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The Research Can
Spinal Surgery Be Prevented by Aggressive Strengthening Exercise? ABSTRACT Objective: To determine if patients recommended for spinal surgery can avoid the surgery through an aggressive strengthening program. Setting: A privately owned clinic, staffed by physicians and physical therapists, that provide treatment for patients with neck and/or back pain. Methods: Over a period of 2 1/2 years, consecutive patients referred to the clinic for evaluation and treatment were enrolled in the study if they
Treatment consisted mainly of intensive, progressive resistance exercise of the isolated lumbar or cervical spine. Exercise was continued to failure, and patients were encouraged to work through their pain. Third-party payors in Minneapolis were surveyed of average costs. Average follow-up occurred 16 months after discharge. Results: Forty-six of the 60 participants completed the program; 38 were available for follow-up and three required surgery after completing the program. Discussion/Conclusions: Despite methodologic limitation, the results are intriguing. A large number of patients who had been told they needed surgery were able to avoid surgery in the short term by aggressive strengthening exercise. This study suggests the need to define precisely what constitutes "adequate conservative care." ©1999 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation TOP
A
Randomized Clinical Trial of Exercise and Spinal Manipulation for Chronic
Neck Pain Key Findings 191 Chronic neck pain patients were randomized to three groups, one receiving chiropractic (manipulation) only, one chiropractic (manipulation) plus aggressive exercise, and one aggressive exercise only. Of the six outcome measures, the patients in the chiropractic plus aggressive exercise group were rated best in four.* The 191 patients patients with chronic neck pain went through 10 weeks of care. The researchers used strength gains, several pain scales and multiple endurance tests to measure the differences between the three groups. The same measurements were given at a 1 year follow-up. The Chiropractic (manipulation) with aggressive exercise group produced greater gains in strength, endurance, range-of-motion, and satisfaction with care. The Chiropractic (manipulation) only group finished last in virtually every category. TOP
A
Rational Approach to the Treatment of Low Back Pain
ABSTRACT At the initial visit of a patient with low back pain, the physician must set a positive tone emphasizing that the problem is common in the human body and can be remedied. Initial treatment is 1 or 2 days of rest, a short course of analgesics, and stretches and other exercises. The 5% to 18% of patients who do not improve within 3 months (chronic pain patients) or have a relapse frequently require an active functional rehabilitation program. Exercises are helpful only if they focus on the lumbar extensors. Patients may need encouragement at the beginning of the program to tolerate discomfort. Expensive imaging studies are reserved for patients who become disabled or show no improvement. Only when a lesion is identified in a patient who has seriously tried and failed conservative rehabilitation is surgery considered. I have read any number of review articles on the treatment of low back pain, most of them well written and technically accurate. Nevertheless, the next day in the office I'd see another patient complaining of low back pain, and again I would be uncertain of what to do. As I once did, you may find it depressing to see on your schedule that the next patient's chief complaint is low back pain. Because these patients are so difficult to help, many of us become conditioned to dislike them, and we approach them with a negative attitude. None of us enjoys treating patients we can't help. Despite this, for the past 3 years, I have limited my practice exclusively to the non-operative treatment of back and neck pain. I have supervised the treatment of more than 4,000 such patients. At one time, I used traditional treatment methods and had the traditionally poor success rate. Now I believe that most of these patients can be treated effectively. The secret is in knowing what to do (active rehabilitation) and what not to do (prolonged passive modalities). In this article, I present a step by step approach to the patient with low back pain, beginning with history taking and a physical examination to rule out causes of back pain that require urgent measures. I describe the initial regimen of palliation and the criteria for progressing to an active, intensive program of functional rehabilitation exercises emphasizing lumbar extension. I also discuss the point at which advanced imaging studies are useful, when to consider surgery, and how to manage the patient with intractable back problems. Initial Encounter The initial visit may be the most important factor affecting the outcome of a. patient with low back problems. During that visit, a psychological template is often created in the patient's mind. If told the injury is serious, the patient easily falls into the sick role. Conversely, if told that back pain is a benign, self-limited condition ubiquitous in humans, the patient may be less likely to take on a seriously "sick" role. No one knows what causes most back pain, and in only 10% to 15% of the patients can a precise, symptom-related diagnosis be made. 1-5 The rest of the time we simply do not know. But, reluctant to tell our patients "I don't know," many of us say some thing, and our reports are often contradictory. The confused patient does not know whom to believe when the chiropractor says that the spine is out of alignment, the surgeon says that the disc has degenerated and vertebrae need to be fused, the physical therapist says that the muscles need electrical stimulation and hot packs, and a neighbor says to wear a copper bracelet and all the pain will go away. The clinician should anticipate this confusion and address it, thereby reducing the chances that the patient will be uncooperative or noncompliant. The statistics are familiar: following an acute back injury, 70% of patients are significantly improved after 2 weeks, and 90% to 95% are recovered within 2 to 3 months. 5-8 Why is it, then, that most patients we see in our offices with acute back injuries do not follow that pattern? The answer, I believe, is that most per sons who injure their back never see a physician and never become patients. Those who seek attention have already selected themselves and are more likely to have chronic problems, or to have more severe injury, or to have a hidden agenda. Whatever the reason, the person with low back pain who seeks medical advice often is among the 5% to 10% who have not improved within 3 months. Given that a precise diagnosis usually cannot be made, a rational approach to the initial visit is to direct efforts at ruling out emergent causes of pain. Normally, by taking a thorough history and performing a thorough physical examination you can exclude tumor, infection, acute fracture, inflammatory arthritis, visceral sources of pain, or progressive neurologic deficit. With such critical diagnoses ruled out, you are able to concentrate on treatment. History The patient's history is probably the best tool for ruling out emergent causes of back pain. Among the questions to ask are:
The answers to these questions may suggest the need for other diagnostic tests. For example, long-standing night pain unaltered by positional change suggests a space-occupying lesion, and imaging studies would be indicated to rule out tumor. A history of fever and chills with or without a previous infection any where in the body would indicate a bone scan to rule out low-grade infection. However, typically more than 90% of the patients will have non-emergent conditions, and in about 85%, an exact diagnosis cannot be made. Imaging Furthermore, the vast majority of magnetic resonance scans are read as abnormal, with findings of bulging disc, desiccation at L5-SI, or facet arthrosis; unfortunately, the patient frequently is not told that abnormalities seen on spinal MRI may be unrelated to pain. Moreover, we tend to forget how intimidating space-age technology may be for a layperson. Lying in an MRI scanner can be a stressful experience and may convince patients that their problem must be serious if such powerful equipment is required. When is a computed tomographic (CT) or MRI study indicated? Only when the results have the potential to change the treatment plan. The cost of a CT scan is approximately half that of a magnetic resonance scan. CT is better for visualizing bony lesions, whereas MRI is superior at depicting soft tissue. Rest or exercise? I am currently participating in a clinical study of chronic low back pain, involving the long-term follow-up of patients who have completed a rehabilitation program. More than one patient has criticized my care because a subsequent physician ordered an MRI study that showed the bulging disc or arthritis or degeneration that I "missed.' Had I discovered the "true" cause of the pain, they believe, I would not have pre- scribed exercise, stretching, and proper body mechanics. I would have told them to "take it easy." But taking it easy does not work for chronic back pain. The Quebec Task Force on Spinal Disorders report, generally considered a balanced and fair evaluation of the passive treatment modalities for chronic back pain, concluded that no passive modalities appear to have any lasting effect. 3 Rest is simply another passive modality, with the added disadvantage that it promotes muscle atrophy, cartilage degeneration, stiffness, and depression. Passive modalities are appropriate in the early stages of an acute injury but have no place in the treatment of chronic pain. Although there are certain spinal conditions that require a reduced activity level, in my experience, the far greater danger for most patients is in doing too little, not too much. Acute or chronic pain? To make rational treatment choices, you must first understand the physiologic distinction between acute and chronic pain. After aback injury, the body automatically begins the healing process, and soft-tissue healing usually is complete by 7 to 8 weeks. Nerve damage is generally secondary to another insult, such as pressure from a herniated disc or chemical irritation associated with inflammation. Treatment of nerve damage or irritation is therefore directed at the primary injury. Nerve tissue often takes longer than 7 to 8 weeks to heal. It is less resilient than many other human tissues and is more susceptible to permanent damage. If pain persists beyond 7 to 8 weeks, it is properly labeled chronic. Since the body has the capacity to heal itself, the goals of treatment following acute injury are to:
These goals are met by using passive modalities, such as hot and cold packs, electrical stimulation, massage, and ultrasonography, in the acute phase to provide palliation while the healing process progresses. Bed rest beyond I or 2 days is avoided, to prevent rapid deconditioning. Also helpful is education for the patient about back protection strategies, including postural advice (lying supine with the hips and knees flexed to 90¡ to reduce disc pressure), lifting strategies (keeping objects close to the body and lifting with the legs rather than the back), and stabilization techniques (finding the body's neutral position and tightening the trunk muscles to stabilize that position). Early introduction of stretches and back exercises that emphasize the lumbar extensors can promote the healing mechanism. These exercises include prone lumbar extensions, prone lower trunk rotations, the single knee to chest stretch, pelvic tilt, and diagonal abdominal curl-up.Ê Most patients improve rapidly. The patient who is not improving after 4 to 8 weeks is at high risk for becoming a chronic-back pain patient. It is these patients who generate about 85% of the costs associated with back pain. What
can you do to prevent a chronic condition from developing?
