Student Number: 10022375

MMR: UZYSF6-40-2

Discuss the use of exercise in the therapeutic management of low back pain In order to discuss the use of exercise in the therapeutic management of low back pain (LBP) it is important to define exercise and understand LBP including the different theories surrounding pain. The International Association for the Study of Pain (IASP) defined pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. This definition incorporates the idea that the nature of pain is multidimensional, including psychosocial aspects as well as the physiological aspects. It steers away from the idea that pain is associated with an external stimulus alone. Non-specific low back pain (NSLBP) can be defined as back pain in the lumbar region resulting from mechanical origin which is usually present between the ages of 20-55 years (Waddell, 2004). It can be caused by a number of structures such as the discs, muscles, joints, tendons and ligament but is not related to serious pathology, fracture or an inflammatory disorder (NICE, 2009). Pain is described as being chronic when it has been present for 12 weeks or more and there is not an underlying pathology (APA, 2002), before this stage it is said to be acute. When pain becomes chronic, the effectiveness of the neuromatrix is strengthened due to the decrease in the activation threshold of peripheral nociceptors (peripheral sensitisation), and other sensory feedback mechanisms, resulting in less input being required to produce pain (Moseley, 2003). During this essay the Pain Gate Theory (PGT), body self neuromatrix theory and the Biopsychosocial theory will be explained and linked to various studies that look into different types of exercise in the treatment of patients with non-specific chronic lower back pain (NSCLBP); focussing mainly on the clinical reasoning behind using extension, strengthening and general fitness exercises. It is thought that 75-80% of adults experience LBP at some point in their lives and that 2-3% will develop disabling chronic LBP (Lewis, 2008). LBP is a major health issue with a high prevalence rate; this causes a huge financial burden on the NHS (Frost, 1998).

Student Number: 10022375

MMR: UZYSF6-40-2

In 1965 Melzack and Wall established the Pain Gate Theory (PGT) which has important implications for the management of pain in physiotherapy (Bovell et al, 1996). A-delta and C-fibres are small afferent fibres that detect noxious stimuli; they synapse with transmission cells in the substantia gelatinosa (SG) within the dorsal horn of the spinal cord which acts as a gateway. A-delta nerve fibres carry fast pain messages, whereas C-fibres carry slow or continuous pain messages. The transmission cells are either associated with spinal reflexes or link to higher centres of the central nervous system via spinothalamic tracts. A-delta and C-fibres have an excitatory effect on the pain gateway thus allowing the pain-gate to remain open and for the information to travel to the thalamus and hypothalamus and be processed by the brain. As well as receiving excitatory input from the A-delta and C-fibres the pain-gate also receives inhibitory input from sensory neurones which carry information such as touch, pressure and temperature via large diameter (A-beta) nerve fibres. This causes the pain-gate to close and in turn modulates pain. The PGT sees the brain as an active system that is able to modulate inputs however it does not take into account brain function (Melzack, 1999). The PGT lead onto extensive research and lead to a new concept: the pain neuromatrix. Moseley (2003) described the neuromatrix as being a multidimensional experience that is produced through activation of an individuals specific cortical pain neuromatrix. The neuromatrix approach includes various dimensions or inputs including cognitive-evaluative: for example, an individuals expectations, beliefs, attitudes and past experience; sensory-discriminative: including location, intensity and the duration of pain; affectivemotivational: an individuals thoughts, anxiety and stress levels. The neuromatrix receives input from all these dimensions and creates specific output patterns in relation to these inputs which are stored within the brain, hence creating individual reactions (Grieve, 2012). In addition to the above theories Engel (1977) produced the Biopsychosocial model which interlinked biological, psychological and sociological areas of health; from disease to wellbeing, and recognises that psychosocial factors have a large impact on health and rehabilitation.
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Student Number: 10022375

