Cognitive Intervention and Therapeutic Exercise for

                                       Chronic Low Back Pain

                                             By Stacy Shoemaker, M.D.

Too often the treatment of patients in chronic pain focuses solely on the elimination or reduction of pain. Traditional medical and surgical training emphasizes targeting pathology and eliminating it when possible. Patients with chronic pain often run from practitioner to practitioner looking for someone who will identify the cause of their pain and "fix" it. When the cause can’t be eliminated, efforts revolve around palliating the symptoms by treatments aimed at physically or pharmacologically interrupting the transmission of pain signals. Unfortunately this process is often prolonged. The mean duration of pain reported by patients at pain clinics exceeds seven years.

During this time period patients with persistent pain often suffer an associated decline in function. There are multiple factors that contribute to this reduction of function. Months or years of inactivity secondary to pain leads to physical deconditioning. There are numerous studies documenting decreased muscle strength, flexibility, and aerobic endurance in patients with persistent pain. In addition to pain or fear of pain, inactivity may also be due to the patients’ fear of damaging themselves or a sense of helplessness in regard to their persistent pain. It is therefore important that the treatment of the patient with chronic pain focuses not only on the reduction of pain but also on restoring function. Successful treatment of chronic pain produces a patient who not only describes his or her pain in mild terms but also engages in productive and engaging activity on a daily basis, is free of excess emotional suffering, and uses medical resources on a prudent level.

    As a physiatrist with SpineCare Medical Group in Daly City, I often work with patients who have chronic low back pain (CLBP). Some of the most extensive research on successful restoration of function in patients with chronic low back pain has been done by James Rainville, M.D., and Carol Hartigan M.D., at the New England Baptist Hospital Spine Center in Boston. In 2003 they evaluated the effects of an intensive outpatient rehabilitation program on 70 patients with chronic low back pain and disability. ¹ At the initiation of the program all subjects underwent an assessment of spine flexibility, strength, and aerobic endurance. Exercise was then used to improve these impairments. These exercises were performed under the supervision of therapy staff in a group format containing up to eight participants. Sessions included stretching, strength training, and aerobic endurance activities such as step aerobics, treadmill, or exercise bicycle. Sessions lasted two hours up to three days a week for six weeks averaging 30 hours of therapy. During stretching, key muscle groups were held statically for at least 30 seconds at their maximum length tolerable. Free weights and isoinertial exercise equipment was used for the strength training portion.

The amount of weight and repetitions was increased at each session in a stepwise manner based on progress toward treatment goals. Aerobic activity was done for at least 15 minutes at 75 percent of maximum heart rate three times week. This amount has been shown to be efficacious in improving endurance. Patients were told that it was safe to exercise despite pain, and the focus remained on achieving measurable quotas in flexibility, strength, and endurance. At discharge, there were significant improvements in Oswestry Disability Index and performance on tests of physical function. Interestingly, patients also demonstrated significant reductions in anticipated and induced pain of physical activities.

In that same year, Rainville et al. did a systematic medline review of all literature looking at back pain and exercise. ² First and foremost they found no evidence exercise increases the risk of additional back pain episodes or work disability. They also found that in addition to improving physical function, quota-based exercise programs also serve as a fear-desensitizing process. Research on fear of pain, fear of work-related activities, fear of movement presumed to cause (re)injury, and pain attitudes and beliefs have all demonstrated that fears, attitudes, and beliefs strongly influence back pain-related disability. Rainville et al. showed that patients who are taught that it is safe to exercise despite pain and that pain does not mean further damage had significantly lower disability scores and abnormal pain beliefs than controls. They theorized that this was due to confrontation rather than avoidance of pain. Patients who are able to effectively confront their pain are able to maintain and increase their physical/social activities leading to reduction in fear over time and recovery. Those who exhibit primarily avoidance responses are more prone to developing chronic symptoms and associated physical impairment and disability. ³ Exercise rehabilitation can serve as a sort of "confrontation" to pain that we hope will spill over to other daily activities.

In summary, patients with chronic pain often demonstrate a significant decline in function with respect to their activities of daily living, recreation, and work. Successful treatment therefore must include not only efforts to decrease nociceptive pain but also must address restoration of function. Quota-based exercise programs have been shown to be effective in improving both physical parameters of strength, flexibility, and endurance as well as psychological factors that influence disability in patients with chronic pain.

References:

1 Rainville J, Hartigan C,  Jouve C, Martinez E. The influence of intense exercise-based physical therapy program on back pain anticipated before and induced by physical activities. Spine J 2004; 4: 176-834

2 Rainville J, Hartigan C, Martinez E, et al. Exercise as a treatment for chronic low back pain. Spine J 2004; 4:106-15

3 Phillips H. Avoidance behavior and its role in sustaining chronic pain. Behav Res Ther 1987;25:273-9