Rehabilitation for Back Pain: Consensus in the research

Post date: 27-Apr-2014 10:04:13

One of the best books on contemporary research in Back Pain Rehabilitation came out last year edited by Hodges, Cholewicki and Van Dieen (2013). It brings together many of the great names in back pain research and tries to highlight some of the key points of agreement between many of the competing approaches, while also acknowledging differences and suggesting how these differences can be accounted for.

I found one of the chapters particularly useful as it addressed the debate around how research observations can be extrapolated to effective treatment (Ch. 20 by Hodges, McGill and Hide). An adapted version of the key content is included below.

While there are a number of contended issues in the rehab of those with back pain, key points of agreement are as follows:

    1. The spine is controlled by a complex interplay of many muscles (i.e. no single muscle is the most important for spine control)
    2. Changing the manner in which a patient controls the spine and pelvis is likely to be beneficial in management of back pain
      • management should require careful consideration of all aspects of control, including posture, movement and muscle activation strategies, identification of the aspects that require correction, and then implementation of a rehabilitation program to achieve/restore/rectify this control
    3. Motor control can be changed with treatment/exercise

Researchers agree that motor control can be changed with treatment, although how best to achieve this has been outlined in a number of ways:

        1. the practice of complex functional tasks with correction of the component considered to be ‘faulty’ (O’Sullivan, 2005)
        2. attention to specific muscles (Richardson et al, 1999) or muscle activation strategies (McGill, 2007)
        3. indirect training using automatic changes in motor patterns of proximal muscles (Bullock-Saxton et al, 1993)
        4. identifying the painful movement and altering the movement pattern coupled with muscular bracing to reduce reported pain (Ikeda and McGill, 2012)
        5. or, no specific attention to correction of muscle activation, posture or movement

Common to all approaches is the use of multiple methods to enhance the restoration of control of posture, movement and muscle activation.

    1. Treatment involves consideration of more than a uni-dimensional focus on a single muscle or muscle activation strategy

In communicating different approaches the message is often reduced to a focus on a single solution for the management of low back pain. This can be as a result of the researchers wishing to highlight the unique aspects of their own approach or the desire of those communicating an approach to simplify it for mass consumption. It is also noted that those wishing to discredit certain techniques may well refer to oversimplified descriptions in order to strengthen their own arguments.

It is suggested that rehabilitation of the whole system is desirable, this needs to be individualised and that some aspects of increasing or decreasing activation of specific muscles is important.

    1. Treatment requires progression to enhanced execution of activities of daily living

Better transfer to function is achieved with practice of the task as close as possible to the ‘real life’ situation (Shumway-Cook & Woollacott, 2007). Treatment programmes should progress from the early rehabilitation of motor control through to complex functional tasks and activities of daily living that will be specific to the individual in questions. This progression would also necessitate the need for attention to pain/avoidance behaviour, psychosocial aspects, balance and sensory issues, and muscular strength, endurance and cardiovascular capacity.

While these points are made in agreement, a key point of disagreement is as follows:

    1. Control of deeper muscles of the trunk, including Tranversus Abdominus and Lumbar Multifidus, should be assessed and addressed if dysfunction is identified

One standpoint is that changes in the deeper muscles are common, changes in the activation of these muscles contributes to a compromise in the quality of control of the load, control of these elements of the system can be restored with exercise, and that restoration of control of these muscles contributes to reduction in pain and disability. The alternative viewpoint is that control of these muscles is not necessary, not possible and potentially counterproductive. While suggestions have been made regarding how this difference in opinion can be enlightened, many of the issues around researching this fundamental issue is that most programmes contain elements of similarity in the way that patients are treated.

The clear consensus is that an intervention is likely to be best when all aspects in a patients presentation are considered (posture, movement and muscle activation, psychological and social aspects) and a multi-dimensional treatment plan is developed.

References and Further Reading

Bullock-Saxton, J. E., Janda, V., & Bullock, M. I. (1993). Reflex activation of gluteal muscles in walking: an approach to restoration of muscle function for patients with low-back pain. Spine, 18(6), 704-708.[abstract]

Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K., Herbert, R. D., & Hodges, P. W. (2010). Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain. British journal of sports medicine, 44(16), 1166-1172.[abstract]

Hodges, P.W., McGill, S. M., and Hides, J.A. (2013) “Motor control of the spine and changes in pain: debate about the extrapolation from research observations of motor control strategies to effective treatments for back pain.” In Spinal Control: The Rehabilitation of Back Pain Edited by Paul Hodges, Jacek Cholewicki and Jaap Van Dieen. London: Churchill Livingstone [google books]

Hodges, P. Cholewicki, J. and Van Dieen,J. (Eds) (2013) Spinal Control: The Rehabilitation of Back Pain. London: Churchill Livingstone [google books]

Ikeda, D. M., & McGill, S. M. (2012). Can altering motions, postures, and loads provide immediate low back pain relief: a study of 4 cases investigating spine load, posture, and stability. Spine, 37(23), E1469-E1475.[abstract]

McGill, S. (2007). Low back disorders: evidence-based prevention and rehabilitation. Human Kinetics.[google books]

O’Sullivan, P. (2005). Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual therapy, 10(4), 242-255.[full text]

Richardson, C., Jull, G., Hodges, P., & Hides, J. (1999). Therapeutic exercise for spinal stabilisation: scientific basis and practical techniques. Churchill Livingstone, Edinburgh.[amazon]

Shumway-Cook, A., & Woollacott, M. H. (2007). Motor control: translating research into clinical practice. Lippincott Williams & Wilkins.[google books]