Or you can prescribe functional rehabilitation, which provides the best chance for a good outcome and is also cost-effective. Lumbar
or Pelvic Function The back can be meaningfully exercised only when the lumbar spine is moving against resistance. The difficulty in achieving true back exercise is demonstrated by a "low back" exercise machine, on which a patient sits, leans backward against a thoracic pad attached to a stack of weights, and performs multiple repetitions against resistance. These machines do not exercise the lumbar spine. Rather, they exercise the pelvic extensors, the hamstrings, and glutei. A patient with a sore back will reflexively change body mechanics to protect the back, substituting pelvic motion for lumbar motion. Even with a severe lumbar injury, a patient may work out on an exercise machine, all the while protecting the lumbar spine from meaningful exercise. A study at the University of Florida confirmed that vigorous exercise on low-back machines does not build strength in the lumbar spine. 13,14 Seventy-seven volunteers were tested for isolated lumbar extensor strength, then were divided into three groups:
At the end of the 12 weeks there was no significant difference (P<.05) in lumbar extensor strength between the standard-machine group and the no-exercise group. There was a large increase in back strength, however, averaging 120% in the fully extended position, in the group that did lumbar extension exercises with the pelvis stabilized. The investigators concluded that exercise without pelvic stabilization was not effective for developing strength in the lumbar extensors. Thus, while standard exercise machines may contribute to a well-rounded rehabilitation program, they do not exercise the lumbar extensors. Some patients may be reluctant to exercise a painful lumbar spine, but they must do so to produce true improvement in lumbar function. Patients usually are willing to work through the initial pain, provided they are convinced that their effort will help their back problem. They must be "sold" on exercise, and this is a responsibility of both the physician and the therapist. Without education and encouragement, many patients quit with the first discomfort. Meaningful lumbar strengthening can be done only with the use of equipment that stabilizes the pelvis and isolates the lumbar spine. Such equipment usually is available only in professional settings. However, patients can do exercises at home to maintain strength. They will not make gains, but they can maintain current strength with a home-based rehabilitation program. Functional
Restoration A functional restoration program presupposes that normal function is known and that the ability to accurately measure function is available. The goal of such treatment is to normalize function, not to decrease pain, although pain relief is a desirable byproduct. If function cannot be normalized, it should at least be maximized, so that a patient reaches as high a functional level as possible. Functional restoration is best accomplished through a program of progressive resistive exercise to strengthen the trunk muscles, especially the lumbar extensors. Such rehabilitative efforts may involve some patient discomfort, especially in a previously sedentary patient. However, provided the exercises are controlled and supervised by a professional, no damage will be done. Pain need not be interpreted as a warning to stop exercising. Many investigators have found that patients with chronic back pain have pain early in a rehabilitation program and experience the benefits only after a month or more. 15-18 An accurate baseline measure of functional ability is established at the initial examination. Pain that increases during a rehabilitation program can be characterized as "bad" (pain associated with deteriorating physical examination parameters and decreasing spinal function as measured by a physical therapist), or "good" (pain associated with improvement in objective function and in physical examination parameters, or at least with no negative changes).Ê If the pain is "bad," then treatment needs to be modified. Exercise frequency or intensity may need to be reduced or a certain exercise stopped. Further diagnostic testing may be in order. If the pain is "good" rehabilitation continues. Even if the patient experiences some discomfort at the beginning of a vigorous rehabilitation program, treatment should continue as long as the patient is measurably, objectively increasing lumbar function. On average, 18 sessions over 2 to 3 months are needed to optimize function. 13, 19-21 Choosing
a Facility
The center should develop goals for each patient and make clear to each patient that the purpose of rehabilitation is to improve spinal function-not to decrease pain. As mentioned previously, the majority of patients able to improve spinal function will also experience a decrease in pain, which is often dramatic but which remains a secondary goal. Education First, explain to patients that back pain is a normal part of human experience. To be alive is to know back pain. Then guide them in maximizing their spinal function, using aggressive, intensive exercise. Also, teach lifelong strategies, such as body mechanics, stabilization, and home exercises, for dealing with the condition. Instilling these attitudes early fosters independence and better outcomes. For an acute episode of back pain, muscle relaxants and non-steroidal anti-inflammatory drugs may have a place short term but are to be avoided as long-term medication. Surgery
*The patient has shown a good-faith effort to get well and does not demonstrate undue signs of symptom exaggeration. *A specific surgical lesion understood to be causing the pain can be identified. I have treated dozens of patients thought to be surgical candidates who, after an aggressive functional restoration program, significantly improved and were able to avoid surgery. Preliminary studies suggest that the improvement is lasting. Among 950 patients who completed a rehabilitation program, 220 had entered the program believing they were surgical candidates, either because of previous diagnosis or severity of the pain. At post program follow-up averaging 13 months, 71% of these believed that rehabilitation had allowed them to avoid surgery. Surgery for a patient showing signs of symptom exaggeration is not recommended. The outcome is usually poor, with patients often continuing to complain of severe symptoms. Similarly, patients treated surgically for poorly defined back pain tend to do poorly. The Quebec Task Force on Spinal Disorders reported that surgery for back pain alone is an unproven remedy. 3 Surgery should he reserved for patients who meet strict criteria. Treatment with functional restoration, on the other hand, is usually successful, especially in patients with lumbar disc syndrome, spondylolysis, spondylolisthesis, degenerative arthritis, degenerative disc disease, lumbar strain, or mechanical low back pain. Elderly patients with spinal stenosis and significant leg pain may also achieve lasting relief through exercise. These patients usually show significant and sometimes dramatic increases in strength, flexibility, and endurance. The Intractable
Problem
