ALEXANDRIA, VA — A new review article published in the Journal of the American Academy of Orthopaedic Surgeons should help convince many patients with low back pain to consider physical therapy as a first line of treatment for their condition, according to the American Physical Therapy Association (APTA). The review, published in February 2009, recommends that in most cases of symptomatic lumbar degenerative disc disease, a common cause of low back pain (LBP), the most effective treatment is physical therapy combined with anti-inflammatory medications. Approximately 75 to 85 percent of adults will be affected by low back pain during their lifetimes.1

Symptomatic lumbar degenerative disc disease develops when a disc weakens (often due to repetitive strain), is injured, or deteriorates from aging. As a result, the disc is unable to hold the vertebrae as it should and the lack of stability can cause back pain.

The review details the different treatment methods for symptomatic lumbar degenerative disc disease, including physical therapy with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and concludes that, in most patients with low back pain, symptoms resolve without surgical intervention. The review also concludes that physical therapy and nonsteroidal anti-inflammatory drugs are the “cornerstones” of non-surgical treatment.

Physical therapist intervention includes strengthening of core muscle groups, including the abdominal wall and lumbar musculature, which can have positive effects in patients with this condition. According to APTA spokesperson Julie Fritz, PT, PhD, ATC, clinical outcomes research scientist at Salt Lake City’s Intermountain Healthcare and associate professor at the University of Utah, physical therapists have several treatment options that can help patients with LBP whether due to degenerative disc disease or a variety of other causes.

Exercise and manual therapy including spinal manipulation, have been shown to benefit many patients.2, 3. In addition, patient education to remain active and use appropriate body mechanics is beneficial. Physical therapists are trained to identify which of these treatment strategies will be most effective for an individual patient, which further improves the effectiveness of care.

In previous systematic reviews of the literature, it was found that exercise has been shown to improve function and decrease pain in adult patients with chronic LBP and that physical therapy was beneficial for the treatment of acute LBP.2, 3 In another systematic review, NSAIDs were found to provide LBP patients with short-term symptomatic relief.4

“Receiving care from a licensed physical therapist can further improve the odds that a patient can maintain their quality of life and avoid surgery,” said Fritz. In addition to building the core muscle groups, hands-on therapy to mobilize the spine has been shown to be particularly effective. 5, 6  “Spinal manipulation can be an important component of physical therapist treatment for low back pain. Supplementing exercise with spinal manipulation is also beneficial for many patients.”

Physical therapists can help patients develop a safe and effective exercise program that is tailored to an individual’s specific needs and goals. “Surgery should be the last option, but too often patients think of surgery as a cure all and are eager to embark on it,” said Luke Madigan, MD, an attending physician at Knoxville Orthopaedic Clinic, Knoxville, TN, and the lead author of the literature review.

Physical therapists are highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility – in many cases without expensive surgery or the side effects of prescription medications. APTA represents more than 70,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Its purpose is to improve the health and quality of life of individuals through the advancement of physical therapist practice. In most states, patients can make an appointment directly with a physical therapist, without a physician referral. Learn more about conditions physical therapists can treat and find a physical therapist in your area at www.moveforwardpt.com.

1Andersson GB: Epidemiological features of chronic low back pain. Lancet 1999; 354:581-585.

2Hayden JA, van Tulder MW, Malmivaara A, Koes BW: Exercise therapy for the treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335.

3Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG: Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev. 2004;(1):CD000447.

4vanTulder MW, Scholten RJ, Koes BW, Deyo RA: Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane collaboration back review group Cochrane review. Spine 2000:25:2501-2513.

5Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Maikowski GR, Delitto A: A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004; 141(12):920-928.

6Chou R, Huffman LH: Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.; American Pain Society; American College of Physicians; Ann Intern Med. 2007; 147(7):492-504.

[Last updated: 02/23/09 | Contact: public-relations@apta.org]

ScienceDaily (Jan. 7, 2009) — The novel design of a deep muscle along the spinal column called the multifidus muscle may in fact be key to spinal support and a healthy back, according to researchers at the University of California, San Diego School of Medicine.

