Special Repor t

Theodor e R. Fields, MD, FACP

Attending Physician, Hospital for Special Surgery
Professor of Clinical Medicine, Weill Cornell Medical College
Low back pain can turn your life upside down. You may be thinking about the pain first right now. But it can
also knock you out of work. That can take away your health insurance. It can ruin everyday pleasures.
Many treatments for low back pain are less than satisfactory. They can't completely get rid of your pain.
Many physical therapists tell you to "work through the pain." They are not dismissing the importance of pain.
They think that focusing on pain too much may slow your progress.
But there is controversy. Should physical therapy focus on pain relief? On getting people back to work quickly?
Graded Exercise vs. Routine Care
How does the controversy play out in physical therapy? In "routine care," you do exercise but stop when pain
occurs. In "graded exercise," you work through the pain. Your exercise quota is gradually increased at each
session - so you learn to tolerate more exercise despite pain.
Is there any proof that graded exercise works better? Yes!
A study of Swedish auto workers tested a graded exercise program.[1] It gave patients exercise that mimicked
their activity at work. And it moved therapy ahead regardless of pain. Results? Those in the graded exercise
program had a lower absence rate than those who received "routine care."
A more recent study of airport workers with low back pain asked: Will a physical therapy program that focuses
on functional milestones - doing certain things by certain dates - lead to a more rapid return to work than
"routine care"? Would that be better than a pain-focused approach?
The study involved airport workers in Amsterdam who had "nonspecific back pain."[2] Patients had been out of
work at least 4 weeks. They were separated into 5 groups based on the work they did: baggage and aircraft
turnaround, passenger services, engineering and maintenance, cargo, and cabin and cockpit. They were
assigned - randomly - to either graded activity or routine care.
The graded activity group received 1 hour of treatment twice a week, for up to 3 months. Exercises were
chosen to match their occupational or home disability.
The control group did general exercises, such as rowing, cycling, or abdominal, or upper and lower back
exercises.
Understanding Conditioning
The graded exercise used the principles of conditioning. The researchers thought that repeated exercise with
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The graded exercise used the principles of conditioning. The researchers thought that repeated exercise with
an activity similar to one patients had difficulty with at work would decrease "pain behavior" - avoidance of the
activity - and allow patients to return to work sooner. Patients would become "conditioned" to continuing work
despite the pain.
Usually, we think of pain as a sign that we are being injured - such as the pain of a cut or a fracture. But low
back pain is different. That type of chronic pain does not necessarily mean ongoing injury.
Once the doctors had examined the airport workers to make sure this was there was no major mechanical
problem with their backs, the graded exercise group received important information.
1. They were reassured that their problem was benign. Nothing serious was wrong with them.
2. It was explained that the goal of exercise was to help them feel safe moving, not to increase strength.
3. They were told that relief of pain was not needed to return to work.
4. Pain relief was de-emphasized as the main goal. Rather, the focus was on "abilities, not disabilities".
5. Each patient, with the therapist, planned a gradually increasing goal for each exercise, to be reached at
each session. The patient was encouraged to achieve the goal despite pain.
6. The patient, with the therapist, agreed on a goal date for return to work.
Results
The study measured the number of days of absence from work in both groups. On average, those in the
graded exercise group missed 58 days. Those in the routine care group missed 87 days - a big difference.
The graded exercise group also reported less pain, but not by much.
The researchers felt that differences in perception of their condition was largely responsible for the program's
success. Those in the graded exercise group went back to work earlier, despite having similar pain to those in
the routine care group. They weren't afraid that moving would lead to more and more pain. They knew what
impact movement would have.
At Hospital for Special Surgery in New York, our Physical Therapy group has for some time used the
conditioning model. We help people get back to their work and leisure activities.
Sometimes, doctors cannot banish your pain. But you need to understand that pain need not stop you from
getting back to work and leisure activity. However, you should be actively involved in planning your exercise
program and back-to-work plan.
This study shows how important it is to get a complete evaluation of your back pain before starting physical
therapy. This evaluation is often done by a rheumatologist (a physician who specializes in rheumatic disease)
or a physiatrist (a physician who specializes in physical medicine and rehabilitation). Once the evaluation
shows no major structural problem, the next step is to identify the activities that cause you pain.
A physical therapy program in which you take a very active part can be extremely helpful. You need to be
involved in:
doing the exercises;
planning the gradually-increasing repetitions; and
planning your return to work and/or to leisure activities.
As part of an overall strategy for controlling back pain and improving function, a physical therapy program that
emphasizes "abilities over disabilities" can play a major role.
Posted: 2/11/2004
Reviewed: 7/17/2009
1. Lindstrom I, Ohlund C, Eek C, Wallin L, Peterson LE, Fordyce WE, Nachemson AL. The effect of graded
activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-
conditioning behavioral approach. Phys Ther 1992;72(4):279-90.
2. Staal JB, Hlobil H, Twisk JWR, Smid T, Kke AJA. van Mechelen W. Graded Activity for Low Back Pain in
Occupational Health Care. Annals Int Med 2004 Jan;140(2):77-84.
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