Talk at length with the patient and explain why more treatment or diagnostic testing is not warranted. Counsel the patient on proper body mechanics and exercise, explain that such injuries cannot be effectively treated with rest and inactivity, and provide reassurance that "hurt" does not necessarily mean "harm." If a patient fails an appropriate rehabilitation program and does not have an identifiable surgical lesion (fewer than 5% do), then further treatment is, at best, palliative and will have no lasting effect. Patients who accept the situation and try to resume a normal life usually do best. A rational strategy based on the known physiology of soft tissue is most effective in treating back pain. Being able to offer help to a patient with spinal pain may change a depressing physician/ patient experience into a rewarding one. References 2. Waddell G: Clinical assessment of lumbar impairment. Clin Orthop 1987:221:110- 119. 3. Quebec Task Force on Spinal Disorders: Spine 1987:12(7 suppl):chap3. 4. Mooney V: Evaluating low back disorders in the primary care office, J Musculoskel Med 1989;6(9):18-32. 5. Waddell G: A new clinical model for the treatment of low-back pain. Spine 1987: 12:632-644. 6. Frymoyer JW: Helping your patients avoid low back pain. J Musculoskel Med 1989; 6(5):83-101. 7. Nachemson A: Recent advances in the treatment of low back pain. Int Orthop 1985:9:1-10. 8. Nachemson AL: The natural course of low back pain, in White AA, Gordon SL (eds): Symposium on Idiopathic Low Back Pain. St Louis, CV Mosby Co, 1989. pp 45-51. 9. Boden SO, McGowin PR. Davis DO, et al: Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg 1984:66A: 1048-1055. 10. Boden SD, Davis DO. Dina TS, et al: Abnormal magnetic-resonance scans of the lum- bar spine in asymptomatic subjects. A prospective investigation. I Bone Joint Surg 1990;72A:403-408. 11. Frymoyer J, Newberg A, Pope MH. et al: Spine radiographs in patients with low-back pain. i Bone Joint Surg 1984:66A:1048- 1055. 12. Win 1. Vestergaard A, Rosenklint A: A comparative analysis of x-ray findings of the lumbar spine in patients without lumbar pain. Spine 1984:9:298-300. 13. Graves JE, Webb DC, Pollock ML. etal: Effect of pelvic stabilization during resistance training on the development of lumbar extension strength, to be published. 14. Pollock ML, LegettSh, Graves JE, etal: Effect of resistance training on lumbar extension strength. Am J Sports Med 1989:17: 624-629. 15. Manniche C, Bentzen L, Hersselroe G: Clinical trial of intensive muscle training for chronic low back pain. Lancet 1988:2:1473- 1476. 16. MayerTG: Orthopedic conservative care: The functional restoration approach. Spine 1986:1:139-147. 17. Mayor TG, Gatchel RJ. Mayer H: A prospective two-year study of functional restora- tion in industrial low back injury. An objective assessment procedure. JAMA 1987:258: 1763-1767. 18. Ritchell Rl, Carmen GM: Results of a multicenter trial using an intensive active exercise program for the treatment of acute soft tissue and back injuries. Spine 1990:15:514-521. 19. Carpenter D. Graves JE. Pollock ML: Effect of 12 and 20 weeks of resistance training on lumbar extension torque production. Phys Ther 1991 ;71:36-44. 20. Graves JE. Pollock ML, Foster D: Effect of training frequency and specificity on isometric lumbar extension strength. Spine 1990: 15:504-509. 21, Pollock ML, Graves JE: New approach to low back evaluation and training. Cent Fla Physician. July 1989:19-20. TOP
Restorative
Exercise for Clinical Low Back Pain A Prospective
Study Design. A comparison of treatment of 412 patients with chronic back pain at two separate centers usœing the same treatment protocols and outcome measures. Outcome was defined by specific strength testing; Short Form-36 scores at intake, discharge, and 1-year follow-up; self-appraisal of improvement at discharge and in a 1-year follow-up; and reuse of health care services afœter discharge. Objectives Summary
of Background Data Methods Study participants were patients with chronic back pain consecutively referred to each treatment site and underwritten by a variety of payers, including workersâ compensation, Medicare, and private insurance. Results Conclusions
The
Clinical Effects of Intensive, Specific Exercise on Chronic Low Back
Pain: A Controlled Study of 895 Consecutive Patients with 1-Year Follow-up ABSTRACT Eight hundred ninety-five consecutive chronic low back pain patients were evaluated. Six hundred twenty-seven completed the program. One hundred sixty-one began, but dropped out, and 107 were recommended for treatment but did not undergo treatment for various reasons. Average duration of symptoms prior to evaluation was 26 months. Forty-seven percent of patients were workers' compensation patients. The primary treatment was intensive, specific exercise using firm pelvic stabilization to isolate and rehabilitate the lumbar spine musculature. Patients were encouraged to work hard to achieve specific goals. Seventy-six percent of patients completing the program had excellent or good results. At 1-year follow up 94% of patients with good or excellent results reported maintaining their improvement. Results in the control group were significantly poorer in all areas surveyed except employment. Chronic low back pain is a pervasive and costly problem in the United States, as it is in the rest of the industrialized world. The scope of this problem continues to grow despite our best efforts. By some estimates, low back pain costs over 40 billion dollars per year.1-6 Further, workers' compensation disability for low back pain is growing at 14 times the population growth6. Finally, and most distressing, only 15% of patients with back pain account for 85% of these enormous costs. The traditional approach to management of sub-acute and chronic back pain has been passive modalities. The modalities may have changed, but the results have remained mostly disappointing. By the mid-80's, evidence began to appear suggesting an aggressive "sports medicine" approach was more effective than traditional methods in this patient group.1,8-11 It was our purpose, therefore, to test the efficacy of a specific, aggressive program in our patients with low back pain. In 1990 the authors began a prospective study to look at the objective results in a large number of patients treated with aggressive exercise. The working hypothesis was chronic low back pain could be treated effectively using intensive, specific exercise. Intensive was defined as muscular exercise (eg, lumbar extensors) against dynamic resistance to volitional failure, ie, exercise performed on a strength training device through a full range of motion. The exercise activity was continued for as many repetitions as possible, so long as the patient could maintain full range of motion (ie, the range of motion demonstrated during the first repetition). Specific was defined as exercise with the pelvis immobilized so as to isolate the lumbar extensor muscles. We were trying to answer the following questions:Ê
Table 1 - Reasons for Quitting Treatment
Materials
and Methods
Figure 1 Average duration of symptoms prior to evaluation was 26 months (range:- 3months to 30 years). Forty-seven percent of the patients were workers' compensation patients. On average, the patients had seen three previous providers for evaluation or treatment and had an average of two diagnostic tests (range: 0 to 10). Fourteen percent had had previous surgery, and the average number of surgeries in this group was 1.7. These patients had tried an average of six different treatments, and 89% of the patients had already failed a "supervised exercise program." Forty-seven percent had tried and failed chiropractic. At the initial evaluation, 36% were employed without restrictions, 24% with restrictions, 22% were unemployed secondary to their back problem, 10% were unemployed, and 7% were either students, retired, or disabled for another reason. Primary diagnoses are shown in Figure 1.
Fig. 2: Specific lumbar testing and rehabilitation was performed in a MedX lumbar-extension machine. Pelvis fixed, spine in flexion (A); pelvis fixed, spine in extension (B); full schematic, patient neutral (C). Specific lumbar testing and rehabilitation was performed in a MedX lumbar- extension machine (Fig 2) and a MedX Torso-Rotation machine (MedX Corporation, Ocala, Fla).
Patients were tightly restrained to lock the pelvis in place (Figs 2A-2B are shown without the weight stack, counterweight, or electronics; 2C shows a schematic of the entire apparatus). This restraint system isolated sagittal movement to the lumbar spine and prevented other muscles (eg, hamstrings, glutei) from contributing to measured torque values. Counter weighting was used to correct for gravity's effect on upper torso weight. Testing results using MedX equipment have previously been shown to be valid and reliable.
