PNBC is operated by board certified physicians. We are actively involved in research and our personnel have published over 40 scientific articles in peer-reviewed medical journals relating to the prevention and treatment of spinal disorders.
PNBC has been nationally recognized for its results in such publications as The Wall Street Journal, The New Yorker magazine, Health magazine, L.A. Times and WebMD.
The Following is a listing of key research published by PNBC personnel:
B. Nelson, D. Carpenter, T. Dreisinger, M. Mitchell, E. O'Reilly, C. Kelly, J. Wegner, A. Coulter, J. Palen, and M. Hogan. Archives of Physical Medicine and Rehabilitation 80:20-25, 1999.
Objective: To determine if patients recommended for spinal surgery can avoid the surgery through an aggressive strengthening program.
Setting: A privately owned clinic, staffed by physicians and physical therapists, that provide treatment for patients with neck and/or back pain.
Methods: Over a period of 2 1/2 years, consecutive patients referred to the clinic for evaluation and treatment were enrolled in the study if they (1) had a physician's recommendation for lumbar or cervical surgery, (2) had no medical condition preventing exercise, and (3) were willing to participate in the approximately 10-week outpatient program. Treatment consisted mainly of intensive, progressive resistance exercise of the isolated lumbar or cervical spine. Exercise was continued to failure, and patients were encouraged to work through their pain. Third-party payors in Minneapolis were surveyed of average costs. Average follow-up occurred 16 months after discharge.
Results: Results: 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.
Discussion/Conclusions: Despite methodologic limitation, the results are intriguing. A large number of patients who had been told they needed surgery were able to avoid surgery in the short term by aggressive strengthening exercise. This study suggests the need to define precisely what constitutes "adequate conservative care."
©1999 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
Carpenter DM, Nelson BW
Medicine and Science in Sports and Exercise 1999 Jan;31(1):18-24
PURPOSE: Chronic low back pain (CLBP) remains one of the most difficult and costly medical problems in the industrialized world. A review of nineteenth and early twentieth century spine rehabilitation shows that back disorders were commonly treated with aggressive and specific progressive resistance exercise (PRE). Despite a lack of scientific evidence to support their efficacy, therapeutic approaches to back rehabilitation over the past 30 yr have focused primarily upon passive care for symptom relief. Recent spine rehabilitation programs have returned to active reconditioning PRE centered around low back strengthening to restore normal musculoskeletal function. Research has shown that lumbar extension exercise using PRE significantly increases strength and decreases pain in CLBP patients. It appears that 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 (BMD). These improvements occur with a low training volume of 1 set of 8 to 15 repetitions performed to volitional fatigue one time per week. CLBP patients participating in isolated lumbar extension PRE programs demonstrate significant reductions in pain and symptoms associated with improved muscle strength, endurance, and joint mobility. Improvements occur independent of diagnosis, are long-lasting, and appear to result in less re-utilization of the health care system than other more passive treatments. Low back strengthening shows promise for the reduction of industrial back injuries and associated costs.
Scott Leggett, MS. ESS.* Vert Mooney, MD., Leonard N. Matheson. PhD, Brian Nelson, MD, Ted Dreisinger, PhD. Jill Van Zytveld, BA, and L. Vie. BA
Study Design. A comparison of treatment of 412 patients with chronic back pain at two separate centers using the same treatment protocols and outcome measures. Outcome was defined by specific strength testing; Short Form-36 scores at intake, discharge, and 1-year follow-up; self-appraisal of improvement at discharge and in a 1-year follow-up; and reuse of health care services after discharge.
Objectives. To investigate the efficacy of standardized treatment methods using isolated lumbar strength testing and strengthening based on progressive protocols using specific equipment. Comparison of results should clarify the effect of the treatment center versus the efficacy of standardized protocols.
Summary of Background Data. There has been little support in the scientific literature for exercise programs based on standardized protocols. The use of specialized equipment to achieve intense specific exercise also has been poorly supported. Overall health benefit has not often been related to specific improvement in strength.
Methods. More than 400 individuals with chronic back pain were evaluated at the initiation of treatment, discharge, and 1 year after discharge. Measures of efficacy were based on Short Form-36 scores, self-appraisal of improvement, and reuse of health care services after discharge. Study participants were patients with chronic back pain consecutively referred to each treatment site and underwritten by a variety of payers, including workers' compensation, Medicare, and private insurance.
