Functional Optimization/Quota Based Exercise for Lumbar Diagnoses Alison Stout DO Fellowship Director Evergreen Healthcare Kirkland, WA

Disclosures 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 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) – 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) – 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 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: , 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 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; Purpose: To compare efficacies of 2 active therapies for CLBP 286 patients randomized – 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 – 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