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surgery prevention & proven effectiveness

Can Spinal Surgery Be Prevented by Aggressive Strengthening Exercise? A Prospective Study of Cervical and Lumbar Patients

Archives of Physical Medicine & Rehabilitation
January 1999 Volume 80, Number 1

Brian W. Nelson, MD, David M. Carpenter, MS, Thomas E. Dreisinger, PhD., Michelle Mitchell, PTA, Charles E. Kelly, MD, Joseph A Wegner, MD

Study Outcomes & Clinical Relevance:

Forty-six of the 60 participants completed the program. At an average of 16 months after completion, 38 patients were available for follow-up while 8 patients could not be located or contacted. Of these 38 patients only three required surgery after completing the program.

In other words, patients who were informed they required back or neck surgery had a 92% chance of avoiding surgery with aggressive spinal strengthening on the MedX Medical Machines.

Can Exercise Therapy Improve the Outcome of Microdiscectomy?

June 2000 Volume 15, Number 25

Dolan P, Greenfield K, Nelson RJ, Nelson IW
Department of Anatomy, University of Bristol, United Kingdom

Study Outcomes & Clinical Relevance:

A 4-week postoperative exercise program can improve pain, disability, and spinal function in patients who undergo microdiscectomy. : A brief course of active-based therapy provided long-term (up to one year) benefits to patients following microdiscectomy. These exercise-induced benefits augmented the outcomes provided by surgery. The authors expound on the long-term deconditioning that likely precedes surgery. A follow up study should thus include a presurgical exercise group. If properly applied, aggressive spinal strengthening performed pre-surgically may have not only improved surgical outcomes, but helped many patients avoid surgery altogether—as previous research has suggested.

The Clinical Effects of Intensive Specific Exercise on Chronic Low Back Pain: A Controlled Study of 895 Consecutive Patients With 1-Year Follow Up

October 1995 Volume 18, Number 10

Brian W. Nelson, MD, Elizabeth O’Reilly, RN, Mark Miller, PT, Mike Hogan, PT, Charles E. Kelly, MD, Joseph A Wegner, MD
Physicians Neck and Back Clinics, Minneapolis, Minnesota

Study Outcomes & Clinical Relevance:

  • 76 percent had good or excellent results
  • Patients with either radicular or referred leg pain (over half of all patients) responded just as well as patients with isolated low back pain
  • Prior to evaluation at PNBC, patients had seen on average three physicians and had failed six different treatment options, including chiropractic, epidural injections, facet injections, ultrasound, traction, medication, and electrical stimulation.
  • Results were independent of diagnosis. Spinal fitness was crucial, regardless of underlying condition.
  • Patients completing the PNBC program had dramatically less (67 percent) medical reutilization in the year after discharge than comparable control group patients treated elsewhere with passive modalities.

Restorative Exercise for Clinical Low Back Pain (A Prospective Two-Center Study With 1-Year Follow Up)

November 1999 Volume 24, Number 9

Scott Leggett, MS, Vert Mooney, MD, Leonard N. Matheson, PhD, Brian Nelson, MD, Ted Dreisinger, PhD, Jill Van Zytveld, BA and L. Vie, BA
Physicians Neck and Back Clinic, Minneapolis, Minnesota
University of California, San Diego

Study Outcomes & Clinical Relevance:

A combined study between Physicians Neck and Back Clinic (PNBC) and the University of California at San Diego, using similar exercise-only protocols were able to achieve comparable excellent results with comparable spine patients.

Health care reutilization was dramatically reduced at both clinics to almost identical levels, thus validating the results of each. In the year after completion of treatment, only 12% of PNBC patients needed to re-enter the health care system for spinal problems.

Early Aggressive Exercise for Postoperative Rehabilitation After Discectomy

April 2000 Volume 25, Number 8

Danielsen JM; Johnsen R; Kibsgaard SK; Hellevik E
Institute of Manual Therapy, Mo i Rana; the Institute of Community Medicine, University of Tromso, and Rana Hospital, Mo i Rana, Norway

Study Outcomes & Clinical Relevance:

Vigorous medical exercise therapy, started 4 weeks after surgery for lumbar disc herniation, reduced disability and pain after surgery. Because no differences in clinical end points were observed, there is hardly any danger associated with early and vigorous training after operation for disc herniation.

As has been demonstrated again and again, active therapy prevails over passive or no therapy. In this study, surgery alone was insufficient to optimize outcomes, even when supplying patients with a few home exercises. Furthermore, several studies indicate spine patients (non-surgical and postsurgical) can tolerate very intensive conditioning programs. Given the present body of evidence, surgeons should be strongly encouraged to refer postoperative spine patients for supervised therapy by skilled professionals to ensure the best possible outcomes.

