Health : New Twist in Treating Back Pain

A growing number of back pain specialists are now preaching what would have been medical heresy a decade ago: that vigorous, aerobic exercise is often the best way to help a hurting back and that bed rest often does more harm than good.

The turnabout in thinking is apparently the result of improved body chemistry science and the increasing willingness of back specialists to question their own long-held assumptions. It has been hastened recently by publication of a new Danish study that found that an especially strenuous exercise program was a much more effective treatment for low back pain than either light exercise or rest.

The Danish program, which was tested on 105 backache sufferers, depends on a sequence of three exercises so demanding that the Copenhagen researchers who described it in the journal Lancet--as well as American experts questioned by The Times--cautioned that the program should only be initiated with a physical therapist in attendance.

Many Options

The American experts said the Danish regimen is only one of an increasing array of exercise options being chosen by progressive back pain specialists. Many of the programs, they said, can be safely followed at home, without direct medical supervision.

“I think most of us have been comfortable for years in prescribing (mild) exercise for many forms of low back pain,” said C. David Tollison, director of Pain Therapy Centers, of Greenville, S.C.

“But when you emphasize the word intensive, which is consistent with the philosophy many of us have sort of preached for the last year or two, it goes from an area of universal agreement to an area of some level of controversy,” he said.

Tollison and Dr. Mark D. Brown, a professor of orthopedics at the University of Miami School of Medicine and another back treatment expert, said changes in the therapy recommended for heart patients and new mothers--which emphasizes a rapid return to normal exercise and life style--prompted orthopedists to question the traditional prescription for the back.

The Opposite Effect

In fact, said Tollison, Brown and Dr. Paul Nutter, a Seattle back pain expert, bed rest or long periods of inactivity actually have the opposite effect of what is intended because muscle structures that support the back, in the back and abdominal area, become deconditioned.

When that happens, Nutter said, and a back pain patient stands and moves about, ligaments--not muscles--then tend to hold the body erect, and the result can be even more intense back pain and the risk of serious injury. Intensive aerobic exercise, the three experts said, builds strength in the back so exercise has the effect of preventing pain, not risking it.

“The reason you do aerobics is not so much to increase strength as to increase endurance,” Nutter said. “As you stay in the upright position, your abdominal and back muscles are able to hold your body erect.”

There is also a fear dynamic in many patients, Tollison said. Often, he said, back pain patients are apprehensive about pain since they erroneously assume it indicates they have sustained a serious injury. But the average case of low back pain is not the precursor of a major spinal catastrophe, they said.

Just as important but less understood, perhaps, Brown said, is the biochemical role of exercise. Within the last decade, neuroscientists have started to understand the function of a family of body chemicals called endorphins, which produce a natural morphine-like pain relief when their production is stimulated.

One of the factors that stimulates endorphins, Brown said, is vigorous aerobic exercise.

This observation, the experts said, has led to the rethinking of back exercise theories first developed as early as 1937 in which back pain treatment included cautious, gentle exercise but avoided anything more vigorous.

Confirms Earlier Work

In this climate, the new Danish study has added confirmation to earlier work by Tollison and at least a half dozen other researchers. Tollison has published studies of 4,100 patients at his clinics that conclude vigorous exercise is valuable treatment modality.

The new Danish study, by a team at the University of Copenhagen, divided research subjects into groups that received one of three forms of treatment--traditional rest, light exercise and intensive exercise--over a three-month period. The intensive exercise group performed vigorous programs of sets of 50 repetitions of three different exercises that emphasized trunk lifting, leg lifting and pull-ups.

“We were surprised to find such a pronounced difference,” the Copenhagen group reported. The researchers said the intensive nature of the program and its length were credited with its success. “On theoretical grounds,” the researchers concluded, “the treatment should probably be lifelong.”

Tollison advocates exercise programs designed for home use that rely on a wider variety of movements, ranging from calf stretching and back arching to pelvic tilts and exaggerated sit-ups. The program, Tollison emphasized, should only be started after a complete medical review.

“I think there is a psychological benefit, as well,” Tollison said. “You give an individual some control over his own destiny, instead of going off to bed and lying there.”