Functional Optimization/Quota
Based Exercise for Lumbar Diagnoses
Alison Stout DO
Fellowship Director
Evergreen Healthcare
Kirkland, WA
Disclosures
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NASS Exercise Committee Chair
ISIS Education Committee
ISIS Patient Safety Committee
AAPMU Faculty
Three Key Practical Steps
1. Provide a rationale – Maladaptive pain
2. Focus on progressive exercise- Quota based
3. Set realistic goals – patient specific
Chronic Maladaptive Pain
Injury to Chronic Pain
• Central and peripheral sensitization
– Repeated/chronic afferent input sensitizes
nerves through neural plasticity
• More pain with small stimulus
• Allodynia – pain with non-painful stimulus
• Larger area of pain
– Increased effect from sympathetic modulation
Transition From Injury to Chronic Pain
Central/Peripheral nerve sensitization, Rat
• Lesion to C5-6 facet
– non-pain nerve fibers change to produce
same chemicals as pain fibers
• After peripheral nerve injury
– New synapses in the spinal cord are made
between non-pain and pain fibers
Non-pain Contingent Exercise
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Smeets RJ, Vlaeyen JW, Kester AD, et al: Reduction of pain catastrophizing mediates the outcomes of
both physical and cognitive-behavioral treatment in chronic low back pain. J Pain 7:261-71, 2006 (RCT)
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Purpose: to examine whether treatments based on different theories change pain catastrophizing and internal
control of pain, and whether changes in these factors mediate treatment outcome.
– 211 patients with NSCLP
• n=52 Active Physical Treatment (APT)
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30 mins Aerobic bicycle (65%-80% HRM), 75 mins Strength Training (70% 1 RM, 3x15-18), 3x/week x 10 weeks
• n=55 Cognitive Behavior Treatment (CBT)
• n=55 Combined Treatment APT+CBT (CT)
• n=49 Waitlist (WL)
– Results:
• All groups improved compared to WL
• APT alone mediated pain catastrophizing to improve outcome = CBT and CT
• Physical treatment alone can improve a psychological factor
Non-pain Contingent Exercise
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Roche G, Ponthieux A, Parot-Shinkel E, et al: Comparison of a functional restoration program with active
individual physical therapy for patients with chronic low back pain: A randomized controlled trial. Arch
Phys Med Rehabil 88:1229-35, 2007
•Purpose: To compare the short-term outcomes of active
individual therapy (AIT) with those of a functional
restoration program (FRP)
•FRP: 6 hrs/day, 5 days/wk x 5 weeks (25 hrs/wk)
•AIT: 1 hr/day, 3x/wk x 5 weeks, 50 mins of home exs. 2x/wk
(3 hrs/wk + home exs)
•Results:
•Pain and Disability improved similarly for both
groups. FRP improved endurance greater than AIT
•Outpatient PT outcomes are similar to more costly
FRPs
Non-pain Contingent Exercise
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Dufour N, Thamsborg G, Oefeldt A, Lunddgaard C, Stender S. A RCT Comparing Group-Based
Multidisciplinary Biopsychosocial Rehabilitation and Intensive Individual Therapist-Assisted Back Muscle
Strengthening Exercises. Spine 2010:35;469-476
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Purpose: To compare efficacies of 2 active therapies for CLBP
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286 patients randomized
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n=142 Multidisciplinary biopsychosocial rehab (75 hrs of moderate muscle training)
n=144 Intensive individual therapist-assisted back muscle strengthening exercise (22 hrs of intensive muscle
training)
Results after 24 month follow-up
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Pain and Disability outcomes improved significantly and nearly identically for both groups
Goal Setting
Patient developed graded set of goals (from
least to most difficult)
1. Predict amount of pain they will experience
2. Engage in goal and compare prediction of
pain to actual pain
Self-Monitoring
• Help patient discover how pain interacts with
psychosocial factors (vice versa) via 1 week diary
• Include patient specific concerns, indicators of key
yellow flags (unhelpful beliefs about pain,
emotional responses, pain behaviors)
• Review the diary record in detail
Conclusions
• Help the recalcitrant patient understand that
maladaptive pain from a neurobiologic and
psychosocial perspective
• Use self monitoring to help the patient understand
the interaction between pain and unhelpful cognitive,
emotional, and behavioral responses.
• In the treatment process, structure learning
experiences that can change how patients think
about and respond to pain
Conclusions
• More exercise does not improve outcome
measures
• Choose methods of exercise appropriate for your
patient and within your available resources
• Specialty equipment is not required