37 Exercises, Conditioning, and Other Nonoperative Strategies
Pain of spinal origin is multifactorial. 1 Exercises for the management of spinal disorders are designed to diminish pain and to increase stability. In part, they accomplish their task of pain management by increasing stability (see the following). Pain may be secondary to stiffness (e.g., restriction of motion); muscle spasm (myofascial pain); instability; and other, less well-defined mechanisms. Stretching exercises can increase the range of motion and relax spasm; strengthening exercises can augment spinal stability. 2 A host of additional management schemes may be used to address the causes of spinal disorders, such as strategies that address obesity, 3 tobacco abuse, 4 and inflammatory processes. 5 , 6 However, it is safe to say that an exercise regimen is the predominant nonoperative strategy for the management of disorders of the spine. It is therefore appropriate to pay particular attention to this aspect of spinal stabilization and pain management. 7 It is also appropriate to consider the fundamentals first, followed by diagnosis and differential diagnosis determination and finally by management strategy determination. 8 Surgery is usually (or should be) a strategy of last resort. 9 Surgical indications for spinal disorders have nevertheless been a hotbed of controversy. 10 , 11 Evidence demonstrating the suboptimal outcome and diminished cost-effectiveness of surgery for back pain and related disorders is both mounting and yet persistently controversial, 12 – 21 although laminectomy for lumbar stenosis appears to be consistently shown to be effective and cost-effective, as has surgery for sciatica. 21 – 24 Further definition of the problem and the afflicted patient is critical. 25 , 26 It is clear that depression, anxiety disorder, and substance abuse disorder are underlying factors that portend a poor outcome with both surgical and nonsurgical traditional treatment techniques and regimens. 27 – 29
37.1 Biomechanics
Muscles, as well as associated fascial and tendinous attachments and ligaments, provide significant support for the spine. They create both a guy wire–like support system (Fig. 37.1a, b) and a cantilever support system (Fig. 37.1c, d). Strengthening either or both of these systems increases axial loading (Fig. 37.2a) as well as angular deformity resistance (Fig. 37.2b). The associated multiplanar deformity resistance augments spinal stability (Fig. 37.3).
Immobility can cause motion segment stiffness by foreshortening ligaments and tendons and by causing fibrous adhesions. This can, in and of itself, be associated with pain. Increasing mobility (e.g., by stretching) may decrease pain (Fig. 37.4).
Finally, lower extremity laxity, or overuse, is associated with back pain. This may be related to the kinetic chain or link theory, in which abnormal forces that are applied caudally are transmitted rostrally. 30 Back pain secondary to activity related to a sport, such as golf, is more common than once thought. Understanding the mechanics of the stresses applied to the spine can assist with management. 31 Motion has even been studied in contortionists, thus illustrating both the advantages and problems associated with the maintenance of extreme flexibility. 32
37.2 Differential Diagnosis of Pain of Spinal Origin
Pain of spinal origin is a poorly understood and heterogeneous condition 33 that is often inadequately assessed. 8 This in part is related to the fact that it is multifactorial. However, it can be broken down into relatively broad categories, the separation of which is relevant from the perspective of determining the prognosis and a management strategy: (1) muscle spasm or strain (e.g., myofascial pain syndrome) 34 (2) mechanical pain; (3) nonspecific chronic pain; (4) functional pain; (5) pain of cataclysmic origin (e.g., malignancy, infection, large herniated disc with spinal cord injury, or cauda equina syndrome), which is usually mechanical or neurogenic in origin; and (6) pain with syndromic and disease-specific etiologies, most specifically inflammatory back pain .
The importance of establishing the category or type of pain before treatment cannot be overemphasized. The characterization and quantification of the pain and disability are likewise very important 35 Myofascial back pain, chronic pain, functional pain, and inflammatory back pain, for example, would not be expected to respond to surgery of any kind.
37.2.1 Muscle Spasm and Myofascial Pain
Muscle spasm, myofascial pain, or strain is occasionally associated with, or synonymous with, the diagnosis of myofascial pain syndrome. 36 It is akin to a “muscle pull.” 37 Stretching exercises, muscle relaxants, and expectant or observational strategies are usually effective. This type of pain is usually self-limiting, particularly if an underlying cause is appropriately addressed. Subsets of this population, however, have a relatively poor outcome. 38 Muscle pain may be related to oxygenation and intramuscular pressure. 39 Neither of these etiologies responds to spine surgery interventions.
