Rehabilitation and Interventions in Management of Spinal Disorders

Summary of Key Points

Exercise is important for the prevention of back pain and recurrent episodes.
Acute low back pain is common and has an excellent short-term prognosis, which should be explained to patients.
Serious causes of low back pain (i.e., cancer, infection, fracture, spondylitis) are uncommon (affecting <5% of patients with back pain).
Imaging is not indicated in patients with acute back pain in the absence of clinical red flags.
Psychosocial risk factors (yellow flags) are predictors of prolonged recovery and disability. Patients with positive yellow flags should be considered for early multidisciplinary rehab, including physical and psychological therapies.
Chronic low back pain in the absence of clear underlying structural pathology may be related to central pain–processing abnormalities (“central sensitization”).
For acute back pain, discourage bed rest and encourage physical activity and early return to work.
Nonpharmacological options, including superficial heat, manipulation, massage, and acupuncture, should be used before or in combination with pharmacological options.
Exercise therapy may be considered in the subacute stage and is definitely recommended as the primary treatment in the chronic stage, with consideration for multidisciplinary rehabilitation.

Back pain is common and costly. It was the most frequent type of pain reported by US respondents in the 2002 National Health Information Survey, whereas neck pain ranked third, with 13.8% of persons reporting at least a 1-day episode. According to 2013 Centers for Disease Control and Prevention data, 29% of Americans have experienced back pain within the last 3 months. Back pain ranks in the top five reasons for visits to primary care physicians in the United States, accounting for more than 57 million office visits per year in 2013, of which more than 45 million were for low back pain and more than 15 million were for neck pain. ^, Up to 71% of the adult population may experience a significant episode of neck pain in their lifetimes, and up to 80% for back pain. ^, Approximately 2% of the US workforce sustains a compensable back injury each year. The direct cost of healthcare attributed for low back and neck pain is estimated at $87.6 billion annually in the United States, with indirect costs of back pain, including lost wages and reduced productivity, exceeding $100 billion annually. ^,

An appreciation of the benign short-term prognosis of acute nonradicular low back pain is fundamental to the management of these patients. Most patients with nonradicular low back pain experience rapid improvement within 1 month, whereas 50% of patients with radiating low back pain will recover spontaneously within 6 weeks. ^, More than 90% of patients have returned to work by 3 months. However, about one-fourth of patients have persistent symptoms at 3 months, and about 20% have substantial limitations of activity at 1 year. ^, Clearly, an important objective of medical treatment should be to reduce the likelihood of progression from acute symptoms to chronic pain and functional impairment. The primary determinants of persistent disability at 12 months are psychosocial in nature. ^, In fact, psychosocial variables have been shown to be superior to structural findings or discography as predictors of both long- and short-term disability, duration of symptoms, and healthcare visits for back pain. High levels of psychological distress, depressive mood, and somatization are well established as risk factors for transition from acute back pain to chronicity. ^, Coping style, particularly “fear avoidance,” has been shown to portend a poor prognosis in patients with subacute low back pain. Failure to recognize these psychosocial issues in patients with low back pain will frustrate even the most well-conceived medical management strategy.

Etiology of Back and Neck Pain

The specific anatomic etiology of nonradicular spinal pain is often ambiguous. Up to 85% of patients have pain that cannot be assigned to a particular pain generator. “Abnormal” findings on plain radiographs, including spondylolysis, spondylolisthesis, facet joint degenerative changes, Schmorl nodes, and mild scoliosis, are common in asymptomatic persons. Radiography of the lumbar spine in patients with back pain of at least 6 weeks duration (mean 10 weeks) has been shown to increase patient satisfaction without any improvement in functional outcome or severity of pain. The addition of lateral dynamic flexion-extension radiographs to the initial evaluation of patients with low back pain rarely provides information that alters clinical management, at the expense of significant additional cost and radiation exposure. Disc abnormalities are found on magnetic resonance imaging (MRI) in more than 50% of asymptomatic persons by age 40 years and include degenerative disc bulging and protrusions, as well as Schmorl nodes. The lack of specificity of clinical symptoms and signs for the multiple potential sources of spinal pain—ligaments, facet joints, discs, paravertebral musculature—confounds the attempt to attribute symptoms to radiographic findings. In some patients previously categorized as having nonspecific pain, interventional diagnostic techniques, including discography, facet joint medial branch block or injection, and sacroiliac joint injection, may suggest a specific pathoanatomic etiology. However, these studies have high false-positive rates, particularly in patients with psychosocial issues, and fail to reliably predict the success of specific surgical or interventional treatments. Chronic low back pain, particularly in the absence of any underlying structural pathology, has been described as residing more in the central nervous system (CNS) than in the musculoskeletal system. This concept implies that an alteration in the CNS occurs in some patients with back pain (central sensitization), resulting in abnormal activation of pain processing centers, and persistent pain despite the absence or resolution of the inciting event. ^,