12-17 Patients required an average of 18 visits to complete the program (range: 4 to 35). Treatment was ended when any of the following criteria were met: 1-The patient was pain-free or nearly pain-free, and objective functional levels were at or near normal. 2-The patient was no longer making objective gains in spinal function. 3-The patient refused to cooperate or give a good effort. Patients were treated an average of twice per week. Each session lasted approximately 1 hour, and the patient was supervised by physical therapists throughout. The mainstay of the treatment involved progressive, resistive exercises of the isolated lumbar spine with the pelvis firmly stabilized. Patients also did aerobic exercise and strength training of other muscles (abdominals, hamstrings, glutei) at each visit. Previous studies have shown that in patients with chronic back pain the lumbar extensor muscles are more likely to show relative weakness than the abdominals; therefore, efforts at strengthening were concentrated here.17-20 Education was considered important and, therefore, all patients were required to watch educational videos, learn body mechanics, and read specific literature. Upon discharge all patients were given a home exercise device (Lifeline GymTM) and taught a home program of progressive resistive exercises of the trunk muscles. Technique was emphasized (ie, extending the lumbar spine rather than extending the pelvis). The goal of the home program was to allow the patient to continue exercising independent of the health care system and not have to purchase home equipment or join a health club. We have no problems with home equipment or health clubs, but this was not feasible for many of our patients. We wanted no excuses for lack of exercise. See Appendix for details on the typical rehabilitation schedule. Every 3-4 weeks, another isometric test was done to chart progress. Progress also was charted in sagittal and rotational range of motion and sagittal and rotational dynamic work capacity. Treatment continued until one of the above three criteria was met. Upon discharge patients were asked to rate their back pain and/or their leg pain in one of the following categories: resolved; greatly improved; improved; slightly improved; unchanged; worse. Patients also were required to rate their functional ability in the activities of daily living using the same scale. At an average of 13 months post-discharge (range: 7 to 18), a questionnaire was mailed to all patients inquiring about their status. Patients who failed to return the questionnaire were phoned. Cost data were obtained from the billing department. Statistics were compiled using SPSS/Windows. Two-tailed t-tests were used to analyze interval grouped data. The Pearson correlation coefficient was used to evaluate the relationship between strength and pain. Nominal variables were analyzed using chi-square methods. Results
Range of
Motion
Dynamic strength
Low back
pain Leg
pain Perceived
functional response Correlation
between isometric strength and change in low back pain.
Overall Response. Response to treatment was graded as excellent (46%), good (30%), fair (14%), or poor (8%). To be rated as excellent or good, a patient had to have both substantial pain relief and substantial improvement in strength. A patient would have to rate their chief complaint as either resolved, greatly improved , or improved and would also have to show substantial increases in strength. Poor results would apply to patients who had slight or no pain relief and who gained little or no strength. Fair results were most often seen in that group of patients who had substantial strength gains but little or no pain relief. There is a good rationale for this grading system. Patients seldom see a doctor because their backs are "weak". They seek medical attention because of pain. Therefore, in the opinion of the authors, without substantial pain relief it is difficult to call a result good or excellent. Studies often look at return to work as the best indicator of treatment effectiveness. But people may often return to work not because their condition has improved, but because of other external pressures. So while the criteria can be argued, the authors still believe this is a valuable, "real world" piece of information. Specific
sub-groups of patients
Return
to work-initial group Follow
up Spinal condition at follow up was broken down into two groups: those with good or excellent results and those with fair or poor results. Of those with previous good or excellent results (N=345), 94% maintained improvement and 6% ceased to improve or became worse. Of those with previous fair or poor results (N=150), 25% improved; 75% were not improved or became worse. Chronic spine patients tend to use the health care system repeatedly, We surveyed for reutilization and then broke down the responses into three groups: non workers' compensation/litigation patients (13% reutilization); workers' compensation/litigation patients (25% reutilization); and >2 Waddell signs (76% reutilization). Waddell signs are signs of symptom exaggeration. These results are best understood when compared with the control group later in this report, but there was a definite trend toward higher utilization in patients with potential secondary gain. Return
to work-Follow up group
Compliance
with home exercise program Control
group The control group was surveyed for utilization of the health care system (13% of non-workers' compensation/litigation patients who completed the program reutilized the system vs 42% of controls; 25% of workers' compensation/litigation patients who completed the program reutilized the system vs 76% of controls), ability to get lasting relief from treatment (70% of patients who completed the program obtained substantial relief for at least 1 year vs 29% of controls), and work status (77% of those who completed the program were gainfully employed at follow up vs 78% of controls). There were significant differences (P<.001) between the treatment and control groups in all areas surveyed except employment.
Discussion This trial supports the use of specific intensive exercise for chronic back pain patients. The presence or absence of leg pain did not alter the results. It confirms results reported by Risch et al in 1993.17 The program was successful even though the vast majority of the patients had previously tried some form of exercise, most of them supervised exercise under the guidance of another health care provider. Bias was present in the selection process because most patients were referred by other providers familiar with our program. It is unknown how many patients these providers did not refer. This bias is somewhat mitigated by the fact that all these patients represent people with long-term chronic pain who have entered the system for treatment. That they will be treated is a given until doctors change and refuse to see chronic low back pain patients. In this respect the patients represent their own control group, because nearly all had tried and failed multiple treatment modalities. Yet most (70%) had good or excellent results that were maintained for at least 1 year. This study suggests that not all exercises are created equal. It appears, in fact, that much of the exercise done is worthless for this group of chronic patients. It is our opinion that this is because so many patients did not follow through on their exercise or stopped exercising at the first hint of discomfort, believing they were doing damage. Many, if not most, of our patients initial periods of discomfort as they vigorously exercised a weak and stiff lumbar spine. This discomfort was not unexpected,1,22 but it was amazing how many patients had been advised to continuously decrease their activity levels and to let pain guide their activity level. Such patients become conditioned to avoid pain. This causes more deconditioning and more dependence on the health care system. The other reason previous exercise was not helpful was because without pelvic stabilization it is almost impossible to meaningfully exercise the lumbar extensors. Graves14 has shown that attempts to strengthen the lumbar spine using traditional equipment (eg, NautilusTM or Cybex EagleTM) are completely ineffective. These and similar devices are capable of strengthening the pelvic extensors but not the lumbar extensors. Our study and others18-20 have shown that lumbar extensor strength is a risk factor in long-term outcome, and this may explain why so many of our patients did well even though they had been doing exercises for months or years. Firm pelvic stabilization has another important benefit: it forces patients to move a painful, stiff spine. Motion promotes healing in the musculoskeletal system, and lack of motion leads to stiffness, cartilage degeneration, and muscle atrophy. More recent evidence suggests that movement of the lumbar spine under load affects disk PH, which may also account for the pain improvement.23 During this study we observed that these patients limited their lumbar movement because of pain. Over time they had learned to perform tasks without lumbar movement such as bending at the knees, rather than at the waist, to pick up an object. They even learned to exercise without meaningful lumbar involvement by substituting pelvic movement for lumbar movement. Exercising with the pelvis firmly anchored forced the lumbar spine to move against resistance. Without such anchoring patients were too easily able to protect the lumbar area from meaningful exercise. In our opinion this is why many of the exercise programs were ineffective. We made a very strong effort in this program to promote independence. Patients were encouraged to be active even if they had discomfort. When pain was severe, they were seen again by the physician and the physical therapist and, provided there had been no significant change in the physical examination (and this was most often the case), exercise was continued. As the trial progressed, it became obvious that a supportive and encouraging atmosphere was critical. It also became very clear that visual evidence of objective progress was crucial to reinforce exercise. At the beginning of the exercise program, people often had some discomfort, and if they had not been able to observe objective strength gains on the individual graphs, we believe many would have quit. Patients needed lots of positive feedback to continue working hard at a program which initially did not always provide pain relief. This brings up another important point. Table1 shows that 41% of the patients who quit the program did so because they did not feel any better. Many of these quit after a week or two. The authors feel that at least some of these patients would have had a good outcome if they had finished the program. As mentioned previously, many patients began to feel better only after several weeks of aggressive exercise. We believe reutilization is one of the best indicators of effectiveness. The patients in the control group reused the health care system at a significantly higher rate (P<.001) than the treatment group. It is this constant reutilization that to a large extent drives the cost. Any reasonably priced treatment that can decrease reutilization is cost effective. Other authors have stated that a precise diagnosis is not possible in most of these patients.5,6 We agree; however, this study suggests that exercise as a treatment is effective regardless of the underlying condition. Because of this the authors believe that much less effort and money should be spent on diagnosis. It makes more sense to rule out emergent conditions such as tumor, acute fracture, progressive neurologic deficit, visceral sources of pain, or infection rather than try to "rule in" a nonspecific source of pain. The emergent conditions can usually be excluded with a good history and physical. Resources are then more effectively devoted to treatment. Initially, there were eight questions we were trying to answer.
