over the course of treatment.¹⁵⁹ At the baseline, patients who had used relaxation less as an initial coping strategy were more likely to succeed in the back school program (CPCI relaxing subscale most improved 1.6+/− 1.0 increased to 2.6 +/−1.1; somewhat improved baseline 2.4+/− 1.7 with no change 2.6 +/− 1.4; unimproved 2.8 +/− 1.2 decreased to 2.0 +/−1.8). The exercise/stretching coping score after back school increased significantly in the much-improved group compared with the slightly improved or unimproved group; of interest the most improved group, as with relaxing, was least likely to use this strategy before the treatment (CPCI exercise subscale most improved 3.11.1 increased to 5.2 +/−1.9; somewhat improved baseline 3.7+/− 1.2 with no change 3.6 +/− 1.6; unimproved 3.8 +/− 1.7 decreased to 3.0 +/−2.0) (P < .035).¹⁵⁹ The patients who benefit most from the program are the ones who need to learn the coping strategies. The authors comment that “these findings suggest that a low level of wellness-focused coping skills at baseline could be predictive of better outcome.”¹⁵⁹

The effectiveness of back school for improvement of pain, disability, and return to work conflicts in the literature but a subgroup of patients who could benefit from instruction on coping with pain by relaxing or exercise may be most helped by this format.

MULTIDISCIPLINARY PROGRAMS

Stanos provides an excellent review and explanation of multidisciplinary pain programs within the context of the biopsychosocial model for the treatment of chronic pain.² He notes that in the collaborative spectrum of patient treatment there exists “parallel, collaborative, coordinated, multidisciplinary, interdisciplinary, and integrative approaches.”² Multidisciplinary treatments often involve one or two physician specialists or practitioners directing the services of a number of team members, who often have independent goals.² Stanos notes that interdisciplinary programs use cognitive and behavioral approaches to provide outcome-focused, coordinated, goal-oriented services to team members who work together for a common goal and make collective therapeutic decisions in team meetings.^2,160 Stanos reports that participation in a well-established interdisciplinary pain treatment programs decreases pain disability scores by about half.¹⁶⁰ Multidisciplinary pain treatment centers may seek accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF).

Several studies have investigated patient traits that may affect outcome in these programs. Pieh et al.¹⁶¹ studied gender differences and response to treatment of chronic pain in multidisciplinary settings and found that women improved more in pain-related disabilities in daily life than men. These distinctions are not due to differences in pain duration, received medication, psychiatric comorbidities, pain chronicity stage, or application for a disability pension.¹⁶¹ MacLaren et al.¹⁶² studied the effect of opioids on patient outcome and noted that significant improvements from pretreatment to posttreatment were shown on all psychological and physical measures for both opioid users and nonusers. Additionally opioid use did not affect or return-to-work outcomes.¹⁶² However, Howard et al.¹⁶³ found that opioid use as well as other factors predicted drop out from multidisciplinary treatment for chronic pain. Persons who dropped out had a longer duration of total disability between injury and admission to treatment (completers, 20 mo vs. noncompleters, 13 mo; P < .001).¹⁶³ Also patients, who were opioid-dependent were 1.5 times more likely to drop out of rehabilitation, and patients diagnosed with a socially problematic Cluster B Personality Disorder were 1.6 times more likely to drop out.¹⁶³ The multivariate logistic regression analysis was found to be significant with the addition of each block. In sum, women may fare better in this therapeutic environment than men. The effect of opioid use on participation is debatable. Longer duration of disability (20 months) and Cluster B personality disorder (Narcissistic, Borderline, Anti-social with dramatic, erratic, or emotional attributes) may suggest patients less suited for this treatment.

A systematic review by van Middlekoop et al.¹⁵⁶ found that multidisciplinary treatment reduced pain intensity in patients with CLBP at short-term but not long-term follow-up compared to both no treatment/waiting list controls and active treatments; evidence was moderate. A systematic review by Scascighini et al.¹⁶⁴ implied that multidisciplinary treatment is a more effective treatment model than other treatments for LBP and they systematically reviewed the literature about multidisciplinary treatment in order to develop the minimum standards for an effective program that should serve as an international model. Scascighini et al.¹⁶⁴ recommend:

Scascighini et al.¹⁶⁴ found moderate evidence of greater effectiveness for multidisciplinary interventions compared to active treatment. Compared to no treatment, strong evidence supporting the effectiveness of multidisciplinary treatments was found.¹⁶⁴ Moderate evidence supported that inpatient programs were more beneficial than outpatient programs.¹⁶⁴ Multidisciplinary programs were more effective for patients with more specific diagnoses like fibromyalgia and chronic back pain, compared to patients with nonspecific diagnoses like chronic pain.¹⁶⁴