Their findings about the potentially important “scaffolding” role of this poorly understood muscle has been published on line in advance of the January issue of the Journal of Bone and Joint Surgery.
“The multifidus muscle was formerly thought to be relatively unimportant based on its fairly small size,” said Richard L. Lieber, Ph.D., Professor and Vice Chair of UC San Diego’s Department of Orthopedic Surgery and Director of the National Center for Skeletal Muscle Rehabilitation Research, based at UC San Diego. Lieber is also Senior Research Career Scientist at the Veterans Affairs San Diego Health System. “Our research shows that it’s actually the strongest muscle in the back because of its unique design. It’s like a long, skinny pencil packed with millions of tiny fibers.”

The researchers discovered that the multifidus has a unique packing design consisting of short fibers arranged within rods, and that these fibers are stiffer than any other in the body. Using laser diffraction methods that they developed to measure muscle internal properties during back surgery, they demonstrated that the multifidus’ unique design serves a critical function as a stabilizer of the lumbar spine. These findings could have implications for surgery, according to Steven R. Garfin, M.D., Professor and Chair of UCSD’s Department of Orthopaedic Surgery.

“It is important to identify what each individual muscle does, and this is just a start, showing that the multifidus contributes significantly to spinal stabilization,” said Garfin. “The more we know about what muscles do, the better we can devise therapeutic interventions such as physical therapy to target specific muscles.”

Garfin explained that currently surgery to treat spinal disorders could actually disrupt the multifidus muscle, which could lead to decreased stabilization and lower back pain. Minimally invasive spine surgery techniques strive to minimize surgical trauma to these muscles in order to best preserve their function.

The lower back, or lumbar spine, can be vulnerable to many pain-causing injuries or disorders because the lumbar vertebrae carry the most body weight and are subject to the most force and stress along the spine. Muscular instability is a risk factor in many injuries and consequent chronic lower back pain, according to Lieber. “The multifidus back muscle keeps us vertical and takes pressure off the discs,” said Lieber. “When muscle function is poor due to back problems, support is lost.”

He explained that many muscles get weaker as they are extended. But the researchers discovered that, unlike all other muscles, the multifidus actually becomes stronger as it lengthens, when the spine flexes.
“The length of the sarcomere—the structure within the muscle cell where filaments overlap to produce the movements required for muscle contraction—is shorter in the multifidus than in any other muscle cell,” explained study’s first author Samuel R. Ward, P.T., Ph.D., Assistant Professor of Radiology at UC San Diego School of Medicine. “But as it gets longer, for instance as a person leans forward, the multifidus actually strengthens.”

Contributing authors to the study include UCSD researchers Choll W. Kim, M.D., Ph.D., Carolyn M. Eng, B.S., Lionel J. Gottschalk, B.S.; and Akhito Tomiya, M.D., Ph.D. Tohoku University School of Medicine, Sendai, Japan. Research was supported by the Department of Veterans Affairs Rehabilitation, Research and Development; the National Institutes of Health and DePuy Spine of Raynham, MA.
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Adapted from materials provided by University of California – San Diego, via EurekAlert!, a service of AAAS.

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A Physical Therapist’s Perspective:

This report should be of interest to any physcial therapist that treats low back conditions because it provides evidence of the role that the multifidus muscle plays in stabilization of the spine. Although, I have issue with the statement that “the multifidus muscle was formerly thought to be realtively unimportant based on it’s fairly small size”. Physical therapy researchers discovered over a decade ago the importance of the multifidus muscle in spine stability and its relation to low back pain. For this reason many physical therapists have advocated the importance of proper rehabilitation following any lumbar spine surgery that disrupts the multifidus muscle.  In addition, much of recurrent and chronic low back pain can be attributed to spinal instability. Thus, there has been much focus in the clinical field of physical therapy to perform exercises that retrain the multifidus in conjuciton with the transverse abdominus and pelvic floor muscles. To read more about the role of motor control exercises for spine related problems read this news release- Report Shows Motor Control Exercises Reduce Persistent Low Back Pain