MMR: UZYSF6-40-2

The above theories can be linked with various studies looking at exercise in the therapeutic management of LBP. Exercise is defined as a subset of physical activity that is planned, structured, and repetitive and has a final or an intermediate objective of the improvement or maintenance of physical fitness (Caspersen et al., 1985). The first two studies discuss the use of the hands off McKenzie approach to LBP along with a strengthening approach. McKenzie is a classification system of mechanical spinal pain and the treatment is based on repeated spinal movements. It is an overall management approach and encourages the patient to take responsibility for their own problem and be able to manage it independently. McKenzie classifies back pain into three main syndromes: postural, dysfunction and derangement. Treatment principles for derangement include repeated movements to try and reduce derangement. This part of the approach is not strictly non-specific as the patient concerned may have been diagnosed with a disc problem; however the repeated movements may be used originally when the pain is non-specific. For dysfunction, exercise is used to recover function and postural advice is given to treat postural syndrome (Phillips, 2012). Petersen et al. (2002) conducted a randomised controlled trial assessing the effects of intensive dynamic strengthening training compared to McKenzies treatment approach in patients with subacute or chronic low back pain. The study consisted of 260 patients between the ages of 18 and 60 years old. Patients were split randomly in two groups. The McKenzie intervention consisted of self mobilising, repeated movements or sustained positions performed in specific directions of movement, with application of overpressure and or mobilisation by the therapist. The strengthening group included a warm up, low resistance trunkal exercises and intense dynamic back strengthening. The intervention for both groups consisted of up to 15 treatments over 8 weeks at a clinic followed by 2 months at home. Data was recorded at the end of treatment, 2 months after treatment and then 8 months after treatment. 30% of patients from each group withdrew before the follow up evaluation; reasons for this were stated in the study. The intention to
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Student Number: 10022375

MMR: UZYSF6-40-2

treat analysis which included all patients showed a reduction in disability in favour of the McKenzie group at the 2-month follow up but there was no difference recorded at the 8 month follow up. The supplementary analysis on the other hand showed no difference between the groups in regards to disability but found at 2 months a difference again in favour of McKenzie in the reduction of pain. At 8 months however there was no difference. The limitations of this study include the loss of participants between the intervention and the follow up; this reduced the validity of the study and could have affected the results. This was recognised by the authors who produced relevant power calculations to ensure the remaining participants would be a sufficient sample size to represent the general population. Intention to treat analysis was included in order to try and reduce bias. Although they had a randomisation procedure in place some baseline characteristics were unequally distributed possibly resulting in reduced reliability, this point was highlighted in the study and an analysis was completed to rule out the possibility that these differences would not contribute to the results. There was no untreated control group; this could have led to bias in the study however this was addressed to the best of the authors ability, by controlling contact time and using therapists that were dedicated to their method of treatment. The outcome of the study suggested the need for a classification system for patients with non-specific LBP and the need for further investigation into the use of the McKenzie approach with CNSLBP patients. A similar study to the above was completed by Browder et al. in 2007. Browder et al. conducted a randomised clinical trial to determine the efficacy of an extension orientated treatment approach (EOTA) in a subgroup of patients with LBP (who were thought to benefit from the program) in comparison to similar individuals who received a lumbar spine strengthening program. The study consisted of 48 subjects: 26 were assigned to the EOTA group and 22 were placed into the strengthening exercise program. The EOTA group received exercises and mobilisation to promote extension of the lumbar spine with the aim of centralising the patients symptoms (in which distal pain is reduced and moves more proximally); whereas the strengthening group were given
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Student Number: 10022375

MMR: UZYSF6-40-2

exercises that targeted strengthening of the deep abdominal muscles and the stabilisers of the spine. The participants attended 8 therapy sessions and completed a home exercise program. Data from the study was collected at 1 week, 4 weeks and 6 months. The primary outcome measures used were disability and pain. Participants needed to be between the ages of 18-60 years and have the presence of the centralisation phenomenon with extension exercises. After the first week and at the 6 month follow up, the EOTA group showed greater improvements in disability than the other group. The EOTA group also showed an improvement in pain however this was seen only at the 1-week follow up. The results of the study however did support the theory that patients who centralise their pain with extension may benefit more from EOTA (McKenzie, 1989). Internal validity was ensured in the initial assessment as the physiotherapists were unaware of the participants group selection. In the re-assessment, although the physiotherapists were sometimes aware of the participants grouping it remained valid as the reassessment was carried out using self reporting questionnaires with no influence from the assessor. Reasons for non participation were given. The study has a few limitations; it was conducted within a military setting with 30 military participants and 18 civilian participants, thus it may be difficult to generalise the results to the general public making the study bias toward military personnel. Also at the 6 month follow up only 73% of the strengthening group and 58% of the EOTA group were able to be contacted, this was partly due to extended deployment. This loss of data in the EOTA group may have lead to an exaggeration of differences between the 2 groups, and therefore reducing the validity of the results. Also in terms of this discussion participants were not specifically chronic and could enter the study at any point of the healing process so the results were not entirely specific to CNSLBP. The study has provided preliminary evidence that suggests EOTA is a more effective treatment than strengthening for patients, within the subgroup demonstrating centralisation with extension movements. The literature linking chronic LBP and McKenzie is limited; to further validate this evidence, more randomised controlled trials with wider

Student Number: 10022375

MMR: UZYSF6-40-2

inclusion criteria, based in different setting could be undertaken. A systematic review by Machado in 2006 suggested that the McKenzie method is more effective for acute LBP patients.