Demoulin studied the effects of a semi-intensive (>30 hr but <100 hr) multidisciplinary program in which patients participated in thirty-six 2-hour sessions at a rate of about twice to three times weekly in a program with PTs and OTs, a physiatrist, and a psychologist.¹⁶⁵ Study outcomes significantly improved, including “pain intensity was decreased by 44%, functional impairment by 40%, and kinesiophobia by 11% whereas knowledge was improved by 59%, back-sparing technique by 95%, trunk muscle strength by 40% on average, trunk extensor muscle endurance by 90%, mobility by 8%, and aerobic capacity by 18%.”¹ Compared to an inpatient or all-day outpatient program, this program allows the patient to continue work.¹⁶⁵

Dufour et al.¹⁶⁶ describe a 12-week 73-hour multidisciplinary program of physical therapy and occupational therapy and education, in comparison to 12 weeks of twice weekly supervised exercise for 1 hour.¹⁶⁶ With regard to pain there were significant improvements in both groups with no difference between groups for the degree of pain improvement (20-30%) and there was no difference in medication usage to relieve pain.¹⁶⁶ Improvements were maintained throughout the 24-month follow-up period.¹⁶⁶ Based on the SF36, both groups improved significantly (P < .05) in all dimensions except for the “General Health” and “Role Limitation Emotional.”¹⁶⁶ Between groups, the improvement in “Physical functioning” and “Physical component summary” was significantly greater in the multidisciplinary group throughout the 24-month follow-up.¹⁶⁶ Scores on the RMDQ significantly improved (P < .05) in both groups, but between groups the multidisciplinary group had a more significant change of 24% versus a 12% change in the exercise-only group.¹⁶⁶ Adverse events included a fall and concussion, herniated disc and surgery, and delayed onset muscle soreness.¹⁶⁶ Based on the study, Dufour et al.¹⁶⁶ conclude that both approaches are effective, with the multidisciplinary group approach being less costly but more time consuming and the individual exercise being more expensive but efficient.

A similar study by Kaapa et al.¹⁶⁷ compared 120 female working subjects in a 70-hour multidisciplinary program consisting of physical therapy and occupational therapy and education to a 10-hour supervised exercise program, with follow-up after the program and at 6, 12, and 24 months. Outcomes measures included: back pain and sciatic pain intensity, disability, sick leaves, health care consumption, symptoms of depression, and beliefs of working ability. In both groups all measures improved; however, P-values do not appear in the text or tables of the article and it is not clear that the improvements have statistical weight.¹⁶⁷ For, example the pain rating changes from 4.6 to 3.5 in the multidisciplinary group and from 5.0 to 4.0 at 24-month follow-up in the control group. There are no differences between groups. The Oswestry score in both groups is approximately 24 at baseline (on a scale to 100) and improves in both groups to about 19 at 24-month follow-up. The authors note that the mild to moderate symptoms of the patients may limit the study design, finding significant differences between the treatments. As in the previous study the authors did not find a significant preference to either treatment but note the low cost of the multidisciplinary program and the time flexibility of the individual therapy program.¹⁶⁷

Monticone et al.¹⁶⁸ compared patients with LBP randomly assigned to a multidisciplinary program consisting of CBT and exercise training versus exercise training alone administered over the course of 1 year. Monticone et al.¹⁶⁸ found that the multidisciplinary program reduced disability, fear-avoidance beliefs, and pain and enhanced the quality of life of patients significantly better than exercise alone for group and time (P <.001) and group-time interaction (P < .001, except SF-36-Physical function, P .002; SF-36-Physical role, P .007; and SF-36-Emotional role, P .01) for up to 1 year. Roche-Leboucher¹⁶⁹ compared a multidisciplinary program versus exercise only to see if the number of sick days differed as a result of treatment. The multidisciplinary group was treated in groups of 6 to 8, and met 6 hours a day, 5 days a week, for 5 weeks.¹⁶⁹ The patients were evaluated and treated by OTs, a physiatrist, psychologist, and dietician, and work site consultation for ergonomic advice from an occupational physician was available.¹⁶⁹ A private-practice physiotherapist treated individual subjects in the exercise group 1 hour 3 times a week, during 5 weeks.¹⁶⁹ There was no difference between groups regarding the number of sick-leave days during the 2 years preceding treatment. In both groups, the number of sick-leave days in the 12 months after treatment decreased significantly but the reduction was significantly greater in the multidisciplinary group (−101.2 ± 126.5 d vs. −79 ± 143.9 d; P < .001). Other functional and physical outcomes included fingertip-to-floor distance, Sorensen test, ito test, intensity of pain on VAS, Dallas daily activities score, Dallas work and leisure score, Dallas anxiety and depression score, and the Dallas sociability score.¹⁶⁹ All physical and functional criteria were significantly improved in both groups except for the Dallas anxiety and depression score and sociability score in the exercise group.¹⁶⁹ The multidisciplinary program had a more robust effect on the outcome of sick days.

