The Management of Low Back Pain: A Comprehensive Rehabilitation Program

Introduction Low back pain (LBP) is a ubiquitous condition with a 60% to 90% lifetime incidence and a 5% annual incidence. It is the most common cause of disability in the United States in people younger than 45 years of age and is second to the common cold as the most frequent reason for visiting the doctor. The annual cost of managing LBP is estimated to be a staggering $56 billion. Although 90% of episodes resolve without medical attention in 6 to 12 weeks, 70% to 90% of patients with LBP have recurrent episodes. Despite a decrease in symptoms, these patients have anatomic and functional changes that increase their chance of reinjury. Therefore, it is essential that rehabilitation focuses not only on resolving the symptoms associated with injured and overloaded tissues but also on identifying and rehabilitating the unique associated biomechanical deficits and functional adaptations. The benefits of exercise are profound and include improved cardiovascular fitness, muscle strength, flexibility, and endurance. Enhanced mood, increased pain tolerance, and better sleep also have been found to be related to exercise. There is also evidence that spine motion improves disk health through more efficient delivery of nutrients and removal of metabolic waste products. Exercise appears to be relatively safe in patients with LBP; there is no evidence that regular exercise increases the risk of additional back problems in patients with acute, subacute, or chronic LBP. Exercise appears to exert a neutral effect or may even slightly reduce the risk of future back injuries. On the other hand, bed rest has deleterious consequences in the setting of LBP, leading to decreased cardiovascular fitness, muscular strength, flexibility, bone density, and disk nutrition; increased spinal segment stiffness and depression are also associated with inactivity. There is no proven benefit of prolonged bed rest for patients with nonradicular pain. Therefore, no more than 2 days of absolute bed rest is recommended for patients with nonspecific LBP. Relative rest, which allows for short periods of rest between activities and helps minimize the negative effects of bed rest, is actually preferred. There are several reasons why the clinician should choose rehabilitation techniques for patients with LBP. Rehabilitation techniques help resolve the clinical symptoms and signs created by a primary lumbar spine injury so that active treatment encouraging independence can be initiated as soon as possible, and the untoward effects of inactivity can be minimized. By addressing both the primary site of injury and secondary sites of dysfunction, rehabilitation restores function, returns patients to activity, and theoretically lessens the chance of recurrence, thus optimizing outcome. Specifically, rehabilitation after a lumbar spine injury may help decrease days lost from work or sports activities and may increase productivity. Rehabilitation of lumbar injuries must continue beyond resolution of symptoms so that all other aspects of the injury complex, including flexibility, strength, power, and endurance, are fully rehabilitated. A plan for prevention of recurrent episodes of LBP is developed based on the comprehensive rehabilitation program so that optimal physiologic and biomechanical fitness is maintained; therefore, the risk of injury is potentially minimized.