Low Back Strengthening for the Prevention and Treatment of Low Back

Medicine and Science in Sports and Exercise

1999 Volume 31, Number 1
David M. Carpenter and Brian W. Nelson

Study Outcomes & Clinical Relevance:

Isolated lumbar extension exercise with the pelvis stabilized using specialized equipment elicits the most favorable improvements in low back strength muscle cross-sectional area, and vertebral bone mineral density. Improvements occur independent of diagnosis, are long-lasting, and appear to result in less re-reutilization of the health care system than other more passive treatments.

Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back Pain

Physicial Therapy
October, 2001 Volume 81, Number 10

Collective Name: Philadelphia Panel

Study Outcomes & Clinical Relevance:

According to this expert panel, only therapeutic exercise has enough scientific support to warrant its recommendation as an intervention in the treatment of chronic, subacute, and postsurgical low back pain. These recommendations essentially match other national and international practice guidelines. Advantages of an active approach to physical rehabilitation include empowering the patient, decreasing dependency on the health care provider, and impacting other health-related risk factors of secondary interest. Of interest to practitioners working in MedX-equipped facilities, this review did include a randomized controlled trial by Risch et al. (1993) that utilized MedX as an effective, high-technology intervention in the treatment of chronic low back pain.

Changes in Isometric Strength and Range of Motion of the Isolated Cervical Spine After Eight Weeks of Clinical Rehabilitation

1992 Volume 17, Number 68

Thomas R. Highland, MD, Thomas E. Dreisinger, PhD, Laura L. Vie, BEd, Garth S. Russell, MD

Study Outcomes & Clinical Relevance:

This study was one of the first studies to objectively measure changes in strength and range of motion in patients with non-spinal cord injuries of the cervical spine. Significant gains were seen in strength as well as range of motion and perceived pain was significantly reduced. This study showed that testing and training of the isolated cervical spine is a safe and viable method of clinical assessment and treatment of a variety of cervical spine disorders.

Effect of Focused Strength Training After Low Back Injury

North American Spine Society
1993 Annual Meeting San Diego, California Federation of Spine Associations’ Council of Musculoskeletal Specialists
1994 Annual Meeting New Orleans, Louisisana

V. Mooney, L. Matheson, D. Holmes, S. Leggett, J. Grant, S. Negri, B. Holmes (University of California San Diego—Orthomed)

Study Outcomes & Clinical Relevance:

Focused training after low back injury appears to be an efficacious approach to treatment with broad effect. Not only were significant effects found with improvement in back strength, but these effects generalized to improvement in lifting capacity, selfperception, pain rating, and activity level.

A Rational Approach to the Treatment of Low Back Pain (Most Patients can Achieve Functional Restoration)

The Journal of Musculoskeletal Medicine
May 1993 Volume 10 Number 5

Brian W. Nelson, MD

Study Outcomes & Clinical Relevance:

At the initial visit of a patient with low back pain, the physician must set a positive tone, emphasizing that the problem is common in the human body and can be remedied. Initial treatment is 1-2 days of rest, a short course of analgesics, and stretches and other exercises. The 5% to 10% who do not improve within 3 months (chronic pain patients) or have a relapse frequently require an active functional rehabilitation program. Exercises are helpful only if they focus on the lumbar extensors. Patients may need encouragement at the beginning of the program to tolerate discomfort. Expensive imaging studies are reserved for patients who become disabled or show no improvement. Only when a lesion is identified in a patient who has seriously tried and failed conservative rehabilitation is surgery recommended.

Surface Electromyography-Verified Muscular Damage Associated with the Open Dorsal Approach to the Lumbar Spine

European Spine Journal
October 2001 Volume 10, Number 5

Kramer M, Katzmaier P, Eisele R, Ebert V, Kinzl L, Hartwig E

Study Outcomes & Clinical Relevance:

The dorsal approach for surgeries to repair vertebral fractures causes damage patterns in the muscles that are caused by the surgery. This approach may disrupt normal function of the multifidi, which can contribute to chronic pain and dysfunction.  This supports the rationale for concerted spinal strengthening in such post-operative patients.

The Effect of Trunk Muscle Exercises in Patients Over 40 Years of Age with Chronic Low Back Pain

Journal of Orthopedic Science
2000 Volume 5, Number 3

Department of Orthopaedic Surgery, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783, Japan

Study Outcomes & Clinical Relevance:

Like many other recent studies, this study confirms the importance of strengthening the lumbar extensors to improve symptoms in patients with chronic low back pain. Rectus abdominis strength is not compromised to the same degree in such patients and thus should be prioritized accordingly. Other contemporary studies fail to support the outdated notion that weak abdominals are of primary concern in the cause or treatment of low back pain.

