Will a patient with chronic low and mid-back pain have better pain reduction with graded exposure to functional limitations or traditional exercise?
While at my first long-term clinical rotation, I began treating a patient in her mid 30’s who had been experiencing mid and low-back pain for about 8 months. She is a PE teacher and upon evaluation, she had increased pain with lumbar and thoracic motions in all directions, and was hesitant to pick up very light objects off floor during functional testing. She had previously received multiple epidural steroid injections and radiofrequency ablation to block her medial branch nerves and had very limited important. She was former collegiate athlete and familiar with exercise, but was fearful of further injury. While forming her plan of care, I was considering two treatment plans to start with; traditional exercise program consisting of core stabilization training and aerobic exercise, or a form of graded exposure to gradually expose the patient to movements that she was hesitant to perform in an effort to reduce fear of movement.
A systematic review performed by Macedo, Smeets, Maher, Latimer, and McAuley (2010) evaluated the evidence regarding graded exposure and graded activity approaches to therapy, and whether or not these lead to reduced pain and disability compared to traditional therapeutic exercises. The internal validity of the study appeared to be high due to the specific inclusion criteria the articles had to meet to be included in the systematic review. Thorough analysis of the research subjects and interventions were performed to ensure that all subjects had non-specific back pain lasting longer than 6 weeks, and all interventions were compared to a control of usual care. Due to the article’s nature as a systematic review, the results generalize to a wide population well. There were no age or sex restrictions in any of the articles included in the review, meaning it captured a wide range of participants. However, due to this high level of generalizability, this also means that it is harder to relate this article to a specific patient case study as I hoped to do. Ultimately, this study found that graded activity was slightly more effective than traditional exercise for pain, disability, and perceived effect in the short and intermediate term, but was not conclusively more effective in the long term.
When discussing both this article and my patient case with my CI and other therapists at my clinical site, a few key points were brought up to help me make my decision about which treatment plan to follow. First of all, considering the patient’s profession and previous experience with exercise is important in determining when and how to implement exercises. As a PE teacher and former collegiate athlete, the patient in this case is used to a high level of activity, and will generally respond well to exercise. My CI also stressed the importance of reducing the patient’s pain levels before embarking on graded activity through manual therapy and sensorimotor control exercises to reduce the chance of movements increasing pain and thus increasing fear avoidance beliefs. Also, I was encouraged to think about what I was most confident in teaching. The study mentioned as well that therapist expertise was a consideration in all studies, and my background in teaching functional exercises in a graded manner meant that this plan of care could work for this patient.
After careful consideration, I decided to use a multi-modal treatment plan that used manual therapy, sensorimotor control activities, and patient education to reduce her pain levels and improve inner core activation for 3 weeks before implementing graded exposure. While the patient was hesitant to bend forward to pick objects off the ground at her evaluation, through slow graded exposure to picking objects up from progressively lower levels, she overcame her avoidance of this activity, and after 6 weeks of treatment is now performing all work duties without pain and picking up 25 pound weights from the floor confidently and safely. Through this case, I learned that carefully matching evidence-based treatment, methods a patient is receptive to, and therapist expertise is important when deciding upon a plan of care to initiate.
References
Macedo LG, Smeets RJ, Maher CG, Latimer J, McAuley JH. Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review. Phys Ther. 2010 Jun;90(6):860-79. doi: 10.2522/ptj.20090303. Epub 2010 Apr 15. PMID: 20395306.