Results. Overall response during the course of the program and at 1-year follow-up was similar between the two centers. Similar proportions of participants at each site demonstrated improvement in SF-36 scores, self-appraisal of improvement, and reuse of health care services.
Conclusions. Standardized protocols using specific strength and measurement equipment can achieve similar benefits at different sites. [Key words: low back pain, outcomes, restorative exercise, strengthening, treatment]
From U.S. Orthopedics, Little Rock, Arkansas; The Department of Orthopedics, University of California, San Diego; Washington University, St. Louis, Mo.; the Physicians Neck and Back Clinic, Minneapolis, MN, Preventive Care, Columbia, Mo.
B Nelson, MD. Journal of Musculoskeletal Medicine 10(5): 67-82, 1993.
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 or 2 days of rest, a short course of analgesics, and stretches and other exercises. The 5% to 18% of patients 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 considered.
I have read any number of review articles on the treatment of low back pain, most of them well written and technically accurate. Nevertheless, the next day in the office I'd see another patient complaining of low back pain, and again I would be uncertain of what to do.
As I once did, you may find it depressing to see on your schedule that the next patient's chief complaint is low back pain. Because these patients are so difficult to help, many of us become conditioned to dislike them, and we approach them with a negative attitude. None of us enjoys treating patients we can't help.
Despite this, for the past 3 years, I have limited my practice exclusively to the non-operative treatment of back and neck pain. I have supervised the treatment of more than 4,000 such patients. At one time, I used traditional treatment methods and had the traditionally poor success rate. Now I believe that most of these patients can be treated effectively. The secret is in knowing what to do (active rehabilitation) and what not to do (prolonged passive modalities).
In this article, I present a step by step approach to the patient with low back pain, beginning with history taking and a physical examination to rule out causes of back pain that require urgent measures. I describe the initial regimen of palliation and the criteria for progressing to an active, intensive program of functional rehabilitation exercises emphasizing lumbar extension. I also discuss the point at which advanced imaging studies are useful, when to consider surgery, and how to manage the patient with intractable back problems.
The initial visit may be the most important factor affecting the outcome of a. patient with low back problems. During that visit, a psychological template is often created in the patient's mind. If told the injury is serious, the patient easily falls into the sick role. Conversely, if told that back pain is a benign, self-limited condition ubiquitous in humans, the patient may be less likely to take on a seriously "sick" role.
No one knows what causes most back pain, and in only 10% to 15% of the patients can a precise, symptom-related diagnosis be made. 1-5 The rest of the time we simply do not know. But, reluctant to tell our patients "I don't know," many of us say some thing, and our reports are often contradictory.
The confused patient does not know whom to believe when the chiropractor says that the spine is out of alignment, the surgeon says that the disc has degenerated and vertebrae need to be fused, the physical therapist says that the muscles need electrical stimulation and hot packs, and a neighbor says to wear a copper bracelet and all the pain will go away. The clinician should anticipate this confusion and address it, thereby reducing the chances that the patient will be uncooperative or noncompliant.
The statistics are familiar: following an acute back injury, 70% of patients are significantly improved after 2 weeks, and 90% to 95% are recovered within 2 to 3 months. 5-8 Why is it, then, that most patients we see in our offices with acute back injuries do not follow that pattern? The answer, I believe, is that most per sons who injure their back never see a physician and never become patients.
Those who seek attention have already selected themselves and are more likely to have chronic problems, or to have more severe injury, or to have a hidden agenda. Whatever the reason, the person with low back pain who seeks medical advice often is among the 5% to 10% who have not improved within 3 months.
Given that a precise diagnosis usually cannot be made, a rational approach to the initial visit is to direct efforts at ruling out emergent causes of pain. Normally, by taking a thorough history and performing a thorough physical examination you can exclude tumor, infection, acute fracture, inflammatory arthritis, visceral sources of pain, or progressive neurologic deficit. With such critical diagnoses ruled out, you are able to concentrate on treatment.
The patient's history is probably the best tool for ruling out emergent causes of back pain.