Moradi et al.¹⁷⁰ assessed the effect size of multidisciplinary treatment, which was found to be moderate for the treatment of chronic LBP. The program was an inpatient treatment lasting 3 weeks, 8 hours per day, 5 days per week for a total of 120 hours of treatment, consisting of physical exercises, ergonomic training, psychotherapy, patient education, behavioral therapy, and workplace-based interventions on an individual basis and in group sessions.¹⁷⁰ There was no placebo or active comparator group. Medium effect sizes (d = 0.6 to 0.7) were shown for VAS after treatment and at 6 months, indicating clinically relevant pain relief.¹⁷⁰ Pain-related disability (d = 0.8) and quality-of-life subscales on SF-36 for physical function, vitality, and mental health (d = 0.5 to 0.8) showed a strong treatment effect immediately after treatment.¹⁷⁰ Low to medium effect sizes were shown for functional capacity (d = 0.4-0.5). Depression improved significantly with strong effect sizes of d = 0.7.¹⁷⁰ Demographically, females, the age group 30 to 39 years, and patients with low physical job exposure showed the most effect size for VAS, based on comparison of effect size.¹⁷⁰ An increase in number of pain locations and severity of accompanying pain in other body areas significantly impaired therapy outcome.¹⁷⁰ Compared to effect sizes reported in the literature, the authors concluded that effect sizes are higher than for monodisciplinary treatments and had the highest effect size for pain-related disability, mental health-related quality of life, and depression.¹⁷⁰

Aftercare following multidisciplinary rehabilitation programs (MRP) has been evaluated. Henchoz et al. compared a 3-month exercise program following MRP versus “usual care” after MRP.¹⁷¹ They found that just after MRP (start of the 3-month exercise program or care-as-usual) there was no difference between groups, and, at 1 year, there was no difference between groups for the outcome measures of physical functioning, physical role, bodily pain, general health perception, vitality, emotional role, mental health, and physical component score and mental component score.¹⁷¹ In both groups quality of life significantly improved at 1-year follow-up.¹⁷¹ No additional benefit to quality of life parameters was found by adding an aftercare exercise program.¹⁷¹ The same group evaluated effects on physical function and found that at the 3-month and 1-year follow-up, both groups maintained improvements in all outcome measures except cardiovascular endurance.¹⁷² No differences between groups were found except the aftercare-exercise group showed significant improvement in disability score and trunk muscle endurance.¹⁷² The authors concluded that after completing a functional multidisciplinary rehabilitation, patients simply need advice to stay active in order to reach long-term improvements. Henchoz et al.¹⁷² recommend that although disability score and trunk muscle endurance improve as a result of additional prescribed exercise, identification of patients receive this limited benefit requires further research.

Multidisciplinary pain treatment programs are an effective treatment model to reduce disability and pain and other outcomes like sick days, kinesiophobia, and physical functioning. Multidisciplinary programs have greater effect sizes than monotherapies, and the highest effect size for pain-related disability, mental health-related quality of life, and depression. A program schedule which is flexible enough to allow the patient to continue to work is probably optimal since more time consuming formats have not been found to be superior. Women may do particularly well in this type of program. Patients with Cluster B personality disorders may not do as well.

FUNCTIONAL RESTORATION

Huge et al. comment that functional restoration programs for CLBP have been shown to be more effective in improving function than in reducing pain.¹⁷³ They compared the outcomes of a 4-week, 6 to 8 hours per day outpatient functional restoration program (education, physical therapy, psychological counseling and relaxation training and ergonomics) to “treatment as usual” with a PT, psychologist, and relaxation.¹⁷³ The authors found that compared with the “treatment as usual” group, pain and disability were significantly improved in patients completing the functional restoration program, and a significant reduction in depression and improvement in quality of life was also observed.¹⁷³ No changes were detected in the “treatment as usual” group.¹⁷³ The authors conclude that a functional restoration program for CLBP significantly improves health-related quality of life and decreases the perception of pain and pain-related disability even in patients with a long history of CLBP.¹⁷³

Beaudreuil studied patients with LBP who had been on sick leave for over 3 months.¹⁷⁴ Patients participated in a 5-week, 5 days per week day hospital program and then the patients were followed for one year.¹⁷⁴ After 1 year, two-thirds of the patients had returned to work and sick leave was decreased by 50% compared to the previous year.¹⁷⁴ Patients who remained on sick leave after 1 year were older and had higher scores on the Dallas Pain Questionnaire's anxiety and depression subscale.¹⁷⁴ The authors conclude that functional restoration returns most patients to work.¹⁷⁴ The argument could be made that if more of the patients were older or more anxious or depressed the return to work rate would not have been as robust. However within the group that did return to work, the program did seem to effect a lower rate of absenteeism.¹⁷⁴

Bendix et al.¹¹⁷ compared a 3-week, 8-hour-a-day functional restoration program (aerobic and strength training, occupational work hardening, psychology, education, stretching, and recreational activity) to an 8-week, three times weekly 1.5-hour aerobic and strengthening program. Review of the statistics confirms the authors’ comment the expensive functional treatment had relatively poor results compared with the results from the less expensive physical therapy treatment.¹¹⁷ Work capability increased in both groups; the functional restoration group increased from 28 to 36 of 48 patients (P < .08) and the outpatient therapy group increased from 21 to 35 of 51 patients (P < .005).¹¹⁷ The authors posited that the control program may have been too substantial or the patient sample may have been “acute” enough that they would have improved regardless of treatment.¹¹⁷

Functional restoration programs significantly improve pain and disability and, like multidisciplinary programs, return to work rates. Older patients or persons with attributes of depression or anxiety may be less likely to return to work.