The reduction in pain found in the above studies may be explained and linked back to pain theories. When the mechanical structures in the spine become injured or inflamed, the large back muscles can spasm and cause LBP and reduced range of movement (ROM). Chronic LBP can lead to avoidance of using the muscles and in turn result in muscle atrophy, weakness and increased back pain due to the lack of stabilisation. Chronic stress linked in with the biopsychosocial model can also lead to muscle weakness and back pain. Stress can cause back muscles to tighten in a fight or flight response this wastes energy and reduces ROM causing pain. Strengthening exercises and extension exercises can reduce this effect through strengthening stabilisation muscles and reducing tension in tight muscles hence making them both effective in the treatment of LBP (Ullrich, 2009).

The third study to be discussed takes a different approach to treating low back pain and combines a back school programme with a fitness program plus the back school alone. Frost et al. (1995) conducted a single blind randomised controlled trial aimed at addressing the hypothesis that patients with chronic LBP attending a supervised fitness programme was more effective than a home exercise programme in reducing functional disability, decreasing pain, providing empowerment, increasing confidence, and increasing endurance. Participants had had LBP for at least 6 months and were between the ages of 18-55 years. The participants were then randomly allocated into 2 separate groups: the back school program or the back school and fitness program. Assessments were carried out by a single blinded examiner before and after treatment, the participants were also re assessed at 6 months via a postal questionnaire. The back school intervention included discussions around the patients problem, education, advice regarding functional activities and exercise, relaxation techniques, ergonomical advice, preventative advice and practical workshops. The fitness program on the other hand included stretches, a circuit of 15
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Student Number: 10022375

MMR: UZYSF6-40-2

progressive exercises, a warm up and a cool down period. Outcome measures used included various questionnaires, pain diaries and the shuttle walking test. A total of 81 patients agreed to participate; 5 people from each group dropped out for reasons not stated in the study. 3 pain diaries in each group were missing in the final analysis and the fitness sessions had an overall attendance percentage of 86%. There was also an 86% response rate to the 6 month follow up questionnaire, however after the second assessment 12 patients from the control group crossed over into the fitness group. Notable differences were found between the groups before and after intervention in disability, pain, self efficacy, functional ability and walking distance. Differences between the 2 groups surrounding general health were not significant but both groups did notice an improvement in their general health. Those patients that moved from the control group after the second assessment noticed reduced disability at the 6 month follow up. The study gained ethical approval from the Central Oxford Research Ethics Committee. The validity of some of the questionnaires used is hard to judge, however the general health questionnaire was a well validated study. After having patients cross over from the control group after the second assessment this limits the validity of the long term follow up. Reasons for participants withdrawal was not clarified this again could cause problems with the validity of the study. The study is relatively old in comparison to the other studies discussed and I have taken this into account when reviewing the results. The implications of this study suggest that back care alone is not recommended to reduce pain and disability and restore patients confidence. As cost effectiveness is important (Swinkels et al., 2009) the study also shows a way of managing people in groups which can be beneficial to the individual and cheaper than one to one treatments. Aerobic exercise has been found to increase the level of endorphins in the body (De Coverley Veale, 1987). Pert (1979) found that endorphins in the body may induce analgesia by inhibiting the transmission of pain and preventing the pain information from gaining access to the limbic structures within the brain that modulate the motivational and long term aspects of the overall pain experience. This may explain the reduction in pain for those taking part in aerobic exercise in Frost
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Student Number: 10022375

MMR: UZYSF6-40-2

et al.s study and also connects the findings to the PGT in that the endorphins have an inhibitory effect on the pain-gate. This supports the neuromatrix theory as you are changing the affectivemotivational inputs into the brain hence changing the specific neuromatrix patterns already imbedded within the brain and associating exercise with positive feelings. Pain relief, increasing function and preventing reoccurrence should be paramount to clinicians when treating low back pain (Waddell 2004). Petersen et al., Browder et al. and Frost et al. all found positive correlation between the therapeutic effects of exercise and LBP but the differences between which exercise is more effective is still not clear. There is a limited amount of randomised controlled trials surrounding CNSLBP as it is difficult to classify. As Petersen et al. found further studies need to be completed to look into the classification of LBP before it is possible to conclude which exercise is more effective for different subgroups. The studies highlight the importance of clinical reasoning and making informed decisions based on appropriate information to formulate treatment plans suitable for the individual patient considering them holistically.