Currently, there is some debate about the need for expensive, computerized testing equipment to rehabilitate the lumbar spine. Some believe the cost is not justified and that results are just as good with low-tech equipment or home programs or health clubs. It is difficult to justify spending money on acute episodes, because the natural history of the disease is so favorable without any treatment at all. However, chronic pain is much different. The natural history is one of recurrence and continuous use of health care resources. For chronic low back pain a modest amount spent to prevent or alter the typical natural history would be very cost effective. This study refutes the viewpoint that home exercise or the use of health clubs suffice in this patient group. Almost all of our patients had tried "low-tech" exercise and failed. Whether or not the expense is justified depends on the value society puts on the treatment of chronic low back pain patients. But until we as a society decide that these patients are not worth treating, they will continue to utilize the health care system. Therefore, it is crucial to know how best to allocate our health care dollars. In this study, patients going through the program re-utilized the health care system at a significantly (P<.001) lower rate than the control group. Many patients, by their own report, were able to avoid surgery. It is certain that had these patients not been referred to our clinic, they would have been referred elsewhere. It is then likely they would have continued to receive treatments similar to what they had received in the past, as occurred with the control group. Many would likely have had surgery. In a large number of chronic low back pain patients, the pain is iatrogenically exacerbated. By encouraging passive modalities we make patients dependent on the health care system for a limitless stream of "feel good" treatment. Giving in to pain and trying to live one's life to avoid discomfort does not promote improved health. Instead it promotes helplessness, loss of self esteem, deconditioning, depression, and soaring health care costs. A better alternative is aggressive activation while encouraging the patient to try to do more, not less. This study suggests that aggressive exercise is a valuable, cost effective treatment for chronic low back pain. Direct comparisons among patients with similar conditions treated in different ways is important. The goal should be agreement among health care professionals on proper management of this difficult condition. This would include agreement on when to use imaging, surgical indications, when care should be ended, and what type of care is indicated at each step of the case.
References 2. Nachemson AL, Bigos SJ. The low back. In: RL Croess, WRJ Rennie, eds. Adult Orthopedics. NY: Curchill Livingston; 1984: 843-937. 3. Nachemson A. The lumbar spine: An orthopaedic challenge. Spine. 1976; 1: 59-72. 4. Nachemson A. Work for all: For those with low back pain as well. Clin Orthop. 1983; 179. 5. Nachemson A. Newest knowledge of low back pain. A critical look. Clin Orthop. 1992; 270: 8-20. 6. Waddell G. A new clinical model for the treatment of low back pain. Spine. 1987; 12(7) 632-645. 7. Quebec Task Force of Spinal Disorders. Spine. 1987; 12(7 supp). 8. Mayer TG, Gatchel RJ, Mayer H, Kishino ND. A prospective two year study of functional restoration in industrial low back injury. JAMA. 1987; 258: 1150. 9. Mayer TG, Gatchel RJ, Kishino N, et al. Objective assessment of spine function following industrial injury: A prospective study with comparison group and one year follow-up. Spine. 1985; 10: 1762-1769. 10. Mayer TG. Orthopedic conservative care: The functional restoration approach. Spine. 1986; 1: 488-494. 11. Mitchell RI, Carmen GM. The functional restoration approach to the treatment of chronic pain in patients with soft tissue and back injuries. Spine. 1994; 19: 623-644. 12. Graves JE, Webb DC, Pollock ML, Matkozich J, Leggett SH. Effect of training with pelvic stabilization on lumbar extension strength. Int J Sports Med. 1990; 11: 403. 13. Graves JE, Pollock ML, Carpenter DM, Leggett SH, Jones A, MacMillan M, Fulton M. Quantitative assessment of full range-of-motion isometric lumbar extension strength. Spine. 1990; 15: 289-294. 14. Graves JE, Webb DC, Pollock ML, Matkozich J, Leggett SH, Carpenter DM, Foster DN, Cirulli J. Effect of pelvic stabilization during resistance training on the development of lumbar extension strength. Arch Phys Med Rehabil. 1994; 75: 210-218. 15. Leggett SH, Graves JE, Pollock ML, Foster DN, Holmes B, Fix C, et al. Specificity of lumbar extension strength. Int J Sports Med. 1991; 6: 403-404. 16. Pollock ML, Carpenter DM, Blanton J, Graves J, Leggett SH. Reliability and variability of isometric torso rotation strength measurement. Med Sci Sports Exer. 1990; 22(2): S20: 81-87. 17. Risch SV, Norvell NK, Pollock ML, Rische E, Langer H, Fulton M, et al. Lumbar strengthening in chronic low back pain patients: Physiologic and psychologic benefits. Spine. 1993; 18: 232-238. 18. Mayer TG, Smith SS, Keeley J, et al. Quantification of lumbar function: Part 2: Sagittal plane trunk strength in chronic low back pain patients. Spine. 1985; 10: 765-773. 19. Pollock ML, Leggett SH, Graves JE. Effect of resistance training on lumbar extension strength. Am J Sports Med. 1989; 17: 624-629. 20. Rodriguez AA. Therapeutic exercise in chronic neck and back pain. Arch Phys Med Rehabil. 1992; 73: 870-876. 21. Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low back pain. Spine. 1980; 5: 117-126. 22. Manniche C, Bentzen L, Hersselroe G. Clinical trial of intensive muscle training for chronic low back pain. Lancet. 1988; 2: 1473-1476. 23. Tatsuro K. Biochemical changes associated with symptomatic human intervertebral discs. Clin Orthop. 1993; 298: 372-377.
Appendix Visit II, Week I: The patient repeated the previous stretching, accessory muscle strengthening, and warm-up aerobic exercises. In the same MedX lumbar-extension machine, the patient performed a dynamic exercise session with the pelvis firmly fixed, thereby using only the muscles of the isolated lumbar spine. The patient was encouraged to work hard but not to the point of failure. When the patient felt he or she was getting close to failure, exercise was stopped. Next, the patient was stabilized in the MedX torso-rotation machine. The pelvis was stabilized and an appropriate weight selected. The patient then rotated the trunk against variable resistance from right to left and from left to right until failure. The number of possible reps times the amount of weight was recorded; this was the initial starting dynamic rotational work capacity. Visit I, Week II: After the appropriate warm-up, stretching, and accessory muscle strengthening, the patient was stabilized in the MedX lumbar-extension machine and dynamic exercise was performed to failure. This established a baseline. Next, the patient was stabilized in the MedX torso-rotation machine and dynamic exercise was performed, but not to the point of failure. Visit II, Week II: After appropriate warm-up, the patient was placed in the MedX lumbar-extension machine and dynamic exercise was performed to just short of failure. The patient was then stabilized in the torso-rotation machine and the trunk rotator muscles were exercised to the point of failure. From the Physicians Neck & Back Clinic, Minneapolis, Minn, and *OFC Back Care Center, Mankato, Minn. Reprint requests: Brian W. Nelson, MD, 3050 Centre Pointe Dr, Ste 200, Roseville, MN 55113. TOP