Tamer S. Issa, PT, DPT, OCS

Tallahassee, Florida, October 20, 2008 – Neck pain is one of the top 10 reasons for a patient to visit a doctor. The lead article in the most recent issue Spine reports on the results of a randomized clinical trial which demonstrated that patients who received manual physical therapy and exercise had twice the improvement in symptoms compared to the current guideline group. The subjects in the study experienced both short and long term improvements in their neck pain. The study compared the use of manual therapy and exercise compared to the current guidelines of advice, rest, and range of motion. The results of this study are comparable to those reported by Hoving et al in 2002, which also demonstrated that manual physical therapy and exercise resulted in excellent clinical results in the treatment of neck pain while also providing a significant cost savings compared to usual physician care (Kothals-de Bos et al 2003). Manual physical therapy includes the use of hands-on techniques including joint and soft-tissue mobilization, designed to restore motion and reduce pain. Hurwitz et al (2008) concluded in a systematic review on neck pain also in the journal Spine, “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain.”

Tim Flynn, PT, PhD, president of the American Academy of Orthopaedic Manual Physical Therapy, expressed confidence that, “This study broadens the base and depth of evidence that manual physical therapy is the first line treatment for patients suffering from neck and arm pain.” He continued, “Year after year the physical therapy profession continues to produce high quality randomized, controlled trials that demonstrate conclusively that our profession provides better outcomes for less money, while also being substantially safer than other medical interventions. Wake up America, to a new day without pain.” If you have neck or back pain or the aches and pains of musculoskeletal problems contact your local physical therapist today.

Month-long Observation Focuses on the Importance of Physical Activity
for Adults and Children

ALEXANDRIA, VA, September 18, 2007 — For the nearly 100 million Americans who are overweight or obese, physical activity must be a crucial component to weight loss and better health, which is the focus of October’s National Physical Therapy Month, the American Physical Therapy Association (APTA) announced today.

According to a recent study conducted by the Trust for America’s Health, a research group that focuses on disease prevention, obesity rates continued their climb in 31 states last year. Health officials say the latest state rankings provide evidence that the nation has a public health crisis on its hands. Last year, The Centers for Disease Control and Prevention cited evidence that found that more than 22 percent of Americans did not engage in any physical activity in the previous month.

A lack of exercise is a major contributing factor to obesity rates. “People who are overweight or obese must follow an appropriate exercise program that includes aerobic conditioning and avoids exercise that can lead to injury,” notes Terry Michel, PT, DPT, DSc, CCS, a physical therapist at Boston’s Mass General Hospital. “Physical therapists will typically recommend a low-impact form of weight training, such as exercise bands that help avoid excessive joint stress, and modified yoga stretches and Tai Chi for promoting flexibility and relaxation,” she adds.

Physical therapists develop fitness plans for both adults and children that promote the ability to move, reduce pain, restore function, and prevent disability. For those who are overweight or obese, physical therapists balance the progression of the exercise prescription with the need for joint protection and safety during exercise.

“We are no longer looking at just adults who have diseases resulting from obesity,” says physical therapist Susan S Deusinger, PhD, professor and director of the Program in Physical Therapy at Washington University School of Medicine. “Rather, physical therapists need to regard obesity as a primary concern for intervention,” she adds. Previous research** conducted by Dr Deusinger confirmed recent rising health concerns on college campuses. Her study of 300 undergrads at Washington University in St Louis found that 70 percent of the students had gained an average of 9 pounds between their freshman and sophomore years, and most were still not meeting recommended guidelines for healthy eating and exercise behavior.

“To say the least, the results of this study are cause for concern,” notes Deusinger. “People are dying from the effects of obesity, and it’s not just our parents and grandparents anymore; it’s our friends, siblings, and colleagues. No one is immune from the dual epidemics of obesity and sedentary behaviour.”