Among the questions to ask are:
The answers to these questions may suggest the need for other diagnostic tests. For example, long-standing night pain unaltered by positional change suggests a space-occupying lesion, and imaging studies would be indicated to rule out tumor. A history of fever and chills with or without a previous infection any where in the body would indicate a bone scan to rule out low-grade infection. However, typically more than 90% of the patients will have non-emergent conditions, and in about 85%, an exact diagnosis cannot be made.
A great number of mistakes in caring for back pain relate to spinal imaging. When unsure of the cause of spinal pain, it may be tempting to blame a "spur" or "degenerated disc" seen on an x-ray film or to order another test. Such abnormalities are equally present in symptomatic and asymptomatic persons, however, and thus may be unrelated to the present symptoms. 9-12
Magnetic resonance imaging (MRI) studies are expensive ($600 to $1,200 each), their yield of clinically useful information is poor, and they should not be used as screening tools in these in stances. Furthermore, the vast majority of magnetic resonance scans are read as abnormal, with findings of bulging disc, desiccation at L5-SI, or facet arthrosis; unfortunately, the patient frequently is not told that abnormalities seen on spinal MRI may be unrelated to pain.
Moreover, we tend to forget how intimidating space-age technology may be for a layperson. Lying in an MRI scanner can be a stressful experience and may convince patients that their problem must be serious if such powerful equipment is required. When is a computed tomographic (CT) or MRI study indicated? Only when the results have the potential to change the treatment plan. The cost of a CT scan is approximately half that of a magnetic resonance scan. CT is better for visualizing bony lesions, whereas MRI is superior at depicting soft tissue.
Rest or exercise?
I am currently participating in a clinical study of chronic low back pain, involving the long-term follow-up of patients who have completed a rehabilitation program. More than one patient has criticized my care because a subsequent physician ordered an MRI study that showed the bulging disc or arthritis or degeneration that I "missed.' Had I discovered the "true" cause of the pain, they believe, I would not have pre- scribed exercise, stretching, and proper body mechanics. I would have told them to "take it easy."
But taking it easy does not work for chronic back pain. The Quebec Task Force on Spinal Disorders report, generally considered a balanced and fair evaluation of the passive treatment modalities for chronic back pain, concluded that no passive modalities appear to have any lasting effect. 3 Rest is simply another passive modality, with the added disadvantage that it promotes muscle atrophy, cartilage degeneration, stiffness, and depression. Passive modalities are appropriate in the early stages of an acute injury but have no place in the treatment of chronic pain.
Although there are certain spinal conditions that require a reduced activity level, in my experience, the far greater danger for most patients is in doing too little, not too much.
To make rational treatment choices, you must first understand the physiologic distinction between acute and chronic pain.
After a back injury, the body automatically begins the healing process, and soft-tissue healing usually is complete by 7 to 8 weeks. Nerve damage is generally secondary to another insult, such as pressure from a herniated disc or chemical irritation associated with inflammation. Treatment of nerve damage or irritation is therefore directed at the primary injury. Nerve tissue often takes longer than 7 to 8 weeks to heal. It is less resilient than many other human tissues and is more susceptible to permanent damage.
If pain persists beyond 7 to 8 weeks, it is properly labeled chronic. Since the body has the capacity to heal itself, the goals of treatment following acute injury are to:
These goals are met by using passive modalities, such as hot and cold packs, electrical stimulation, massage, and ultrasonography, in the acute phase to provide palliation while the healing process progresses. Bed rest beyond I or 2 days is avoided, to prevent rapid deconditioning. Also helpful is education for the patient about back protection strategies, including postural advice (lying supine with the hips and knees flexed to 90
PNBC Research & Information
This page is designed to help you learn as much as possible about spinal pain. Because the source of back and/or neck pain is often obscure, confusion reigns. Every doctor or therapist has a different opinion about the source of your pain and what to do about it. In this environment your education about spinal disease is even more important.
Here is something you need to know: About 85% of the time, an exact source of back pain cannot be identified. Here is what the New England Journal of Medicine says:
Perhaps 85% of patients with isolated low back pain cannot be given a precise pathoanatomical diagnosis. The association between symptoms and imaging (e.g., MRI, Xray, CT) results is weak. Thus, nonspecific terms such as strain, sprain, or degenerative processes, are commonly used. Strain and sprain have never been anatomically or histologically characterized and patients given these diagnoses might accurately be said to have idiopathic (source is unknown) low back pain.