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the Research Menu Manuscripts / Journal Articles Publications: Work in Progress: Submitted for Publication Manuscripts/Journal
Articles "The Clinical Effects of Intensive, Specific Exercise on Chronic Low Back Pain: A Controlled Study of 895 Consecutive Patients With 1-Year Follow Up." ORTHOPEDICS, Vol. 18, No. 10, October 1995. B. W. Nelson, E. O'Reilly, M. Miller. "The Effect of Workplace Based Strengthening on Low Back Injury Rates: A Case Study in the Strip Mining Industry." Journal of Occupational Rehabilitation, Vol 5, No. 3, 1995. V. Mooney, M. Kron, P. Rummerfield, B. Holmes. "The Impact of Managed Care on Musculoskeletal Physical Treatment." ORTHOPEDICS Vol. 18, No. 11, November 1995. V. Mooney. "Manipulative Therapy for Acute Back Pain - Con." Journal of Spinal Disorders. V. Mooney. Correspondence and Reprints to: Vert Mooney, M. D., University of California, San Diego, 4150 Regents Park Row, Suite 300, San Diego, CA 92037. "Relationships Between Exercise Rehabilitation and Symptom Reduction." Correspondence and Reprints to: Vert Mooney, M. D., University of California, San Diego, 4150 Regents Park Row, Suite 300, San Diego, CA 92037. "Why exercise for low back pain?" The Journal of Musculoskeletal Medicine October 1995. V. Mooney. “The Primary Care Approach to Low Back Pain." Primary Care Reports Vol 1, No. 4, February 27, 1995. L. Kuritzky and D. M. Carpenter. Reprints available: American Health Consultants, P. O. Box 740056, Atlanta, Georgia 30374. "Comparison of Lumbar Range of Motion Using Three Measurement Devices in Patients With Chronic Low Back Pain." Spine 19(7): 779-783, 1994. Fred R. Shirley, Patrick O'Connor, Michael E. Robinson, and Michael MacMillan. "Controversies - Trunk Strength Testing in Patient Evaluation and Treatment." SPINE Vol 19, No. 21, pp 2483-2485, 1994. Vert Mooney and Gunnar B. J. Andersson. "Functional assessment for prediction of lifting capacity." Spine 19(9): 1021-1026, 1994. D. L. Wheeler, J. E. Graves, G. J. Miller, P. O'Connor and M. MacMillan. "Functional Evaluation of The Spine." Current Science, 5:54-57, 1994. V. Mooney. "Helping your back pain patients make the most of spinal motion." The Journal of Musculoskeletal Medicine Vol. 11, No. 1, January 1994. Rowland G. Hazard, Robin A. McKenzie, and Vert Mooney. "Pelvic stabilization during resistance training: Its effect on the development of lumbar extension strength." Archives of Physical Medicine and Rehabilitation Vol 75, February 1994. J. E. Graves, D. C. Webb, M. L. Pollock, J. Matkozich, S. H. Leggett, D. M. Carpenter, D. N. Foster, J. Cirulli. "The Use and Misuse of Performance Testing." Orthopedics Vol. 17 No. 5, May 1994. Thomas E. Dreisinger. "A rational approach to the treatment of low back pain." The Journal of Musculoskeletal Medicine 10(5): 67-82, May 1993. B. W. Nelson. "Frequency and Volume of Resistance Training: Effect on Cervical Extension Strength." Archives of Physical Medicine and Rehabilitation Vol 74, October 1993. M. L. Pollock, J. E. Graves, M. M. Bamman, S. H. Leggett, D. M. Carpenter, C. Carr, J. Cirulli, J. Matkozich, and M. Fulton. "Lumbar strengthening in chronic low back pain patients: Physiologic and physiological benefits." SPINE 18(2): 232-238, 1993. S. V. Risch, N. K. Norvell, M. L. Pollock, E. D. Risch, H. Langer, M. Fulton, J. E. Graves, and S. H. Leggett. "Physical Treatment of Soft Tissue Injuries." Western Journal of Medicine, pp 159, October 1993. Vert Mooney. "Understanding, Examining For, and Treating Sacroiliac Pain." J. of Musculoskeletal Medicine, 10:37-49, 1993. V. Mooney. "What is Going to Happen to Back Pain?" The Journal of the Royal Society of Medicine 86:273-276, 1993. V. Mooney. "Why Do Workers Compensation Medical Costs Keep Going Up and How Can We Change This?" J. of Disabil. 3:101-109, 1993. V. Mooney. "Back Injuries: Successful Prevention and Management." The Journal of Workers Compensation, 1(2):18-27, 1992. V. Mooney. "Effect of focused strength training after low back injury." North American Spine Society Eighth Annual Meeting. V. Mooney, L. Matheson, D. Holmes, S. Leggett, J. Grant, S. Negri, and B. Holmes. University of California San Diego. 600 South Grand Avenue, Suite 101, Santa Ana, California 92705. "Can We Measure Function in the Sacroiliac Joint." First Interdisciplinary World Congress on Low Back Pain and its Relation to the Sacroiliac Joint. 407-421 Nov. 5-6, 1992. V. Mooney. "Changes in Isometric Strength and Range of Motion of the Isolated Lumbar Spine After Eight Weeks of Clinical Rehabilitation." Spine Vol. 17(6), 1992. Thomas R. Highland, Thomas E. Dreisinger, Laura L. Vie, and Garth S. Russell. "Comparison of female geriatric lumbar extension strength: Asymptomatic vs. chronic low-back pain patients and the response to active rehabilitation in the symptomatic group." Presented at the North American Spine Society Annual Meeting, Bopston, MA, 1992. B. Holmes, S. Leggett, V. Mooney, J. Nichols, S. Negri, and A. Hoeyberghs. "Comparison of Two Restraint Systems for Pelvic Stabilization during Isometric Lumbar Extension Strength Testing." Journal of Orthopaedic Sports Physical Therapy, 15(1), January 1992. J. E. Graves, C. K. Fix, M. L. Pollock, S. H. Leggett, D. N. Foster, D. M. Carpenter. "Degenerative disc disease in a collegiate volleyball player." Presented at the American College of Sports Medicine Annual Meeting, 1992. T. R. Highland, T.E. Dreisinger. "Effect of Instructions on Isokinetic Trunk Strength Testing Variability, Reliability, Absolute Value and Predictive Validity." Spine 17(8):914-921, 1992. L. Matheson, V. Mooney, V. Caiozzo, G. Jarvis, J. Pottinger, C. DeBerry, K. Backlund, K. Klein, and J. Antoni. "Effect of reduced frequency of training and detraining on lumbar extension strength." SPINE l7(12): 11497-1501, 1992. J. T. Tucci, D.M. Carpenter, M. L. Pollock, J. E. Graves, and S. H. Leggett. "Functional Restoration, Pitfalls in Evaluating Efficacy." Spine 17(8):988-995, 1992. R.J. Gatchel, T.G. Mayer, R.G. Hazard, J. Rainville, and V. Mooney. "Function and the Industrial Back Pain Patient."J. of Occupational Rehab., 2:95-120, 1992. V. Mooney. "Limited range-of-motion lumbar extension strength training." Medicine and Science in Sports and Exercise 24Z(1): 128-133, 1992. J. E. Graves, M. Pollock, S. H. Leggett, D. M. Carpenter, C. K. Fix, and M. N. Fulton. "Occupational Back Injury: Sports Medicine for Working People." Pain Management, Jan./Feb. Issue, 1992. V. Mooney. "On the Dose of Therapeutic Exercise." ORTHOPEDICS Vol 15, No. 5, May 1992. V. Mooney. "Proposed Strength Training Regimens in Rehabilitation of the Lumbar Spine." Presented at the North American Spine Society Annual Meeting, Boston, MA, July 1992. G. S. Russell, T.E. Dreisinger, L.L. Vie, T.R. Highland. "Reliability of lumbar isometric torque in patients with chronic low back pain." Physical Therapy Vol. 72(3), 1992, pp 186-190. M. E. Robinson, J.E. Graves, P. O'Connor, M. MacMillan. "Should We Go Soft?" Orthopedics 16(2):129-130, 1992. V. Mooney. "Strength Testing Can Identify Malingering." The Journal of Workers Compensation 2(1):55-64, 1992. V. Mooney, S.H. Leggett, B. L. Holmes, and S. Negri. "Treating Cervical Spondylosis." Rehab Management February/March: 99, 1992. S. Negri, B. Holmes, S. Leggett, and V. Mooney. "Back pain and the exercise prescription." Clinics in Sports Medicine, Nicholas DiNubile (ed.) Vol. 10(1), pp, 197-209, 1991. D. N. Foster and M. N. Fulton. "Effect of 12 and 20 weeks of resistance training on lumbar extension torque production." Physical Therapy 71(8): 580-588, 1991. D.M. Carpenter, M. L. Pollock, J. E. Graves, S. L. Leggett, and D. Foster, B. Holmes, and Michael N. Fulton. "Quantitative assessment and training of isometric cervical extension strength." The American Journal of Sports Medicine, Vol. 19, No. 6. 