AQUATIC THERAPY

Aquatic therapy adapts any of the main exercise types, stretching, aerobics, and strengthening, in a buoyant environment. Buoyancy can help a patients achieve an end-ROM that they are unable to achieve on land in gravity. Aqua-running with a weight belt is a common sports medicine technique. Air-filled bladders that offer resistance in the water can be used for strengthening. Persons with arthritis just seeking to walk may do so more comfortably in waist to chest deep water.

A systematic review of aqua-therapy concluded that there was sufficient evidence to suggest that therapeutic aquatic exercise is potentially beneficial to patients suffering from CLBP and pregnancy-related LBP.¹⁷⁵ Review of the seven included trials does not clarify whether the study participants were in a pool setting supervised by a licensed therapist or not.¹⁷⁵ One case report described the use of pool therapy progressing to land based walking over a 26-week period in a patient 10 status after a multilevel spinal fusion for spinal stenosis and reporting high levels of persistent postoperative pain with minimal activity.¹⁷⁶ The progression of the pool program started as pool exercise only, five times per week for 6 weeks, and then brief land based walking followed by pool exercise, five times per week for 8 weeks and the last phase for 11 weeks was land-based walking only, 5 days per week, completely phasing out the pool once the patient could walk about one mile.¹⁷⁶ At 10 months the patient's surgical wound would be healed. However, it is important to note that pool therapy could not commence before complete healing of any open wounds or surgical was complete.

Dundar et al.¹⁷⁷ compared physical therapy supervised water therapy with flexibility, aerobic, and strengthening components that convened five times a week for 4 weeks to a land-based home exercise program.¹⁷⁷ At 12-week follow-up statistically significant improvements were detected in both groups, compared with baseline, for lumbar flexion, extension and rotation tests, pain at rest, with movement and at night, for disability (Modified ODQ and the SF36).¹⁷⁷ However, improvement in disability questionnaire and physical function and role limitations subscales of the Short-Form 36 Health Survey were better in aquatic exercise group (P < .05).¹⁷⁷ The authors concluded that a water-based exercise program produced improvement in disability and better quality of life.¹⁷⁷

Cuesta-Vargas et al.¹⁷⁸ compared PT-supervised deep water running three times per week for 4 months to an educational booklet only as treatments for nonspecific CLBP.¹⁷⁸ At 1 year findings included significantly more improved VAS (P < .05), disability (P <.05), physical health (P <.05), and mental summary component of the SF-12 (P <.05) in favor of the deep water running group.¹⁷⁸ The authors found this treatment to be significantly better for the relief of pain and disability and improvement of quality of life. Cuesta-Vargas et al.¹⁷⁹ in a different study added 20 minutes of deep-water running to and education and physical therapy program but found no added benefit of the deep water running. Both interventions (PT + education vs. PT + education + deep water running) resulted in significant improvements in pain, disability, and physical health.¹⁷⁹

Baena-Beato evaluated the dose response of water aerobic activity and found that groups participating in water exercise twice or three times a week for 8 weeks had a significant decrease in levels of back pain and disability, increased quality of life, and improved health-related fitness in adults with CLBP without effects in body composition.¹⁸⁰ Dose-response effects were observed in some parameters, with greater benefits when exercising 3 days per week compared with 2 days per week.¹⁸⁰

Compared to a booklet, aquatic therapy improves pain, disability, and quality of life significantly more. Aquatic therapy is better than home exercise but par with supervised physical therapy for improvements in pain disability and quality of life for persons with chronic back pain. A dose response is noted between twice and three times weekly therapies.

NOVEL APPROACHES TO PHYSICAL THERAPY

A case series (n = 3) on Sensorimotor Retraining which involves graphesthesia training and a variety of exercise maneuvers, some with a applied sensory feedback component, was reported by Wand et al.¹⁸¹

Significant improvement in pain level, disability, and pain interference was reported.¹⁸¹

Gatti et al. reported on the effectiveness of trunk balance exercises versus trunk strengthening to improve pain intensity, disability, and quality of life.¹⁸² The authors note that the patients with CLBP have difficulty maintaining balance, especially under challenging conditions such as single-limb support.¹⁸²

The experimental group performed trunk balance exercises in addition to standard trunk flexibility exercises, and the control group performed strengthening exercises in addition to the same standard trunk flexibility exercises.¹⁸² A significant difference in scores on the Roland-Morris Questionnaire (P < .011) and the physical component of the 12-Item Short-Form Health Survey (P < .048) was noted in the time-by-group analysis, and between groups for pain reduction (P < .03). The number of participants reaching the minimal clinically important difference for the RMDQ and reduction of painful positions (P < .03) was in favor of the experimental treatment.¹⁸² Medication use decreased in both groups but was not significant.

