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|  Functional Restoration: A Therapeutic Approach to Low Back Pain By DANIEL TANENBAUM, M.D. AND TIM PRICE, PT Low back pain is one of the most common yet controversial and poorly understood clinical entities in healthcare. It affects men and women, young and old, active and sedentary. It is the second most common reason people visit physicians. Currently, low back pain is treated by numerous medical and surgical specialists, including but certainly not limited to osteopaths, homeopaths, chiropractors, physical therapists, acupuncturists, and herbalists. First, the good news about this subject: Although acute low back pain is very common, it is generally a self-limited problem. Once the "red flags" suggesting serious medical illness or an acute surgical problem have been ruled out, treatment is usually conservative and successful over a few weeks or months. Now for the bad news: Chronic low back pain is considerably more difficult to treat. Often, there are medical and non-medical co-morbidities that decrease the likelihood of a good outcome. Negative prognostic factors include psychosocial factors such as secondary gain from medico legal issues, work stress, family stress, reactive depression, anxiety, and personality disorders. Medical co-morbidity or a history of previous lumbosacral surgery should be "red flags." There are multiple studies regarding the use of different medications and injections in the treatment of chronic low back pain. For the most part, these are equivocal in their results. Commonly used medications include non-steroidal anti-inflammatory medications (including the new Cox-2 inhibitors), corticosteroids (oral or injected into trigger points, sacro-iliac joints, facet joints, the epidural space, etc.), narcotic and non-narcotic analgesics, and multiple classes of "muscle relaxers." Functional Restoration Approach Once the search for more specific diagnoses and "cures" has been abandoned, treatment of chronic low back pain is often most productive when approached from a multi-disciplinary functional rehabilitation point of view. This approach is often called "functional restoration." A functional restoration therapy program includes exercise and education. Exercise needs to include a stretching program, strengthening exercise, aerobic/endurance training, and body mechanics/coordination training. A home exercise program needs to be provided. At Fairlawn Rehabilitation Hospital, we often prescribe a health club membership for the patient so he or she may continue to exercise aggressively. Education is necessary to allow back pain sufferers to better understand their symptoms, to allay fears of a more serious underlying pathology, and to allow patients to make an informed decision regarding the treatment protocol they feel fits best with their symptoms and lifestyle. After completing their formal therapy program, some patients are not motivated to continue rehabilitation independently; others do not have access to adequate exercise equipment. These people cease making gains following discharge from therapy and often return to the same symptoms and functional level they had before beginning their rehabilitation program. It is a common misconception that an increase in pain must accompany an increase in physical activity. The fear of exacerbating symptoms often causes those with chronic low back pain to lead increasingly sedentary and limited lives. Consequently, there may be a downward spiral of pain, fear, disability, deconditioning, and despair that can be very difficult to reverse once it has progressed too far. Recent studies of patients with chronic low back pain have shown that objective physical performance measures such as range of motion, cardiovascular endurance, and strength improve significantly with a well-designed quota-driven exercise program. These increases occur relatively quickly (over a few months) and may be dramatic. For example, lifting ability may more than double. While this may seem intuitively obvious, what is less expected is that pain levels do not change significantly with this increase in physical activity and capacity. In other words, there is no clear correlation between physical performance and pain in patients with chronic low back pain. Therefore, if patients can be educated not to anticipate an increase in pain with exercise and functional activities, their behavior and lifestyle change for the better. The success in physical exercise that patients achieve in a structured therapy setting carries over into their daily lives. The rehabilitation goals of improved independence (with less dependence on healthcare providers) and a more functional lifestyle can be achieved in these patients just as they can in other more "traditional" rehabilitation patients. Dr. Daniel I. Tanenbaum is a physiatrist and Medical Director of Outpatient Services at Fairlawn Rehabilitation Hospital. Tim Price formerly served as a physical therapist for Fairlawn's outpatient Spine Center. | ||||||||