37.2.2 Mechanical Pain
Mechanical pain is usually deep and agonizing and is exacerbated during assumption of the upright posture and during activity in general (loading). It is diminished with bed rest or a decrease in activity (unloading). This pain is akin to the hip pain associated with a badly degenerated hip joint. This pain increases with activity (loading) and decreases with inactivity (unloading; Fig. 37.5). Mechanical pain is usually observed in adults, particularly aging adults. However, it is also observed in adolescents, often related to stress injuries of the pars interarticularis in athletic individuals. 37 , 40 It may even be familial. 41
Mechanical pain, if associated with dysfunctional motion segment–related instability, can be effectively treated with a stabilization operation, or more often with core-strengthening exercises. External fixators, in fact, have been used as a tool to determine the potential efficacy of future surgery. 42 , 43 It is emphasized that both the clinical syndrome—that is, the triad of (1) deep and agonizing pain that is (2) worsened with spine loading and (3) improved with spine unloading—and imaging correlation must be present to meet the criteria for surgical intervention.
It is indeed worth mentioning that the last component of the syndrome triad is critical. The patient must be able to seek and find a position of relative comfort. If this cannot be done, the likelihood of achieving relief with stabilization surgery is significantly diminished. To put it another way, a fusion procedure, under these circumstances, is not likely to find and secure such a position of comfort if the patient cannot voluntarily and volitionally do so. Various tests have been employed to heighten diagnostic advantage, such as discography and modified magnetic resonance imaging, with varying results. For the most part, the utility of such diagnostic strategies is at best conjectural, and some evidence exists to suggest that discography may cause harm by injuring the annulus fibrosus. 41 – 53
37.2.3 Nonspecific Chronic Pain
Nonspecific chronic pain is, as its name implies, difficult to characterize. Often, these patients have had one or more previous spine operations, and their pain cannot be strictly categorized as having either a mechanical or muscle strain cause. Depression and other psychiatric conditions, directly or indirectly, play a significant role in many patients with back pain, 28 , 54 , 55 as do psychosocial stresses. 56 Contributing to the confusion is the fact that spine pathology, as defined by radiography, does not correlate with back pain. 57 – 79
37.2.4 Functional Pain
Functional pain (i.e., malingering) is unfortunately not uncommon. This type of pain is associated with, and exacerbated by, a secondary gain mechanism, such as financial, social, legal, or primary psychiatric aberrations. 60 – 63
37.2.5 Pain of Cataclysmic Origin
Pain of cataclysmic origin may arise from causes such as a large acute herniated disc, metastatic tumor of the spine, and infection. Even cervical spine compression may be the culprit. 64 These causes may be associated with the rapid progression or sudden onset of deterioration that may not be reversible. Tumor-related pain has been characterized as being worse during bed rest, whereas mechanical back pain, in contrast, is improved with bed rest. Diurnal variations in cortisol levels may contribute this type of pain, with diminished levels occurring during the hours of sleep.
37.2.6 Pain with Syndromic and Disease-Specific Etiologies
Disease-specific etiologies include the whiplash syndrome and the flat-back syndrome. The whiplash syndrome is poorly defined, acute in onset, and not too dissimilar from muscle spasm in character. It appears to be much more complex than routinely thought. 36 It may be associated with ligamentous strain or tear, or facet joint abnormalities.
The flat-back syndrome is associated with loss of the normal spine contour. In the lumbar spine, a loss of lumbar lordosis or the presence of lumbar kyphosis may create an abnormal posture (Fig. 37.6a). This may cause excessive pelvic tilt, so that knee flexion and often cervical extension are required to maintain forward vision (see Chapter 27 and Fig. 37.6b). The loss of lumbar lordosis is often associated with the loss of thoracic kyphosis as a compensatory mechanism. This may obviate the need for excessive cervical extension that would otherwise be necessary to attain sagittal balance if a loss of thoracic kyphosis were not present (Fig. 37.6c). The pain associated with this anatomical variant is for the most part nonspecific. However, it may be characterized as back pain that extends dorsally to the thighs (hamstring tightness) and is associated with knee flexion that is obligated by the need to minimize the effect of pelvic flexion. The latter is adaptive. It provides for forward vision (see Chapter 28).