Connie Cushing, PT, MS, a 17-year-veteran physical therapist at Children’s Hospital in Birmingham, Alabama, is a member of a practice team that focuses on overweight and obese children and teens at the Hospital’s Center for Weight Management. Along with a psychologist, physician, nurse practitioner and nutritionist, Cushing evaluates each child individually (both before they enter and leave the Center). As a result, Cushing can determine whether the patient is at risk for joint and musculoskeletal problems, as well as implement what the collective team learns regarding other commonly seen issues such as diabetes or asthma. “Patients often have multiple, pre-existing medical conditions that can affect their ability to exercise and what specific exercises they are capable of doing,” notes Cushing.

“For the younger children at the Center we recommend restricting television viewing and video game playing and encourage family games that can be played both indoors and outdoors at home,” says Cushing. “It becomes a bit more complicated with teens, as we need to factor in what their interests are, both in and out of school; if they work better in groups or individually; and if they prefer being outdoors or indoors. Based on their profile, we determine a list of goals and the best ways to achieve those goals. We’ve also found that having teens keep daily logs of their physical activity provides great incentive.” She adds, “The goal of the Center is not solely weight loss. Our ultimate goal is for these kids to make lifestyle changes. Yes, we want them to lose weight, but we also want them to eat better, sleep better, and to feel better physically and emotionally.”

Consumers can find information about the fight against obesity and about National Physical Therapy Month, whose theme is “Physical Therapy: The Science of Healing. The Art of Caring,” by visiting APTA’s Consumer Web page at www.apta.org/consumer.

Physical therapists are health care professionals who diagnose and treat individuals of all ages, from newborns to the elderly, who have medical problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives. PTs examine each individual and develop a plan of care using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability. Physical therapists also work with individuals to prevent the loss of mobility by developing fitness- and wellness-oriented programs for healthier and more active lifestyles.

The American Physical Therapy Association (www.apta.org) is a national organization representing 70,000 physical therapists, physical therapist assistants, and students nationwide. Its goal is to foster advancements in physical therapist education, practice, and research. Consumers can access “Find a PT” to find a physical therapist in their area, as well as physical therapy news and information at www.apta.org/consumer.
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** Racette SB, Deusinger SS, Strube MJ, Highstein GR, Deusinger RH. “Weight Changes, Exercise and Dietary Patterns During Freshman and Sophomore Years of College.” Journal of American College Health, vol. 53 (6); pp. 245-251, May/June 2005.

Most everyone has heard the saying “no pain, no gain” when it comes to exercise. This may be true in terms of a healthy individual and when it refers to the muscle burn sensation that accompanies exercise. It may also be true in terms of the two days of soreness that follows the start or progression of a strengthening exercise program, or that follows the performance of an activity that has not been performed in a while. This soreness is better known as “delayed-onset muscle soreness” and is a normal part of the adaptation process of muscle breakdown.

“No pain, no gain” is not true when one has been injured. When one is recovering from an injury it is not wise to exercise with pain. When one is performing their rehabilitation program, one should only exercise in a pain-free range. If there is always a bit of pain present, as it is true after an injury or surgery, then you should never do exercise that creates more pain or increases your pain response. The increase of pain perception is the body’s way of letting you know you are overdoing things and that some tissues are not able to handle the stress that is put on them. The soft tissues (tendons, ligaments, muscles, and fascia) involved become weak and over-stressed.

Pain is a subjective feeling that we all have experienced at one time or another. We expect that we are going to experience pain after an injury or trauma. However, if there is no presence of pain during exercise we may think that there is nothing to worry about. This may not always be the case. Pain during exercise is the body’s way of telling us whether we are exercising too hard or overstressing our bodies. But just because pain is not present, does not mean that we may not be doing harm. For instance, a sedentary or deconditioned individual may not experience a pain response during exercise. However, then one day they find they have back pain or neck pain due to a lack of muscle endurance or some other musculoskeletal problem. For this reason, many people move into pain patterns without any apparent reason or trauma.

In summary, exercise should be performed without any increase in pain. Therapeutic exercise is utilized to promote healing, increase metabolism, and introduce gentle controlled loads so that the soft tissues can adapt to normal forces. Periodic maintenance through exercise can prevent non-traumatic pain patterns from occurring. It is important to give plenty of feedback to your physical therapist or other health professional so he or she can monitor and make any adjustments to your exercise program.