Pozo-Cruz evaluated the effectiveness of the vibration therapy, done twice weekly for 12 weeks, and compared to activity as normal, for the treatment of LBP. Vibration therapy entails the use of oscillatory muscle stimulation.¹⁸³ The authors explain that a foot is placed on a platform that vibrates at a predetermined frequency and amplitude, which are then transmitted throughout the body, eliciting reflexive muscle stimulation, with the short and fast changes in muscle length detected by different proprioceptive organs.¹⁸³ Significant improvements in the vibration group included anterior posterior stability (P < .031), ODQ (P < .013), RMDQ (P < .001), quality of life (P < .042), and 24.13% improvement in VAS in back pain (P = 0.006).¹⁸³ Proprietary devices to provide the therapy as well as perform follow-up measurements may be limitations to this therapeutic strategy.

Telephone coaching of patients with low to moderate expected responses from physical therapy intervention by therapists trained in health coaching yielded significant improvement in the Patient Specific Functional Scale and recovery expectation at 12 weeks.¹⁸⁴ The billing code for this service would need clarification to make this service economically viable in a busy rehabilitation outpatient service.

PREDICTING OUTCOME

Very little is known about factors that predict treatment outcome.¹⁸⁵ A systematic review by Wessels et al. to discern the predictors of nonoperative treatments of CLBP showed that functional coping mechanisms and pain reduction, but not physical performance factors, were associated with a decrease in disability and increase in return to work.¹⁸⁶ Decreases in disability and functional coping mechanisms as well as physical performance factors were associated with pain reduction.¹⁸⁶ In obese patients with LBP referred for physical therapy, pain-related fear of movement predicted self-reported disability with walking and overall Oswestry scores despite similar pain ratings to normal weight patients.¹⁸⁷ Participants with recurrent LBP currently working participated in an 8-week exercise program; ratings of poor self-efficacy for physical activity, greater disability, and higher pain ratings were the most consistent independent predictors of long-term poor outcome of disability and pain.¹⁸⁸

Both the components of the treatment program as well as patient characteristics can affect outcome. The characteristic that best predicted improved pain in patients who participated in an adaptive community based exercise program for one year was adherence to the exercise program (participation >75% of session) In the same group, presence of depressive symptoms and poor self-rated health best predicted no improvement in pain at one year.¹⁸⁹ Among the patients with improved pain and adherence to the program, factors that correlated with adherence were proximity of exercise facilities, positive perception of exercise trainer, and positive perceived health and functional status.¹⁸⁹

SUMMARY

In the end, skilled physical therapy alone or in combination with other allied health professionals in a multidisciplinary program is in the spectrum of possible treatments for a person experiencing pain. Exercise does not “cure” pain, and like the other moieties we prescribe there are responders and nonresponders and, among responders, the effect is, most often, only partial. For example, if the pain numerical rating scale is reported at six, a successful therapy intervention may decrease the NRS to three or four. The tabulated data of many of the papers reviewed was included in the tables and texts of this chapter not to provoke ennui but to allow the physician or provider reading this chapter to gauge whether the “significant outcome” described in the specific paper is applicable to the physician or provider's own patients, and, if so, how much improvement as a result of skilled therapy the patient can expect.

REFERENCES

PHYSICAL MODALITIES

Modalities are commonly used to produce a response in tissues and include heat, water, cold, sound, and electricity. These modalities should not be used as the primary mode of treatment but rather used in adjunct with the main intervention such as physical or occupational therapy. This chapter will discuss the more common modalities used as well as briefly discussing electrical stimulation. Box 97-1 describes factors to consider prior to selection of a specific therapeutic modality.

HEAT

Therapeutic uses for heat are based on analgesia, increase in collagen elasticity, and hyperemia to decrease pain, reduce contractures and joint stiffness, and decrease muscle spasms.¹ Therapeutic range for heat is 40° to 45°C and is commonly maintained for about 5 to 30 minutes. It is important to note that the temperature for pain threshold in humans is 45°C.² Heat can be divided by superficial and deep heat and is dependent on depth of heat and form of transfer of heat which include convection, conversion, conduction, and radiation. Convection is the contact between two surfaces at different temperatures with resultant flow through this medium to transport thermal energy. Examples include contrast baths and hydrotherapy. Conduction is the transfer of thermal energy between two bodies by contact at different temperatures with examples such as hot water and hot packs. Conversion is the transformation of energy to heat such as ultrasound and microwave diathermy. Lastly, radiation involves thermal radiation from any surface or body with temperature above absolute zero. General precautions for the use of heat are listed in Box 97-2 but can include acute inflammation, ischemic locations, bleeding disorders, impaired sensation, malignancy, scar tissue, and those with inability to communicate or respond to pain.³