Leg pain, in combination with back pain, has obvious diagnostic and therapeutic implications. These implications, however, may not be as straightforward as they appear on the surface. 65 Associated hip pathology can complicate both diagnosis and treatment. 66 In fact, greater trochanteric pain accounts for a substantial proportion of the patients referred to spine physicians for evaluation of low back pain and as such is one of several nonspinal masqueraders of spinal pathology. 67 , 68 Finally, coccydynia must be included in the differential diagnosis of pain in the low back and sacral region. 69
Inflammatory back pain is often associated with inflammatory afflictions of the spine, such as ankylosing spondylitis. It usually presents in younger patients (younger than 40 years) and is worse in early morning hours before they arise. It then dissipates over a short period of time after they arise and ambulate. This is in stark contrast to mechanical back pain, which usually worsens throughout the day and is worsened with spinal loading. The differentiation between the two is critical. Unnecessary operations should be avoided, and early treatment of the inflammatory back pain can retard the advancement of disease. The age of the patient is a critical differentiating factor. Patients with inflammatory back pain are in general much younger than those with mechanical back pain. A simple blood test (HLA-B27) and a pelvic X-ray (sacroiliac joint pathology/fusion) may be diagnostic under such circumstances. Regardless, if inflammatory back pain is suspected, consultation with a rheumatologist would seem prudent.
37.3 Management Strategies
Pain of spinal origin, as well as its management, is extremely complex and hence poorly understood. The costly nature of treatment adds yet another layer of complexity and confusion. 70 This is so for neck pain 71 and for back pain. 72 – 77 The problem is at least somewhat simplified by establishing the appropriate diagnostic category. Once the diagnostic category is determined, management strategies may be similarly determined. These include, at a fundamental level, education and injury prevention strategies. 2 They also include a variety of nonoperative management strategies.
37.3.1 Education
Augmentation of the patient’s knowledge base and awareness is always of benefit. This is particularly true with respect to back pain. An awareness of the spinal and paraspinal anatomy (Fig. 37.7) and some of the biomechanical principles outlined above is imperative. This usually helps the patient regarding his or her contribution to injury prevention or the rehabilitation process, 2 , 78 , 79 which includes education about factors that indirectly impact back pain, such as cigarette smoking. 80
37.3.2 Prevention
Although exercise programs have not been shown to be consistently efficacious regarding the prevention of work-related injuries, it is becoming increasingly clear that augmentation of the strength of the supporting muscles via exercise is of clinical significance. 81 , 82 An increase in the strength of the paraspinous muscles has been shown to be associated with a decrease in neck pain, back pain, and extremity pain. 83 – 86
37.3.3 Nonoperative Strategies
Many nonoperative strategies may be used for the management of spine pain. 87 These include bed rest, bracing, yoga, chiropractic care, acupuncture, magnets, intradiscal electrothermy, vertebroplasty, and medication, as well as other schemes that use stretching, strengthening, and many other, less well-known strategies. 88 – 90 It is imperative that the natural history of the spinal disorder be taken into consideration during the decision-making process. 91 – 93 For example, myofascial pain is often episodic. The pain can be expected to dissipate without treatment and with “tincture of time.” The patient should be so educated. Obviously, such episodes are most effectively managed by preventing them. Good body and lifting mechanics and core-strengthening exercises are critical in this regard.
Finally, multidisciplinary rehabilitation programs have been shown to be effective for the management of back pain. Although expensive, they may indeed be cost-effective. 90 , 94
Bed Rest and Traction
Bed rest has been touted as a treatment for pain of spinal origin. Proponents cite posttraumatic anatomical remodeling as one of many rationales for such a strategy. 95 – 99 Close scrutiny, however, has demonstrated either a negative effect or no effect related to long- or short-term bed rest. 100 – 105 Furthermore, an early return to normal (rather than restricted) duties has been shown to be beneficial regarding the management of back pain. 106 Of note, traction has been shown to lack efficacy. 107
Bracing
Spinal bracing supports the spine. Traumatic injuries without posterior column disruption are often effectively treated with bracing. 108 However, others have found that the efficacy of bracing is not related to posterior column ligamentous injury. 109 Spinal remodeling spontaneously occurs in trauma and nontraumatic disc disease, thus further underscoring the ultimate efficacy of this approach, at least in selected cases. 95 – 99
Bracing should theoretically alleviate or diminish most pain of spinal origin (mechanical pain) by means of supporting the spinal column. This essentially unloads the spine and its supporting structures. A major disadvantage of bracing, however, is the associated limitation of motion, as well as obligatory inactivity and subsequent atrophy of the supporting muscles of the spine. Back belts have not been shown to be efficacious 110 and are therefore controversial. 111
Yoga
Yoga has been associated with the alleviation and improvement of pain. 112 However, the cause-and-effect relationship for the management of back pain is not entirely clear.
