Does this guy need more strengthening for his low back pain? Really?

I like to put up a slide of this chap when teaching courses to raise the obvious question.

This chap came in to see me in 2004 with left sided low back pain for 6 months duration.

His only aggravating factors was prolonged standing. It was an insidious onset. It was relieved with sitting or bending. It was not improving and was getting slightly worse in that it now came on with about 20 minutes standing whereas at the beginning it was about an hour.

So does he need more strengthening? It was probably not possible to get this guy any stronger. He had numerous provincial power lifting records at the time. I think one or two Canadian records as well (but not sure).

During left prone over bed hip extension, his ASIS moved anteriorly almost immediately then his lumbar lordosis increased. He also had a positive one leg standing test on the left.

I asked him to do an isometric contraction of gluteus maximus and then perform this movement and stop when his ASIS moved. I also asked him to do his lumbar multifidus.

This chap had strong beliefs about strengthening as you can imagine. He had mechanical pain, had good motor skill learning, no symptoms of low grade inflammation and an obvious movement control pattern issue with articular related pain. Some basic education on movement and motor control was required and he was happy to do the rehab. He got good temporary pain control from the exercises and it was better than sitting or bending. He felt he was fully recovered in 3 sessions.

The purpose here is not to get in to the clinical reasoning of my assessment or rehab, but to highlight the gross problems with a one size fits all approach as strengthening as a rehab tool. With appropriate sub-classification, specific motor control rehab is an effective rehabilitation strategy.

Equally, specific motor control rehab as a one size fits all approach is also inappropriate.Specific motor control rehab is suitable for someone if they have:

• Mechanical pain
• Good Motor Skill Learning
• Low Behavioral Factors
• Low co-morbid medical symptoms (which are a surrogate for low grade systemic inflammation)

Related post

https://smarterehab.blogspot.com/2019/12/some-issues-to-consider-with-strength.html

Some issues to consider with a strength assessment for low back pain

Strengthening exercises seem to be getting more popular and making a bit of a comeback for musculoskeletal pain conditions, including low back pain. This is despite the considerable body of evidence showing small treatment effects; or a clear mechanism of benefit. It isn't actually known why strengthening can help low back pain and it is isn't clearly known who will be harmed or who will benefit from strengthening.  

Another issue is the rather blind recommendation that often occurs for a strength based intervention without actually knowing if there is a strength deficit and if this deficit is relevant for the patient in front of you.

There are numerous reasons why systematic reviews can be incorrect. Sadly, "exercise" gets lumped in to one group. There very well may be a small subgroup that responds very well to a form of strengthening.

What strength assessment is best?

I don't know the answer. It is likely individual and logic says it should be based on the patient's functional requirements. It surely can't be a "one size fits all". Unfortunately, there are very few tests that are reliable. In any case the purpose of this post was to highlight a few key issues related to the assessment of strength in low back pain (and all musculoskeletal pain).

·         Behavioral Factors

o   behavioral factors (fear, stress, anxiety) influence motor control. Although fear of movement / kinesiophobia has been the most assessed behavioral factor and influences the results. They need to be assessed and accounted for.

·         Functional Considerations

o   As  noted above, a strength assessment is likely individual and should be functionally related to the symptoms. Is a squat assessment the best functional test for someone that only gets low back pain during prolonged sitting?

·         Sensation of Effort

o   There are several terms related to effort which should not be confused.The sensation of effort is related to how much cognitive effort (central) is required to perform a given task. This is directly related to sensory motor function (as well as fatigue). Sensory motor function is impaired in a variable manner in people with low back pain (and in other musculoskeletal pain and in the pain free population who have neurological factors such as cognitive deficits or neurodevelopmental disorders). So when someone appears to have reduced strength on a test, are they really weak? This raises the fundamental question: "What is actually being assessed during a strength test"? As well: "Is strengthening going to correct that deficit"? And is correcting that deficit going to lead to a clinically meaningful change (beyond the small treatment effects we see) in pain, disability, function, quality of life?

·         Chronic Low Grade Systemic Inflammation

o   This is now known to be the root cause of all chronic disease. It is also now known that it influences muscle stiffness / tone in at least certain populations. So the same questions raised above can again be asked.