Cancer and infection are serious, but fortunately uncommon, specific causes of back pain found in 0.7% and 0.01%, respectively, of patients presenting in a primary care setting. Ankylosing spondylitis is identified in about 0.3% of patients with low back pain, typically younger men. Acute or subacute vertebral compression fractures are identified in about 4% of patients. A variety of nonspinal conditions may present with symptoms that mimic spine disorders. These include common musculoskeletal problems, such as greater trochanteric bursitis and osteoarthritis of the hip, as well as visceral problems, such as kidney stones, aortic aneurysms, and peptic ulcers.

The American College of Physicians (ACP) and American Pain Society’s 2007 evidence-based clinical practice guideline for the management of back pain suggests a focused history and physical examination should permit placement of patients with back pain into one of three broad categories: nonspecific low back pain, back pain with radicular symptoms, including lumbar spinal stenosis, and back pain associated with another specific spinal cause. Diagnostic imaging is recommended only when a serious etiology (such as cancer, infection, fracture) is suspected or when surgical or other interventional treatment is imminent ( Box 72.1 ). In 2017 the ACP released a new guideline for the noninvasive treatment of low back pain. The new guidelines place a higher emphasis on the use of nonpharmacological treatment and provide a summary of the quality of evidence for each of these treatments ( Box 72.2 ).

Box 72.1

American College of Physicians and the American Pain Society: Recommendations for the Evaluation of Low Back Pain

Recommendation 1: Conduct a focused history and physical examination to assign patients into one of three categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spine cause. Evaluate for psychosocial risk factors that predict risk for chronic, disabling low back pain.
Recommendation 2: Imaging or other diagnostic tests should not be obtained routinely in patients with nonspecific low back pain.
Recommendation 3: Perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurological deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination.
Recommendation 4: Evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection.

Box 72.2

American College of Physicians: Recommendations for the Treatment of Low Back Pain

Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacological treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacological treatment is desired, clinicians and patients should select nonsteroidal antiinflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).
Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacological treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).
Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacological therapy, clinicians and patients should consider pharmacological treatment with nonsteroidal antiinflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).

Medical Treatment Options

Prevention

A metaanalysis published in 2018 found that exercise alone reduced the risk of low back pain by 33%, and exercise combined with education reduced the risk by 27%. It was also found that exercise decreased the severity of low back pain, as well as the disability associated with low back pain. A routine that combines strengthening with stretching or aerobic exercise two to three times per week could be helpful in preventing low back pain. No other method of low back pain prevention was found to be effective, including workplace modifications, shoe insoles, lumbar supports, stress management, and reduced lifting programs. ^, Smoking has been linked to a higher prevalence of low back pain, greater pain severity, and increased risk of transitioning to chronic back pain, therefore smoking cessation or avoidance may be another useful strategy to prevent back pain. Because obesity has also been associated with increased severity of back symptoms, weight loss could be another effective tool for preventing and reducing back pain.

Initial Management

The management of nonspecific low back pain can be guided by stratifying patients either by duration (acute, subacute, chronic) or by risk of poor clinical outcome. Examples of risk stratification tools include the Keele STarT Back Screening tool, Orebro Musculoskeletal Pain Questionnaire, and PICKUP. Current major clinical guidelines are in agreement on initial management of patients categorized as acute/subacute and low risk. These patients should be counseled and reassured regarding the favorable course of low back pain. Patients should be recommended to avoid bed rest and encouraged to continue daily activities, remain physically active, and return to work as soon as possible. Upon review of progress after 2 weeks, if further treatment is necessary, current guidelines support starting with nonpharmacological treatments, such as superficial heat, massage, manual therapy/spinal manipulation, and acupuncture. For patients that are not adequately responding, pharmacological treatment can then be considered, favoring nonsteroidal antiinflammatory drugs (NSAIDs) as first-line treatment.