Superficial heat is considered to be 1 to 2 cm and deep heat generally involves increasing tissue temperature to a depth of 3 to 5 cm or more. Examples of superficial heat include heating pads, hydrocollator packs, whirlpool baths, and paraffin baths which achieve maximal tissue temperature in the skin and subcutaneous fat. Hot packs such as hydrocollator packs are commonly stored in heated water tanks and need to be wrapped in layers of insulation prior to being applied to the skin. Caution should be used as this type of modality is one of the most common reasons for burns in therapy sessions. Radiant heat in the form of heat lamps can also be used therapeutically and is usually placed 30- to 60 cm from the patient's body and is useful when the patient cannot tolerate the weight of the heating pads. Paraffin baths is another type of modality that is used with wax and mineral oil. Immersion technique has been shown to provide the greatest duration of temperature increase and is commonly applied in scleroderma patients.⁴ Superficial heat is commonly used to treat low back pain, arthritic conditions, neck pain, and various chronic musculoskeletal injuries.⁵ Examples of deep heat include ultrasound, shortwave, and microwave diathermy. These modalities transfer heat through conversion and the differences are outlined in Table 97-1. Ultrasound diathermy should not be confused with diagnostic ultrasound. Ultrasound heats the greatest at the bone-tissue interface while short wave diathermy heats fat more so than muscle. Ultrasound that is therapeutic in nature uses high frequency energy to produce a deeper tissue response and the most commonly used frequency is a range from 0.8 to 1.1 MHz. Thermal response in tissues involves energy absorption causing heat production in tissues whereas nonthermal responses cause distortion and movement of tissues.⁶ Techniques for ultrasound application can vary with the most common technique involving stroking the probe over the affected site as opposed to static application. Contraindications for therapeutic ultrasound include areas over fluid-filled cavities, laminectomy sites due to concern for heating the spinal cord, open epiphysis in the growing adolescent, pacemakers, and prosthetic cements.⁷

Shortwave diathermy is used to treat deep muscles and joints and commonly uses a frequency of 27.12 MHz. This type of modality can involve two condenser plates placed on either side of the body part or induction coils that can be molded to the body part. Through conversion, electromagnetic energy converted to thermal energy travels between the coils or condensers to cause deeper heating of tissues. Contraindications for this type of treatment include pacemakers, metal objects, and heating over the eyes. General contraindications for the three modalities for deep heat are listed in Table 97-2

CRYOTHERAPY

Therapeutic uses for cold are based on immediate local vasoconstriction to reduce swelling and acute inflammatory response, decreased pain and muscle spasm, decreased spasticity, slowing of the nerve conduction velocity, and decrease in local metabolism. Cryotherapy is often used in acute musculoskeletal conditions as well as for spasticity management.⁸ Mechanisms for cold transfer include conduction, convection, and evaporation. Examples of conduction include cold packs and ice massage; convection includes cold baths; and evaporation includes vapocoolant sprays. Cold packs can generally be applied for 20 to 30 minutes with external compression providing increased effectiveness of cooling.⁹ Vapocoolant sprays are commonly combined with stretching of a contracted muscle to treat various musculoskeletal related conditions.¹⁰

General precautions and contraindications for cryotherapy are listed in Box 97-3 and include cold intolerance or hypersensitivity, impaired sensation, communication or cognitive deficits, arterial insufficiency, and cryopathies such as paroxysmal cold hemoglobinuria or cryoglobulinemia. In general, cold application should be avoided over superficial nerves due to increased risk of affecting nerve conduction.

HYDROTHERAPY

The main forms of hydrotherapy are contrast baths, shower carts, and whirlpool baths with therapeutic use in arthritic conditions and also for burn injuries with gentle debridement. Whirlpool baths are commonly used for partial body immersion while Hubbard tanks are larger and used for total body immersion. With increased body immersion and extremes in temperature change, there is increased potential for change in core body temperature. As mentioned previously, burns or infected areas of the skin can be therapeutically treated with antiseptic conditions with sodium hypochlorite most commonly used as an antibacterial solution. General contraindications for hydrotherapy include bowel and bladder incontinence, unstable blood pressure, and uncontrolled epilepsy.

Briefly, other modalities that may be encountered include iontophoresis and phonophoresis. Iontophoresis involves the use of an electrical field to move charged particles across a biologic membrane. For therapeutic purposes it is used to deliver medicines directly to soft tissues with a small electric current which limits systemic absorption.¹¹ The therapeutic medication is placed on the electrode of the same polarity with the opposite electrodes placed on the skin. A current is applied to drive the medication away from the electrode into the directed tissue target. Common diagnoses that are treated with this modality include various bursitis and plantar fasciitis. Phonophoresis involves the use of ultrasound on topically applied medicines to facilitate migration of the medication into the skin. Corticosteroids are the most common medications used and are indicated to treat bursitis, osteoarthritis, and contractures.