1991. S. H. Leggett, J. E. Graves, M. L. Pollock, M. Shank, D. M. Carpenter, B. Holmes, and M. Fulton. "Effect of training frequency and specificity on isometric lumbar extension strength." SPINE Vol. 15, No. 6, June 1990. J. E. Graves, M. L. Pollock, D. Foster, S. H. Leggett, D. M. Carpenter, R. Vuoso, A. Jones. "Functional Capacity Testing: Its Role in Assessing and Treating Back Pain." Pain Management, 3(2):107-113, 1990. V. Mooney. "Non-specificity of limited range-of-motion lumbar extension strength training." Medicine and Science in Sports and Exercise 22(2): S19, 1990. J. Graves, M. Pollock, S. Leggett, D. Carpenter, C. Fix, and M. Fulton. "Rehabilitation and testing . . . conservative treatment for lower-back and cervical problems." Rehab Management 3(April/May); UF2-40, 1990. M. Fulton, G. Jones, M. Pollock, J. Graves, J. Cirulli, S. Leggett, D. Carpenter, and A. Jones. "When is Surgery Appropriate for Patients with Low Back Pain?" Journal of Musculoskeletal Medicine, 7(2):61-85, 1990. V. Mooney. "Quantitative assessment of full range-of-motion isometric lumbar extension strength", SPINE, Vol. 15, No. 4, April 1990. J. E. Graves, M. L. Pollock, , D. M. Carpenter, S. H. Leggett, A. Jones, M. MacMillan, and M. Fulton. "Comparison of two versus three days per week of variable resistance training during 10 and 18 week programs." International Journal of Sports Medicine 10: 450-454, 1989. R.W. Braith, J.E. Graves, M. L. Pollock, S.H. Leggett, D.M. Carpenter, and A.B. Colvin. "Effect of resistance training on lumbar extension strength." The American Journal of Sports Medicine Vol 17, No. 5, 1989. M. L. Pollock, S. H. Leggett, J. E. Graves, A. Jones, M. Fulton, and J. Cirulli. "New approach to low back evaluation and training." Central Florida Physician July: 19-20, 1989. M.L. Pollock and J.E. Graves. "Specificity of limited ranged-of-motion variable resistance training." Medicine and Science in Sports and Exercise 21(1): 84-89, 1989. J.E. Graves, M.L. Pollock, A.E. Jones, A.B. Colvin, and S.H. Leggett. "Training on lumbar extension strength." The American Journal of Sports Medicine, l7(5) 1989. M. L. Pollock, S. H. Leggett, J. E. Graves, A. Jones, M. Fulton, and J. Cirulli. "Where is the Lumbar Pain Coming From?" Ann. Med., 21:321-325, 1989. V. Mooney. "Effect of reduced training frequency on muscular strength." International Journal of Sports Medicine 5(9): 316-319, 1988. J.E. Graves, M. L. Pollock, S.H. Leggett, R.W. Braith, D.M. Carpenter, and L.E. Bishop. "Lower Back Pain: New Protocols for Diagnosis and Treatment." Rehab Management Nov./Dec., 1988, P. 39-41. Michael Fulton, M.D. "Relationship of Lumbar Strength in Shipyard Workers to Work Place Injury Claims." V. Mooney, K. Kenney, S. Leggett, B. Holmes. Correspondence and Reprints: Vert Mooney, M.D., UCSD OrthoMed, 4150 Regents Park Row #300, La Jolla, CA 92037. "Relationships Between Myoelectric Activity, Strength, and MRI of Lumbar Extensor Muscles in Back Pain Patients and Normal Subjects." V. Mooney, J. Gulick, M. Perlman, D. Levy, R. Pozos, S. Leggett, D. Resnick. Correspondence and Reprints: Vert Mooney, M.D., UCSD, 4150 Regents Park Row, Suite 300, La Jolla, CA 92037. "Successful Management of Clinical Low Back Pain: A Prospective Multicenter Study With One Year Follow-Up." S. Leggett, B. Nelson, V. Mooney, T. Dreisinger, J. Van Zytveld, and L. Vie. Correspondence and Reprints: Scott Leggett, UCSD OrthoMed, 4150 Regents Park Row, Suite 300, La Jolla, CA 92037. TOP
BOOKS Breakthrough For Back Pain! Lester Street Publishing, Tucson, Arizona, 1992. William V. Zucker and Brian W. Nelson. The Lumbar Spine. Sequoia Communications, Santa Barbara, CA, 1988. A. Jones, M. Pollock, J. Graves, M. Fulton, W. Jones, M. MacMillan, D. Baldwin, and J. Cirulli.TOP
BOOK CHAPTERS "Back pain and the exercise prescription," Clinics in Sports Medicine, Nicholas DiNubile (ed.) Vol. 10(1), pp, 197-209, 1991. D. N. Foster and M. N. Fulton. "The lumbar musculature: Testing and conditioning for rehabilitation," Rehabilitation of the spine: Science and Practice. M.L. Pollack, J.E. Graves, D.M. Carpenter, D. Foster, S.H. Leggett, M.N. Fulton. "Muscle." THE LUMBAR SPINE. Sequoia Communications, Santa Barbara, CA, 1988. Michael L. Pollock, James E. Graves, David M. Carpenter, Daniel Foster, S. H. Leggett, and M. N. Fulton. "Spinal Rehabilitation (Part 1) - Measuring True Functional Ability in Clinical Practice." THE LUMBAR SPINE. Sequoia Communications, Santa Barbara, CA, 1988. Michael N. Fulton. "Spinal Rehabilitation (Part 2) - The Requirement for Specific Exercise in Clinical Practice." THE LUMBAR SPINE. Sequoia Communications, Santa Barbara, CA, 1988. Michael N. Fulton. "Spinal Rehabilitation (Part 3) - The Need to Identify Abnormal Function in Clinical Practice." THE LUMBAR SPINE. Sequoia Communications, Santa Barbara, CA, 1988. Michael N. Fulton. "Spinal Rehabilitation (Part 4) - What Should Follow Clinical Rehabilitation?" THE LUMBAR SPINE. Sequoia Communications, Santa Barbara, CA, 1988. Michael N. Fulton. TOP To MedX Menu
ABSTRACTS "Effect of pelvic restraint on hamstring, gluteal, and lumbar muscle EMG activation." Med. Sci. Sports Exerc. (Supplement) Vol. 27(5), 1995, p S210. B. Udermann, J. Iriso, and J. Graves, FACSM. "Resistance Exercise Training Restores Bone Mineral Density After Heart Transplantation." 1995 American College of Sports Medicine Annual Meeting, Indianapolis, IN. R. W. Braith, R. M. Mills, M. L. Pollock, FACS, M.A. Welsch, and J. Keller. West Virginia University, Morgantown, WV, and University of Florida, Gainesville, FL. "Evaluation of isometric lumbar extension strength using a 2-angle testing protocol." Res. Quart. Exerc. Sport 65 (supplement), 1994, p A-56. J.E. Graves, S. Leggett, D. Foster, M. Pollock, and D. Carpenter. "Adaptations in strength and cross-sectional area of the lumbar extensor muscles following resistance training." Med. Sci. Sports Exerc. Vol. 25(5), 1993, p S47. D. Foster, M. Avillar, M. Pollock, J. Graves, G. Dudley, D. Woodard, and D. Carpenter. "Gender and age-specific isometric strength norms of the isolated lumbar extensor muscles." Presented at the American Physical Therapy Association Annual Conference, Cincinnati, OH June 1993. D. Carpenter, M. Pollock, J. Graves, D. Foster, S. Leggett, L. Garzarella, and D. Feurtado. "Effects of isolated lumbar extension resistance training on bone mineral density of the elderly." Med. Sci. Sports Exerc. Vol. 24(5), 1992, p S66. M.L. Pollock, L. Garzarella, J.E. Graves, D.M. Carpenter, S.H. Leggett, D. Lowenthal, M.N. Fulton, D. Foster, J. Tucci, R. Mananquil. "Influence of knowledge of results on variability during maximal and submaximal isometric lumbar extension strength measurement." Res. Quart. Exerc. Sport Vol. 63(1), 1992, p. A51. J.E. Graves, G. Young, J. Cauraugh, L. Garzarella, D. Carpenter, S. Leggett and M.L. Pollock. "Quantitative assessment