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References Australian Physiotherapy Association (APA). (2002) Low Back Pain Position Statement: Summary Produced by Musculoskeletal Physiotherapy Australia. Available from: http://www.nephysio.com.au/downloads/doctors_resources/APA%20Position%20Statement%20on %20LBP%20%2020051023.pdf [Accessed 23 February 2012]. Bovell, D., Nimmo, M. and Wood, L. (1996) Principles of Physiology: A Scientific Foundation of Physiotherapy. London: WB Saunders Company Ltd. Browder, D.A., Childs, J.D., Cleland, J.A. and Fritz, J.M. (2007) Effectiveness of an ExtensionOrientated Treatment Approach in a Subgroup of Subjects With Low Back Pain: A Randomized Clinical Trial. Physical Therapy. 87(12), pp. 1608-1618. Caspersen, C.J., Powell, K.E. and Christenson, G.M. (1985) Physical activity, exercise, and physical fitness: definitions and distinctions for health related research. Public Health Reports [online]. 100(2), pp.126-131. Available from: www.ncbi.nlm.nih.gov/pmc/articles/PMC1424733/. [Accessed 23 February 2012]. De Coverley-Veale, D.M.W. (1987) Exercise and Mental Health. Academic Department of Psychiatry. 76, pp. 113-120. Available from: veale.co.uk [Accessed 23 February 2012]. Engel, G.L. (1977) The need for a new medical model: a challenge for biomedicine. Science. 169(4286), pp. 129-136. Available from: http://faculty.weber.edu/eamsel/classes/adolescent%20risk%20taking/Lectures/5%20Bio%20Psyc ho%20Social%20Model/Biomedicine.PDF [Accessed 23 February 2012]. Frost, H., Klaber Moffett, J.A., Fairbank, J.C.T. and Moser, J.S. (1995) Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. British Medical Journal [online]. 310(151). Available from: http://www.bmj.com/content/310/6973/151.abstract. [Accessed 10 February 2012]. Grieve, R. (2012) Pain A Brain Response to Perceived Danger. Musculoskeletal management and rehabilitation [online] Available from: https://blackboard.uwe.ac.uk/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2Fweba pps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_200420_1%26url% 3D. [Accessed 12 February 2012].
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MMR: UZYSF6-40-2

Lewis, A., Morris, M.E. and Walsh, C. (2008) Are physiotherapy exercises effective in reducing chronic low back pain? Physical Therapy Reviews. 13(1), pp. 37-43. Machado, L.A.C., von Sperling de Souza, M., Ferreira, P.H. and Ferreira, M.L. (2006) The McKenzie Method for Low Back Pain A Systematic Review of the Literature With a MetaAnalysis Approach. SPINE. 31(9), pp. 254-262. McKenzie, R.A. (1989) The Lumbar Spine: Mechanical Diagnosis and Therapy. New Zealand: Spinal Publications Ltd Melzack, R. (1999) From the gate to the neuromatrix. PAIN. 6, pp. 121-126. Melzack, R. and Wall, P.D. (1965) Pain Mechanisms: A New Theory. Science. 150, pp. 171-179. Mosely, G.L. (2003) A pain neuromatrix approach to patients with chronic pain. Manual Therapy. 8(3), pp. 130 140. National Institute for Health and Clinical Excellence (NICE) (2009) Understanding NICE guidance: Early management of persistent non-specific low back pain [online]. London: National Institute for Health and Clinical Excellence. Available from: http://www.nice.org.uk/nicemedia/live/11887/44346/44346.pdf [Accessed 20 February 2012]. Peterson, L. And Renstrom, P. (2001) Sports Injuries: Their Prevention and Treatment. 3rd Edition. London: Martin Dunitz Ltd. Pert, A. (1979) Role of Endorphins in pain modulation. Ann Intern Med. 91, pp. 244-246. Available from: www.jospt.org/members/getfile.asp?id=5001. [Accessed 23 February 2012]. Peterson, T., Kryger, P., Ekdahl, C., Olsen, S. And Jacobsen, S. (2002) The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: A Randomized Controlled Trial. Spine [online]. 27(16), pp. 1702-1709. Available from: http://ovid sp.uk.ovid.com/sp-3.5.1a/ovidweb.cgi [Accessed 21 February 2012]. Phillips, S. (2012) Hands off. Musculoskeletal management and rehabilitation [online] Available from: https://blackboard.uwe.ac.uk/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2Fweba pps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_200420_1%26url% 3D. [Accessed 23 February 2012].
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The International Association for the Study of Pain (2011) Working together for pain relief: IASP Taxonomy. Available from: http://www.iasppain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/default.htm [Accessed 23 February 2012]. Ullrich, P.F. (2009) Spine-Health Back Muscles and Low Back Pain. Available from: http://www.spine-health.com/conditions/spine-anatomy/back-muscles-and-low-back-pain. [Accessed 23 February 2012]. Waddell, G. (2004) The back pain revolution. Edinburgh: Churchill Livingstone.

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