If this is true, why is it that every time you see your doctor or chiropractor or therapist, you get told where the pain is coming from…… "You have a degenerative disc", "Your back is out of alignment", "Your hamstrings are tight causing the pelvis to tilt causing your back to compensate", "You have arthritis", "You have the back of an 82 year-old", “You have fibromyalgia" (click for more information about fibromyalgia).
Here's why: Most people go to the doctor for answers. They want to know what is wrong and what can be done. They don't want to hear the doctor say "I don't know." Moreover, doctors don't like to say "I don't know." They like to give patients what they want. With this dynamic firmly in place it is not surprising that an answer emerges.
But that answer is most often a guess. An educated guess, perhaps, but a guess nonetheless about 85% of the time.
In the 1990s the US government, in response to rapidly increasing costs for spinal pain (estimated at more than $100 billion yearly in the US alone), convened the Agency for Healthcare Policy Research to study the subject. The group was composed of researchers from some of the most prestigious universities in the country. They produced a report that included the question:
What do the following terms have in common?
"These terms are commonly used to describe the cause of low back pain. However, scientific studies have not been able to show a connection between these diagnoses and back symptoms."
This doesn't mean that none of these conditions can cause back pain. It simply means that we have not been able to prove it. It means that you may have degenerative disc disease or arthritis or spondylolisthesis visible on a scan or x-ray but those abnormalities may have nothing to do with your pain.
Fortunately, there is still an approach that makes sense. After a good initial evaluation, the physician makes a sure you don't have something serious such as a tumor, infection, new fracture, pancreatitis or peptic ulcer disease (these can masquerade as back pain), rheumatoid arthritis (or one of its many variants), etc. This may require an imaging study but often it does not. Next, are you one of the 15% of patients with a definable source of pain (for example a limbar disc herniation causing leg pain)? If not, you fall into the 85% group-those patients with nonspecific back or neck pain.
These patients often have symptoms of pain or tingling into the arms or legs. But the exact pain generator is obscure.
It is hard to live with uncertainty. But that is where the current state-of-the-art is with spinal pain.
One piece of good news is that exercise seems to be effective regardless of the diagnosis (click here for reference). As patients get into better condition, they usually feel better and are able to do more. The evidence is pretty clear on this point: Rest and inactivity don't work on chronic spine pain. Instead, inactivity promotes diffuse atrophy, stiffness, and more pain in a downward spiral.
For those contemplating an exercise program a few key points need to be made. First, "effective" exercise for chronic spinal pain is not easy - it requires real effort and patience.
Some get worse before they get better. Nevertheless, even if the pain increases initially, patients, provided they are properly supervised, rarely cause any harm to the spine. A neck or low back that has been painful for a long time can be likened to a rusty gate. The first few swings are creaky and lurching. A few more swings and the movement gets easier. More swings eventually lead to a smoothly functioning gate. Spinal movement against resistance is like adding oil to the rusty gate.
Maybe the most important result from strengthening the neck or the low back relates to recovery time. Even a spine optimized for strength, flexibility, and endurance can experience pain. But recovery is much faster. For example, after a large snowfall you grudgingly pick up a shovel and head out to battle the latest 12 inches. You get sore. But you have been diligent about maintaining your spinal fitness so the next day you are back to normal. A weak, stiff spine cannot recover like a strong, flexible one.
Below are a few conditions you may have heard about but don't fully understand. Most respond well to the right kind of exercise. Don’t be alarmed if your PNBC physician has a different opinion than what is expressed below. Our opinions are based on our experience in treating over 75,000 patients and on our interpretation of the scientific evidence. However, we want all patients to be as informed as possible so they can be active participants in their own care. As stated above, there are great differences of opinion about matters pertaining to the spine. Digesting the information below will help you to ask better questions and wade through what can often be a confusing picture.
Scheuermann’s disease/ Juvenile Disc Disease
Degenerative disc disease
Sacroiliac joint dysfunction
Spinal abnormalities such as an extra lumbar vertebra or an extra sacral bone
The purpose of this section is to educate readers so they can make a more informed decision about their own care. Don't just be an observer. Be an active participant. Ask a lot of informed questions. There are many different treatments for spinal pain. Arm yourself with knowledge before you make your choice.