·         Proximal Stability

o   This will be a contentious issue for many. The idea that there needs to be a "stable base" for the muscles to operate / attach to in order to generate force has been around for over 25 years. This has been widely criticized of course. One needs to look no further than the active straight leg raise test for any validity of this concept. With light pressure on the pelvis, many people report that lifting the leg is "easier", "less effort", leg feels "stronger". This concept is not relevant all the time, but may be when there is a more severe articular related presentation. So the same questions raised above can again be asked.

·         Neurological Factors

o   The upper end of the more severe sensory motor deficits noted above under sensation of effort may also be considered under Neurological Factors. But this groups also presents with reduced neurocognitive deficits, the presence of neurologicla soft signs such as widespread primitive reflexes. These neurological soft signs significantly influence motor control. Hence, this group is known to have reduced strength in a variety of tests (they respond best to a neurological based approach - primitive reflex inhibition). 

In summary:

Numerous factors can influence a strength assessment. Be very careful how you interpret the results of a test and decide to do rehab.

There is a very clear need to define a standard therapy for research so that there can be a proper "head to head" comparison

Exercise types with pictures, descriptions need to be standardized in journals to allow replication studies.

Strengthening may be a stage of rehab for some people. It isn't known if this should be first, middle, last...

Now that we know chronic low grade systemic inflammation influences muscle tone / stiffness, strengthening may be a strategy to try and counteract this. The best strengthening approach for low grade inflammation is not known. (Note: when significant LGI is present, the best approach is a dietary lifestyle approach - Functional Medicine)

https://smarterehab.blogspot.com/2019/12/modified-ketogenic-diet-and-supplement.html

Pain is complex. Simple solutions are not going to work for most people. There are many deficits between healthy controls and those with low back pain. These include numerous motor, behavioral, immune, sensory motor, neurological differences. A comprehensive sub-classification based approach is required. With a hierarchical  and concurrent approaches to address the individual presentation.

Are co-morbid medical symptoms associated with poor response to sub-classification based management of chronic low back pain? A retrospective case-control study

Reference as:

Gibbons SGT (2019) Are co-morbid medical symptoms associated with poor response to sub-classification based management of chronic low back pain? A retrospective case-control study. Proceedings of: The 10^th Interdisciplinary World Congress on Low Back Pain. October 28-31, 2019; Antwerp, Brussels

Introduction:

There is a growing evidence base for sub-classification based management in chronic low back pain (CLBP). A category may be used for sub-classification if it provides: a diagnosis, prognosis, predicts response to treatment, or provides an underlying mechanism. Contemporary sub-classification categories include behavioral factors, pain mechanisms, and motor control interventions (MCI) (e.g. movement patterns, segmental spinal control). For each subgroup, evidence based recommendations exist, however these are not universally accepted. Medical co-morbidities (MC) are associated with CLBP. Some of which are known to be associated with chronic low grade systemic inflammation (CLGSI). CLGSI is now known to be an underlying mechanism for many behavioral conditions; conditions associated with non mechanical pain and other conditions known to presents with neurological symptoms. Despite this, there has yet been little effort to consider MC or CLGSI as a unique subgroup. It was hypothesized that co-morbid medical symptoms (CMS) would be present to a greater extent in non responders to patients sub-classified as being suitable for a MCI.

Purpose

The purpose of the study was to perform a retrospective case control study to assess the association of CMS to poor outcome of MCI in subjects with CLBP.

Materials and Methods:

The Neuro-Immune-Cardiometabolic-Endocrine symptoms Questionnaire (NICE-Q) consists of a 'review of systems' (19 categories and 126 items). A category is scored as 1 if any symptom was rated as being present "sometimes" or more frequent. This was given to 118 subjects (39M; 79F) with CLBP who had a poor outcome following a MCI over 12 weeks. A poor outcome was defined as not achieving the minimally detectable change in pain, disability or function outcome measures. Subjects were matched for age, sex, sub-classification status (non-mechanical pain, behavioral factors, poor motor skill learning ruled out by questionnaire), CLBP duration, to 127 subjects (42M; 85F). The NICE-Q was dichotomized into scores of > 12 or not. A standard 2 x 2 table was used to calculate odds ratios (OR).

Results:

The OR for a poor outcome to a MCI with > 12 on the NICE-Q =13.7.

