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Treatment isn't a recipe from a cookbook: Strategies for individualizing rehabilitation

This is an excerpt from Low Back Disorders 3rd Edition With Web Resource by Stuart McGill.

Finding the Best Approach

Given the wide variety of patients with low back issues, we cannot expect to succeed in low back rehabilitation by treating everyone with the same cookbook program. The following strategies will help guide clinical decisions to individualize - and thus optimize - the rehabilitation program.

• Encourage patients to train for health versus performance. The notion that athletes are healthy is generally a myth, at least from a musculoskeletal point of view. Training for superior athletic performance demands substantial overload of the muscles and tissues of the joints. An elevated risk of injury is associated with athletic training and performance. Unfortunately, many patients observe the routines used by athletes to enhance performance and wrongly conclude that copying them will help their own backs. Training for health requires quite a different philosophy; it emphasizes muscle endurance, motor control perfection, and the maintenance of sufficient spine stability in all expected tasks. Although strength is not a goal, strength gains do result. If a patient with back pain states that his objective is to play tennis or golf, then he has the wrong short-term objective. First and foremost, the objective is to eliminate pain. Then the objective may shift toward a performance objective such as participation in a sporting activity.
• Integrate prevention and rehabilitation approaches.The best therapy rigorously followed will not produce results if the cause of the back troubles is not addressed. Part II provided guidelines for reducing the risk of back troubles: the importance of removing the cause of tissue overload cannot be overstressed. Linton and van Tulder (2001) demonstrated the efficacy of exercise for prevention; exercise satisfies the objective for both better prevention and better rehabilitation outcomes. First, teach patients what is causing their troubles; then work with them to eliminate the cause.
• Work toward a slow, continuous improvement in function and pain reduction. The return of function and the reduction of pain, particularly for those with chronic bad backs, is a slow process. The typical pattern of recovery is akin to that of the stock market. Daily, and even weekly, price fluctuations eventually result in higher prices. Patients have good days and bad days. Many times lawyers have hired private investigators to make clandestine videos of people with back troubles performing tasks that appear inconsistent with those troubles. I am hired to provide comment. Some of these people are true malingerers and get caught. Others are simply having a good day when they are video-recorded. In such cases, I see all sorts of movement pathology consistent with their chronic history, and they are exonerated.
• Have the patient keep a journal of daily activities. Sometimes it is difficult to hone in on the pain mechanism and the correct dosage and exercise form. Examining daily pain and activity patterns can help identify the link with mechanical scenarios that exacerbate the pain. Two critical components should be recorded in a daily journal: how the back feels and what tasks and activities were performed. When patients encounter repeated setbacks, they should try to identify a common task or activity that preceded the pain episode. Likewise, even when progress is slow, patients should be encouraged to see some progress nonetheless. Without referring to the diary, patients sometimes do not realize that they are improving. Linking pain with a dose of activity is different from recording pain on a 10-point scale, which is typical of behavior modification programs. I have seen too many patients from these programs obsessing over their pain levels; for these people, we suggest stopping pain recording.
• Ensure a positive slope in progress. Chapters 10 and 11introduce the big three exercises in different forms. We designed these exercises to spare the spine from large loads and to groove stabilizing motor patterns. Use the three to establish a positive slope in patient improvement. Once the slope is established, you may choose to add new exercises one at a time. The patient may tolerate some exercises well and others not so well. If the improvement slope is lost after adding a new activity, remove it, go back to the big three, and reestablish the positive slope. If the patient requires advanced exercises for athletic performance, perhaps to increase spine mobility, you may add exercises to achieve such objectives after establishing the positive slope. How long should each stage be? There is no single answer for everyone. Some progress quickly, whereas others require great patience. Your job is to determine the initial challenge, to gauge progress and enhance the challenge accordingly, and to keep the patient motivated, even during periods of no apparent progress. The great clinicians blend keen clinical skills and experience with scientifically founded guidelines and knowledge.
• Determine whether the patient is willing to make a change. Obviously, the patient must change the current patterns that caused her to become a back patient. This requires motivation, which is not always easy to establish. Some have listed the importance of, and steps for developing, a change in motivation and attitude (e.g., Ranney, 1997). Briefly, such a program begins with the setting of goals - for example, returning to a specific job or partaking in a leisure activity. The employer's role in enhancing motivation is to ensure that modified work is available together with the opportunity for a graduated return to duty. Employers can also enhance motivation by fostering a culture in which worker success equates to company success, which in turn helps the worker. The second step in a motivation program is to formulate a realistic plan for reaching the goal established in the first step. It is beyond the mandate of this book to develop the components of maintaining and enhancing motivational opportunities at each stage of recovery.
• Determine whether the patient needs initial mobilization. Although everyone should incorporate spine stabilization exercises into daily activity, a small group of people will benefit from some directed soft tissue work (e.g., manipulation, trigger point therapy, Active Release Techniques, the use of foam rollers). These techniques are not the focus of this book. A word of caution is required here. Too many make the mistake of trying to mobilize a painful spine region that already has mobility. Nonetheless, there is good evidence that those with documented hypomobility may benefit from some initial manipulation or mobilization with a transition into stabilization training (Fritz, Whitman, and Childs, 2005).
• Consider other soft tissue treatments. A good manual medicine clinician may perceive local muscle spasms and odd-feeling local muscle texture. Further, these spasms and local neurocompartment disorders are associated with larger dysfunctions of the agonist and synergist muscles involved in a movement. In many cases these dysfunctions delay recovery or prevent complete recovery. Clinicians use a variety of soft tissue treatments to reduce spasm and release tissues that can impede attaining more normal muscular and joint function. Documenting them is beyond the scope of this book. We simply alert you to their potential significance and role in rehabilitation.
• Avoid spine power. Spine power is the product of velocity and force (power = force × velocity). This means that the spine is bending quickly and there is velocity in the muscles' lengthening and shortening. Techniques that involve high velocity in the spine have been shown to lead to back troubles, because they usually indicate high power (Marras et al., 1993; Stevenson et al., 2001). To minimize power and maximize safety, the forces transmitted through the trunk must be low if the spine is moving. If the forces transmitted through the trunk are high, then the velocity must be low. The power must be generated at the hips and shoulders and transmitted through an isometrically stabilized torso. Fortunately, this fundamental tenet for safety also helps to maximize performance.

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