ELECTRICAL STIMULATION

One of the most common forms of electrical stimulation used for treatment of pain is transcutaneous electrical nerve stimulation (TENS). Based on the Gate Control theory proposed by Melzack and Wall in 1965, TENS stimulates the large Ia myelinated afferent nerve fibers “gating” or blocking afferent pain transmission at the dorsal horn, thus modulating ascending pain signals to the brain.¹² TENS units are often used as adjuvant therapy to a more active rehabilitation program including exercise, stretching, and strengthening. The most common and effective type of stimulation is a high-frequency, low-intensity stimulation which results in increased tolerance and shorter onset pain relief. On the other hand, low-frequency, high-intensity stimulation causes more immediate discomfort but more commonly leads to longer lasting analgesia. Contraindications include circulatory impairment, pregnancy, active hemorrhage, malignancy, and decreased skin sensation.

ORTHOSES

An orthosis is an external device applied to the body that can provide multiple different functions including support and stability, prevention or correction of a deformity, assistance in weak muscles, controlling spasticity, and limit range of motion or unload damaged joints. Orthotics assist for the spine as well as the upper and lower extremities. This section will focus on the more commonly encountered orthoses including spinal orthotics, ankle foot orthoses (AFO), knee orthosis, and static wrist-hand orthosis.

SPINAL ORTHOTICS

These orthoses can be subdivided into the more common cervical and thoracic and lumbar orthosis. The Philadelphia collar is a common cervical orthosis used for stable bony or ligamentous injuries with more control of flexion and extension. The Philadelphia collar is commonly used during emergency transport, after cervical fusion, or halo removal. The Philadelphia collar limits flexion and extension by 70% and less with rotation. This orthosis is used to wean off more rigid orthosis such as the sternal occipital mandibular immobilizer (SOMI) brace which is used for bedridden patients due to lack of posterior uprights, stabilizing the cervical and thoracic regions and limiting flexion by 75%. This brace is easier to don and doff in contrast to the halo vest which has a rigid headpiece secured by pins and posters that connect to a vest or plaster body cast. The halo device provides the best control of motion in all planes and is commonly used to treat unstable cervical fractures and dislocations. The halo is used for approximately 3 months and the pins should be checked for tightness every 1 to 2 days. Table 97-3 shows normal cervical motion from the occiput to the first thoracic vertebra and the effect of different cervical orthoses on limiting motion.¹³

Rigid truncal orthoses include the Jewett brace which uses a three-point pressure system to allow extension but limit flexion, leaving the abdomen free and applying pressure on bone prominences (i.e., sternum, pubis anterior, and the thoracolumbar junction posteriorly). It is typically used to treat lower thoracic or upper lumbar compression fractures or is used after surgical stabilization. The thoracolumbosacral orthosis (TLSO) extends from the sacrum to the inferior angle of the scapula and is commonly used to prevent progression of scoliosis and to stabilize the trunk from the middle thoracic segments to the lower lumbar spinal segments. It is most commonly used during postoperative stabilization from spine surgery. The TLSO is also used to decrease load on the spine by increasing intraabdominal pressure which decreases load on the spine. Lastly, the Taylor brace provides flexion and extension control similar to a TLSO and is primarily used to treat kyphosis from osteoporotic fractures.

ANKLE FOOT ORTHOSES

The ankle foot orthosis (AFO) is commonly used to assist the ankle joint that may be affected due to weakness or pain. The composition of the AFO may be plastic or metal with a plastic design being more advantageous because of its light weight, cosmetic appearance, and intimate fit whereas the metal AFO can accommodate fluctuating edema. The three most common types of plastic AFOs include the posterior leaf spring, semirigid plastic, and solid AFO. The posterior leaf spring AFO is composed of a thin plastic piece placed behind the ankle that allows the patient to push off or plantar flex at the ankle thus overpowering the brace when needed. This is typically used in patients with flaccid foot drop. The semirigid AFO provides much less motion than posterior leaf spring AFO and increases mediolateral stability at the ankle. The semirigid AFO is used when increased stability of the ankle is needed or there is foot drop with associated extensor tone. Lastly, the rigid plastic AFO is used when the patient exhibits high levels of spasticity or complete immobilization of the ankle is required. It is important that the calf band be at least 1 inch below the fibular neck in order to avoid compression of the common peroneal nerve.