of isometric cervical rotation net muscular torque." Med. Sci. Sports Exerc. Vol. 24(5), 1992, p S172. D. Foster, J. Graves, M. Pollock, A. Hepler, D. Carpenter. "Quantitative assessment and training of cervical extension strength." Med. Sci Sports Exerc. Vol. 24(5), 1992 p S172. S.H. Leggett, J.E. Graves, M.L. Pollock, D.M. Carpenter, M. Fulton, M. Shank, and B. Holmes. "Accuracy of counterweighting to account for upper body mass in testing lumbar extension strength." Medicine and Science in Sports and Exercise. Vol. 23(4), 1991, p S66. M. L. Pollock, J.E. Graves, S.H. Leggett, W.G. Young, L. Garzarella, D.M. Carpenter, M.N. Fulton, and A. Jones. "Effect of testing order on isometric torso rotation strength." International Journal of Sports Medicine 2(12): 246, 1991. D. Carpenter, J. Graves, J. Blanton, S. Leggett, and M. Pollock. "Effect of training frequency on cervical rotation strength." Med. Sci. Sports Exerc. Vol. 23(4), 1991, p S118. S.H. Leggett, G. DeFilippo, J. Trinkle, J.E. Graves, M.L. Pollock, and D.M. Carpenter "Quantitative assessment of isometric lumbar extension net muscular torque." Medicine and Science in Sports and Exercise 23(4): S65, 1991.D. Carpenter, S. Leggett, M. Pollock, J. Graves, G. Young, L. Garzarella, and A. Jones. "Quantitative assessment of isometric torso rotation net muscular torque." Archives of Physical Medicine and Rehabilitation 72(10): 804, 1991. D. Carpenter, J. Graves, M. Pollock, S. Leggett, and J. Blanton. "Comparison of two methods of pelvic stabilization on isometric lumbar extension strength." Medicine and Science in Sports and Exercise 22(2): S19, 1990. C. Fix, J. Graves, M. Pollock, S. Leggett, D. Foster, and D. Carpenter. "Effect of frequency, volume, and mode of training on cervical extension strength." Proceedings of the American Physical Therapy Association Annual Conference, Anaheim, CA: 35-36, June, 1990. J. Pollock, J. Graves, S. Leggett, D. Carpenter, C. Fix, J. Cirulli, J. Matkozich, and M. Fulton. "Effect of order of multiple joint angle testing for the quantification of isometric lumbar extension strength." Medicine and Science in Sports and Exercise 22(2): S20, l990. S. Leggett, J.E. Graves, M.L. Pollock, D.M. Carpenter, D. Foster, B. Holmes, C. Fix, M. Shank, J. Tucci, and M. Fulton. "Effect of training with pelvic stabilization on lumbar extension strength." International Journal of Sports Medicine 11(5): 403, 1990. J.E. Graves, D. Webb, M.L. Pollock, J. Matkozich, S.H. Leggett, D.M. Carpenter, and J. Cirulli. "Effect of 12 and 20 weeks of training on lumbar extension strength." Medicine and Science in Sports and Exercise 22(2): S19, 1990. D. Carpenter, J. Graves, M. Pollock, S. Leggett, D. Foster, B. Holmes, and M. Fulton. "Effect of upper body mass on the measurement of isometric lumbar extension strength." Presented at the Orthopaedic Rehabilitation Association Annual Meeting, San Antonio, TX, November, 1990. J. Fulton, S. Leggett, J. Graves, M. Pollock. D. Carpenter, and B. Colding. "Lumbar strengthening in chronic back pain patients: Psychological and physiological benefits." Presented at The American Psychological Association Annual Meeting, Boston, August, 1990. S. Risch, N. Norvell, M. Pollock, E. Risch, H. Langer, M. Fulton, S. Leggett, and J. Graves. "Non-specificity of limited range-of-motion lumbar extension strength training." Medicine and Science in Sports and Exercise 22(2): S19, 1990. J. Graves, M. Pollock, S. Leggett, D. Carpenter, C. Fix, and M. Fulton. "Quantitative assessment of full range-of-motion cervical rotation strength." Presented at the Cervical Spine Society Annual Meeting, San Antonio, TX, December, 1990. M. Pollock, D. Carpenter, J. Trinkle, G. DeFilippo, J. Graves, S. Leggett, and M. Fulton. "Reliability and variability of isometric torso rotation strength measurement." Medicine and Science in Sports and Exercise 22(2): S20, 1990. M. Pollock, D. Carpenter, J. Blanton, J. Graves, and S. Leggett. "Specificity of lumbar extension strength training." International Journal of Sports Medicine 11(5): 403-404, 1990. S.H. Leggett, J.E. Graves, M.L. Pollock, D. Foster, D.M. Carpenter, and R. Vuoso. "Effect of training frequency on lumbar extension strength." Medicine and Science in Sports and Exercise 21(2): S88, 1989. D. Foster, S.H. Leggett, J.E. Graves, M.L. Pollock, D.M. Carpenter, B. Holmes, and R.W. Braith. "Quantitative assessment of full range-of-motion cervical extension strength." Medicine and Science in Sports and Exercise 21(2):S52, 1989. S.H. Leggett, M.L. Pollock, J.E. Graves, M. Shank, D.M. Carpenter, and C. Fix. "Quantitative assessment of full range-of-motion lumbar extension strength." Medicine and Science in Sports and Exercise 20(2): S87, 1988. S.H. Leggett, M.L. Pollock, J.E. Graves, A. Jones, M. MacMillan, D.M. Carpenter, and K. Onodera.TOP To MedX Menu
PUBLICATIONS: WORK IN PROGRESS: SUBMITTED FOR PUBLICATION: "Relationship between isometric and dynamic muscular strength: Acute changes and training responses." (in review). J.E. Graves, S.H. Leggett, M.L. Pollock, R.W. Braith, and D.M. Carpenter. "Effect of submaximal effort and knowledge of previous results on the reliability of lumbar extension strength." (in review) N. Delude, J. Graves, D. Carpenter, D. Feurtado, M., Pollock, and D. Foster. "Effect of training frequency on the development of isometric torso rotation strength” (in review). P.L. DeMichele, M.L. Pollock, J.E. Graves, D.N. Foster, D. Carpenter, L. Garzarella, W. Brechue, and M. Fulton. "Effect of concurrent visual feedback and knowledge of results on isometric lumbar extension strength." (in preparation) J. Graves, S. Leggett, D. Carpenter, M. Pollock, and B. Colding. "Quantitative assessment and training of cervical rotation strength." (in preparation). S. Leggett, M. Pollock, J. Graves, D. Carpenter, J. Trinkle, and G. DeFilippo. "Effect of dynamic and combined dynamic/isometric training on cervical extension strength." (in preparation). M. Pollock, J. Graves, C. Fix, M. Shank, S. Leggett, and D. Carpenter. "A physiological evaluation of elite professional water skiers." National Strength and Conditioning Association Journal (in press). S. Leggett, M. Pollock, J. Graves, D. Carpenter, M. Fulton, M. Shank, A. Engmabb, D. Kaufman, and K. Studstill. "Single vs. multiple set dynamic and isometric lumbar extension training." Spine Rehabilitation (in press). J. E. Graves, B. L. Holmes, S.H. Leggett, D.M. Carpenter, and M. L. Pollock. "Effect of pelvic stabilization during resistance training on the development of lumbar extension strength." Archives of Physical Medicine and Rehabilitation (in press). J.E. Graves, D. Webb, M. L. Pollock, J. Matkozich, S.H. Leggett, D. M. Carpenter, and J. Cirulli. "Isometric lumbar extension net muscular torque values for men and women. Orthopaedic Transactions." J. Bone Joint Surg. (in press). M. Fulton, D. Carpenter, M. Pollock, J. Graves, S. Leggett, G. Young, and L. Garzarella. TOP
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Page Contents • Can Spinal Surgery Be Prevented by Aggressive Strengthening Exercise? • A Randomized Clinical Trial of Exercise and Spinal Manipulation for Chronic Neck Pain • A Rational Approach to the Treatment of Low Back Pain • Restorative Exercise for Clinical Low Back Pain A Prospective • The Clinical Effects of Intensive, Specific Exercise on Chronic Low Back Pain: A Controlled Stu |
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