A Randomized Clinical Trial of Exercise and Spinal Manipulation for Patients with Chronic Neck Pain

April 2001 Volute 26, Number 7

Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H Northwestern Health Sciences
University Bloomington, Minnesota

Study Outcomes & Clinical Relevance:

For chronic neck pain, the use of strengthening exercise, whether in combination with spinal manipulation or in the form of a high-technology MedX program, appears to be more beneficial to patients with chronic neck pain than the use of spinal manipulation alone. An additional finding was that 85% of the patients with chronic neck pain were able to engage in MedX therapy with no exacerbation of head or neck pain, and the remaining patients experienced only transient, self-limited discomfort.

Serial Changes in Trunk Muscle Performance after Posterior Lumbar Surgery

May 1999 Volume 15, Number 24

Department of Orthopaedic Surgery, Toyama Medical and Pharmaceutical University, Japan

Study Outcomes & Clinical Relevance:

Back muscle injury was directly related to the muscle retraction time during surgery. The damage to the multifidus muscle was more severe and the recovery of extensor muscle strength was delayed in the long-retraction-time group. In addition, the incidence of postoperative low back pain was significantly higher in the long-retraction-time group.

Although lumbar surgery is often thought to fix whatever is broken, it can introduce new dysfunction such as injury to the multifidi musculature. An active course of spinal therapy to specifically retrain the multifidi may decrease postoperative low back pain resulting from weakness associated with muscular insult.

Evidence-Informed Management of Chronic Low Back Pain with Lumbar Extensor Strengthening Exercises

The Spine Journal
2008 Volume 8

John Mayer, DC, PhD, Vert Mooney, MD, Simon Dagenais, DC, PhD
School of Physical Therapy and Rehabilitation Sciences, University of South Florida
US Spine & Sport Foundation
CAM Research Institute
Department of Orthopaedic Surgery, University of California
Division of Orthopaedic Surgery and Department of Epidemiology and Community Medicine, University of Ottawa

Study Outcomes & Clinical Relevance:

The current evidence suggests that in the short-term, lumbar extensor strengthening exercise administered alone or with co-interventions is more effective than no treatment and most passive modalities in improving pain, disability, and other patient-reported outcomes in CLBP. The effect of exercise intensity during lumbar extension strengthening programs is unclear. Hyperextension during dynamic lumbar strengthening exercise does not appear to offer additional benefit compared with extension movements to a neutral lumbar posture.

Lumbar extensor strengthening exercise administered with co-interventions also appears more effective than stabilization exercise and home exercise in improving lumbar paraspinal muscle cross-sectional area. Lumbar extensor strengthening exercise administered alone or with cointerventions is more effective than no treatment and passive modalities in improving lumbar muscle strength and endurance. High-intensity lumbar strengthening exercise appears to be superior to low intensity in improving muscular strength and endurance.

Twenty Years Of Specific, Isolated Lumbar Extension Research: A Review

Journal of Orthopedics
2008 Volume 5, Number 14

Dave Smith, Stewart Bruce-Low, Gary Bissell
Manchester Metropolitan University, UK
Southampton Solent University, UK
ProPhysio, UK

Study Outcomes & Clinical Relevance:

Most commercially available “low-back” machines, which do not isolate the lumbar extensors, are worthless for their intended purpose; they can increase the strength of the gluteal and hamstring muscles but cannot improve lumbar function. Specific, isolated exercise can increase lumbar extension strength to a large degree in a relatively short space of time. In addition, this strengthening can also greatly reduce LBP, protect people from the risk of future low-back injury, increase bone mineral density and even eliminate the need for spinal surgery in the vast majority of patients. Isolated lumbar extension exercise should be tried as a matter of course for prevention and treatment of LBP, and should always be tried prior to spinal

The Effect of Early Isolated Lumbar Extension Exercise Program for Patients with Herniated Disc Undergoing Lumbar Discectomy

October 2005, Volume 57, Issue 4

Choi, Gun M.D., Ph.D.; Raiturker, Pradyumna Pai M.D.; Kim, Myung-Joon M.S., P.T.; Chung, Dai Jin M.D.; Chae, Yu-Sik M.D.; Lee, Sang-Ho M.D., Ph.D.

Study Outcomes & Clinical Relevance:

For postoperative herniated lumbar disc patients, the use of early isolated lumbar extension exercises results in positive effects on pain, return to work and strength of back muscles.