KNEE ORTHOSES

Knee orthoses may be used to provide support of the knee and typically are used to either provide mediolateral stability or prevent hyperextension of the knee. They may be used during increased physical activity, unstable knees, or in the rehabilitation period. Knee orthoses are classified as prophylactic, rehabilitative, and functional. Prophylactic knee bracing helps to prevent or reduce severity of injuries although evidence for this is lacking.¹⁴ Common types of prophylactic orthoses include flexible orthoses typically made from rubber to enhance proprioceptive feedback at the knee and provide minimal stability. More rigid and durable rehabilitative orthoses include the Swedish knee cage and Lenox-Hill derotation orthoses that not only provide structural protection but also limit knee hyperextension. Functional braces provide stability for unstable joints. They may be useful in stabilizing a laterally displacing patella or a weakened or torn anterior cruciate ligament (ACL).^15,16 Patients with advanced osteoarthritis may be fitted with a knee orthosis to unload increased pressures across the knee with a focus along the medial compartment of the knee. To date, bracing has shown a small beneficial effect with a recent Cochrane review demonstrating that the use of a knee brace may increase walking distance but does not lead to improvement in pain or function.¹⁷

STATIC WRIST-HAND ORTHOSIS

There are multiple types of upper limb orthoses used to immobilize, stabilize, support the joints, prevent contractures, and facilitate healing of different types of injuries. The static wrist-hand orthosis, also known as the resting hand splint, may be the most commonly encountered type of orthosis of the upper limb. This is commonly used to treat and rest an injured hand or prevent or stretch a contracture. It is usually applied to the volar surface of the arm and the wrist is usually placed in neutral with the thumb abducted and the metacarpal phalanges in flexion to 70°.

ASSISTIVE DEVICES

Assistive devices are tools that make a particular function or task easier to perform. They can aid persons with disabilities to perform their activities of daily living. This section will discuss mobility aids with a special focus on canes, walkers, and crutches. Table 97-4 outlines general fitting guidelines for selected mobility aids. It should be noted that supervision or training with a therapist as well as strengthening of the upper extremities can enhance the benefits and safety of these devices.¹⁸

CANES

Canes are usually prescribed to improve balance, reduce weight-bearing forces of injured joints or structures, compensate for weakened muscles, and decrease pain. The cane can vary in the components from an inexpensive adjustable metal cane to a small or a wide-based quad cane provides a wider base of support. The function of the cane should be to increase the base of support, provide additional sensory feedback, and decrease loading on the lower limbs. In general, the cane should be held in the hand opposite of the affected lower limb and is advanced with the affected limb. This reduces the load on the affected limb 20% to 25%. The cane length should be from the bottom of the shoe heel to the height of the greater trochanters with the elbow flexed from 20° to 30°.¹⁹ When climbing up and down stairs, patients should be counseled to ascend stairs with the strong and unaffected limb and to descend stairs with the affected limb.

WALKERS

Compared to canes, walkers provide wider and more stable bases of support. The walker can allow up to 100% of weight-bearing relief of the affected lower limb and common indications can vary from bilateral lower extremity weakness or incoordination to general support to aid in mobility. One disadvantage of the walker is the slow and awkward gait pattern that may not only promote poor posture, but also cause difficulty maneuvering stairs and small spaces. A properly fitted walker is set with the elbows flexed to 20° with the patient standing straight and shoulders relaxed. The three most common types of walkers include the rolling walker, hemiwalker, and platform walker. The rolling walker is used for patients who cannot lift the upper limbs to advance the walker and also when a smoother reciprocal gait is desired. The hemiwalker is used by hemiplegics who need a wide base of support. The platform walker is used to allow weight bearing at the elbow without putting pressure on the distal upper extremities.

CRUTCHES

Crutches are more stable than canes because of the two points of contact with the body. Increased energy expenditure is needed to maneuver with crutches rather than canes and preparation with strengthening of the shoulder depressors such as the latissimus dorsi and other muscles such as the triceps, biceps, and hip extensor and abductors are crucial to avoid muscle fatigue. The most common crutches prescribed are the axillary, forearm (Lofstrand), and platform crutches. The axillary crutches are inexpensive and easier to use at the expense of requiring good strength and increased cardiac demand on the patient. Crutch length should be the distance from the anterior axillary fold to about 6 inches lateral to the foot with the patient standing. The hand piece should allow the elbow to be flexed to 30° with the wrist in extension and fingers forming a fist. The axillary nerve can be compressed with improper use; however, when used properly, the affected lower limb can be fully nonweight-bearing. Contrary to common belief, the axillary part of the crutch should not be padded as it is not designed to take on body weight as this can cause nerve injury. The patient should be able to raise the body 1 to 2 inches by extending the elbow. Forearm crutches are indicated when pressure on the axilla is contraindicated and also for freedom for hand activities. Unilateral forearm crutches may decrease body weight transmission by 40% to 50% to the opposite limb. However, they provide less trunk support than axillary crutches and may require more strength and skill to maneuver. Use of the bilateral forearm crutch may offload 80% of body weight on the affected limb.²⁰ Platform crutches are useful when the distal upper extremities are affected such as fractures of the wrist or hand because they avoid weight-bearing through the wrist and hand. However, they are heavy and may be difficult to maneuver. The patient's elbow should be flexed to 90° with the patient standing straight with shoulders relaxed.

REFERENCES