Exercise and Physical Therapy

Clinical guidelines recognize exercise and physical therapy as useful treatments for back pain; however, there are varying suggestions amongst the different guidelines in regard to when exercise or physical therapy should be initiated. Self-management is generally recommended early on, which can include self-directed exercise as tolerated. The ACP guidelines do not specifically recommend any exercise during the acute/subacute phase. Meanwhile, guidelines from Canada suggest that therapeutic exercise could be beneficial based on clinical experience, and UK and Belgian guidelines support the combination of exercise with manual or psychological therapies. ^, Those patients identified as medium- or high-risk using a risk stratification tool should be referred early for formal physical therapy and considered for multidisciplinary treatment, including physical and psychological therapies. Individual and group therapies may be used. All major guidelines recommend exercise therapy as the cornerstone treatment in the chronic stage of back pain. Guidelines evaluating numerous studies, including head-to-head trials comparing various types of exercise, have been unable to declare any one form of exercise as superior. Instead, various forms of exercise have been recommended. ^,

A program consisting of aerobic exercise combined with stretching and strengthening exercises can be useful for the prevention of back pain, and can also be used as self-management or structured rehab during an episode of back pain. ^, There has not been sufficient evidence to support aerobic exercise alone as treatment for low back pain, with or without radicular pain. Evidence does support the use of group exercise consisting of biomechanical and aerobic components, and has shown clinical benefit for short- and long-term pain and function. Aerobic exercise could improve psychological functioning in patients with chronic low back pain, based on observed decreases in scores on the Hospital Anxiety and Depression Scale. ^,

Compared with minimal intervention, motor control exercise (stabilization) was found to decrease pain and improve function for short- and long-term chronic low back pain (low-quality evidence). ^, Motor control exercise also led to a small decrease in pain intensity compared with general exercise at short- and intermediate-term follow-up (low-quality evidence). ^, Evidence suggests the superiority of neck stabilization exercises, with some advantages in pain and disability outcomes, compared with isometric and stretching exercises in combination with physical therapy agents (transcutaneous electrical nerve stimulation, continuous ultrasonography, and infrared irradiation) for the management of neck pain.

Pilates focuses on controlled movement, posture, breathing, and core strengthening. A systematic review of Pilates for chronic low back pain found a small effect on pain versus usual care plus physical activity, but no clear difference versus other types of exercise for pain and function. Another systematic review determined that Pilates can be useful as a rehab tool for reducing pain and disability in a variety of conditions, including low back pain.

Yoga represents a mind-body exercise intervention that addresses both the physical and mental aspects of pain with core strengthening, flexibility, posture, breathing, and relaxation. There are multiple forms of yoga that vary based on posture, technique, and emphasis on meditation. A systematic review suggested a slight functional improvement, slight reduction in pain, and heightened chance of clinical improvement for chronic low back pain. Tai chi is another mind-body exercise, and also a martial art, that focuses on slow, controlled movements, breathing, and meditation. Studies have shown tai chi to produce moderate improvement in pain compared with waitlist or no tai chi, and small improvement in function. ^, ^,

The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is a unique and comprehensive approach to neck or low back pain that includes both assessment and intervention. The assessment is designed to detect a directional preference, which refers to a particular direction of movement or sustained posture that causes symptoms to centralize, decrease, or be abolished. Centralization is defined as the sequential and lasting abolition of all distal referred symptoms and subsequent abolition of any remaining spinal pain in response to a single direction of repeated movements or sustained postures. The finding of centralization has positive prognostic value, provided treatment is guided by assessment findings. Pain that does not centralize is a strong predictor of poor prognosis and correlates well with “nonorganic” signs. A 2018 metaanalysis found that MDT was not superior to other rehabilitation options (spinal manipulative thrusts, lumbar range of motion exercise, joint mobilizations, and first-line care) for acute low back pain in regards to pain and disability. For chronic low back pain, however, MDT was superior to exercise or education alone for improvements in pain and disability, although the effect size was small to moderate. Data comparing MDT with combined manual therapy plus exercise was more variable, and therefore unable to determine superiority.

Therapeutic aquatic exercise in warm water is potentially beneficial to patients suffering from chronic low back pain and pregnancy-related low back pain. Patients with barriers to land-based programs, including lower extremity joint disorders and obesity, are often able to exercise actively in the pool. Canadian guidelines now recommend aquatic exercise for chronic low back pain. Deep-water running was shown by one study to reduce both short- and long-term pain intensity in low back pain without sciatica.

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