Conclusion:

Moderate to high CMS have a high association with poor outcome in CLBP sub-classified as being suitable for a MCI. This provides preliminary evidence that CMS may be a unique subgroup of CLBP in that they predict a poor response to therapy. There is growing evidence that CLBP is part of a more complex health problem and CMS screening may provide insight into identifying this subgroup. The NICE-Q may be a promising screening tool to predict a poor response to motor control interventions. CMS should be assessed  prospectively and for other sub-classification categories.

Keywords: Sub-classification, low-grade inflammation, motor control

Modified ketogenic diet and supplement based intervention for adults with chronic widespread pain and widespread co-morbid medical symptoms. A case series

Reference as:

Gibbons SGT (2019) Modified ketogenic diet and supplement based intervention for adults with chronic widespread pain and widespread co-morbid medical symptoms. A case series. Proceedings of: The 10^th Interdisciplinary World Congress on Low Back Pain. October 28-31, 2019; Antwerp, Brussels

Introduction:

Chronic low back pain (CLBP) is often associated with chronic widespread pain (CWP). There is growing evidence this presentation is part of a more complex health problem that includes multiple medical co-morbidities, multiple bodily systems and chronic low grade inflammation.  There is preliminary evidence to support the use of dietary and supplement interventions for certain inflammatory and musculoskeletal pain conditions. Sub-classification has been suggested as a strategy to manage CLBP. It was hypothesized that a subgroup of CLBP exists with more severe co-morbid medical symptoms (CMS), which would benefit from a dietary and supplement based intervention.

Purpose/Aim:

The purpose of this study was to assess if a subgroup of cases of CLBP with severe CMS symptoms would have a global improvement with a dietary and supplement based intervention.

Materials and Methods:

56 consecutive subjects (M= 18; F=38) were asked to participate. Inclusion criteria: between the ages of 18-65; CWP; CMS based on a score of 19/19 on the Neuro-Immune-Cardiometabolic-Endocrine symptoms Questionnaire (NICE-Q); unhealthy diet pattern based on a survey; normal medical screening. The main outcome measure was the Global Rating of Change (15 pt) (GROC). Secondary outcome measures included: Numerical Pain Rating Scale (NPRS);  Patient Specific Functional Scale (PSFS); quantitative sensory testing (QST); nociceptive flexion reflex (NFR).Subjects were interviewed and explained the study protocol to ensure compliance. Included subjects went through an orientation phase up to 3 weeks (healthy eating). Following this they took supplements q.d. in the morning (omega 3 fatty acids: 3.5g; curcumin: 1g; probiotics: 50B; Inulin: 10g; Vitamin D3: 10,000IU); followed a healthy ketogenic diet and eliminated foods containing gluten, dairy and soy for 6 weeks. Subjects attended twice a week during the first 3 weeks and once a week for six weeks. Blood ketones were measured with a blood ketone meter. Questionnaire outcome measures were taken at baseline, nine weeks, 6 months and 12 months. QST and NFR were assessed at baseline and 9 weeks. Descriptive statistics were used.

Results:

8 subjects did not want to participate due to the dietary changes. 3 subjects withdrew after 6 weeks due to difficulty maintaining the diet. 48 subjects (17M; 36F) completed the outcome measures at each stage. The mean change at 9 weeks was GROC: +4.8 (2.8-7.0); NPRS: -3.4; PSFS: +10.6. QST and NFR improved in all subjects and returned to within normal limits in 37 subjects (77%). All subjects noted clinically relevant changes within 2 weeks. At 12 months the GROC was +5.4 (3.2-7.0); NPRS -3.8; PSFS: +12.2.

Conclusion:

This study provides preliminary evidence that in a subgroup of subjects with CWP, CMS and normal medical screening, a ketogenic diet and supplement intervention may be beneficial for: global improvement, pain, function, and laboratory measures relating to sensory hypersensitivity in subjects with CWP, CLBP and severe CMS. Further research is needed in a larger sample, other subgroups and a clinical trial.

Keywords: Chronic widespread pain, ketogenic diet, sub-classification

Note: the reason I chose a ketogenic diet was because I could measure it to know if subjects were complying. A normal functional medicine approach would match the dietary and supplement needs to the specific person and address the cause(s) of the low grade inflammation.