Spinal Surgical Alternative: Exercise?

Abstract & Commentary

Synopsis: Provided there is no physical deterioration, emphasizing activity tolerance as a means to symptom relief is sensible, empowering, and precise.

Source: Nelson BW, et al. Arch Phys Med Rehabil 1999;80:20-25.

To determine if patients recommended for spinal surgery can avoid it through an aggressive strengthening program, a privately owned medical clinic treated consecutive referred patients. Study entry criteria included a physician’s recommendation for lumbar or cervical surgery, no medical condition preventing exercise, and willingness to participate in an outpatient 10-week program.

Intensive, progressive resistance exercise of the isolated lumbar or cervical spine was practiced and continued to failure, and patients were encouraged to work through their pain. Forty-six of 60 participants completed the program; 38 were available for follow-up (average 16 months, range 12-30 months after discharge); three required surgery after completing the program.

Comment by John La Puma, MD, FACP

Back pain hurts. It is the leading cause of disability in the United States, and a pile of frustration among practitioners and patients alike. It is also expensive—early 1990s data from the Worker’s Compensation Back Pain Claim Study show that "the average cost per industrial back injury in the U.S. is now more than $24,000." Here, Nelson and colleagues present surgical cost data of $60,000 for a cervical laminectomy and more than $168,000 for a lumbar fusion.

Of 651 patients referred for rehab, 62 with chronic pain (mean 28 months) met the inclusion criteria. Sixty began the outpatient program; 14 dropped out. Twenty-eight men and 18 women, mean age 42, completed the 10 weeks in an average of 21 visits, most to physical therapists. Nearly all patients—90%—had already tried and failed some type of exercise program.

The program emphasized progressive resistance, and used lumbar and cervical extension devices to isolate and strengthen lumbar extensors, cervical extensors and rotators, and thoracic rotators. A self-monitored maintenance program was also taught to maintain strength, vigor, self-care, and newly improved body mechanics.

Statistically significant gains in strength for lumbar and cervical extensor and rotator muscles in men and women were reported, and only three patients underwent surgery.

Nelson et al acknowledge their methodologic limitations—unblinded, no control group, no randomization, selection bias, variable follow-up, only regrets offered for the nearly one-quarter drop-out. Yet they observe that even patients recommended for spinal surgery can tolerate intensive, specific exercise. By specific they mean isolated musculature; by intensive they mean muscular exercise against dynamic resistance to volitional failure, through a full range of motion.

These bold investigators take a hands-on approach to patients famed for fragility, who "develop a keen sense of fear when it comes to spinal motion ... few understood that literally millions of people develop the same radiologic diagnoses with few or no symptoms." Provided there is no physical deterioration, emphasizing activity tolerance as a means to symptom relief is sensible, empowering, and precise.

Committed, motivated patients who wish to avoid back or neck surgery may be able to do just that. This innovative program deserves better evaluation. (Dr. La Puma is Adjunct Professor of Nutrition, Kendall College, Director, C.H.E.F. Clinic, C.H.E.F. Skills Research, Alexian Brothers Medical Center, Elk Grove Village, Ill.)