Spinal Manipulation
Chiropractic and other forms of manipulation similarly have been associated with improvement of back and neck pain. 72 , 107 , 113 – 122 However, spinal manipulation is a very common, and perhaps overused and costly, management strategy. Selected patients appear to be effectively treated with such strategies. Therefore, spinal manipulation should not be discarded as a rational treatment option for some patients.
Acupuncture
Acupuncture has been used for the management of spinal disorders with mixed results. There are many explanations for the aforementioned mixed results. Variations in control groups, flaws in study design, and inadequacies of sample size have contributed to the uncertainty. Hence, definitive information regarding efficacy is not truly available at this time. 123 , 124
Magnets
Permanent magnets have been touted as a treatment for back pain. However, a randomized, double-blinded crossover study demonstrated no effect. 125
Vertebroplasty and Kyphoplasty
Structural support of a collapsed segment of the spine may alleviate a mechanical type of pain associated with vertebral body collapse (Fig. 37.8a). The elevation of vertebral body height, the reversal of kyphotic deformity, and the elimination of vertebral body deformation (Fig. 37.8b, c) are the probable mechanisms of reported pain relief with vertebroplasty and kyphoplasty. 126 , 127
Intradiscal Electrothermy
Alteration of the protein makeup of the dorsal annulus fibrosus and/or denervation may be of benefit to some patients. 128 – 131 The extent of efficacy is yet to be proved, particularly when the obligatory need for a controversial diagnostic tool, discography, is considered. 57 , 132 – 135
Medication
Medication, in particular muscle relaxants, is associated with a diminution of spine pain symptoms. Anti-inflammatory medications may also be helpful. 6 , 136
Injection Therapy
Trigger point, facet joint, nerve root, and epidural injections have been sporadically used for back, neck, and radicular pain. Results have been mixed, and in general poor. 137 – 143 The intraligamentous injection of sclerosing solutions (prolotherapy) has been used for the management of pain of spinal origin. The results have been mixed, so this treatment strategy has been used only sporadically. 144
Injections into the region of spinal implants in patients with recurrent back pain after a failed degenerative lumbar spine operation have been employed to determine the potential efficacy of subsequent implant removal. 145 Obviously, such strategies have not been validated.
Finally, nerve root and epidural blocks and injections can be associated with significant complications, including paraplegia. 146 Therefore, these should be considered in the decision-making process.
Back Exercises: Traditional Schemes
Traditional schemes for the management of back pain may be divided into four categories. As a group, they are herein termed GASS exercises: (1) general well-being augmentation, (2) aerobic exercises, (3) stretching exercises, and (4) strengthening exercises. Each is discussed in the following text. The exercise component has arguably been best typified by McKenzie exercises. 147 – 160 Proponents emphasize that they are best taught by trained therapists. 161 Spinal extension is emphasized as a mechanism to “centralize pain”; however, this may have significant biomechanical and anatomical limitations in many cases. 162 The importance of aerobic exercise in the overall scheme should not be over- 163 or underestimated. 164
General Well-Being Augmentation
Psychosocial factors, as well as the patient‘s gender and personality, affect mechanical loading of the spine 56 and obviously, in turn, affect back pain. They should be considered and modified when possible.
Smoking, as an aside, is a major risk factor for a negative outcome of the treatment of back pain by any means. 165 , 166 This should be carefully considered, and appropriate counseling and alterations in decision-making strategic planning should be undertaken for smokers. The negative effect of smoking, however, may have been underemphasized. Smoking plays a significant role in back pain. Smoking increases back and leg pain, and the cessation of smoking decreases back and leg pain. 167 However, smoking has been shown to be a weak risk factor regarding back pain. 4 This must be taken into consideration clinically.
Similarly, obesity is a risk factor for refractory back pain. This may be related to excessive and eccentric spinal loading and is relieved to some degree by weight loss. 168 – 171 Such excessive and abnormal loading may affect nutrient supply to the nucleus pulposus and accelerate the degenerative process, with a resultant augmentation of pain. 172
Weight loss decreases axial loading of the spine (Fig. 37.9a). Gained weight is predominantly located ventral to the C7 plumb line (see Chapter 27). As a result, the patient extends the spine to maintain sagittal balance (Fig. 37.9b, c). This may cause or exaggerate back pain (Fig. 37.9d). Weight gain has been shown to be weakly associated with back pain. 3
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