Correction of posture may be the simplest technique to relieve symptoms in patients with nonspecific neck or low back pain, though it is extremely difficult to change habits. The physician should instruct patients to assume their worst postural “slump position” with forward protrusion of the head, flexion of the neck, rounding of the shoulders, and increased thoracic kyphosis and reversed lumbar lordosis while sitting. Next, the physician should instruct patients to correct these postural abnormalities through retraction and extension of the head, retraction of the shoulders, extension of the thoracic spine, and return of the lumbar lordosis.
Pearson et al
48 demonstrated in a trial of repeated neck retractions that ROM was not affected, but resting posture was significantly improved. Black et al
49 demonstrated the effects of sitting posture on neck positioning with increased lumbar kyphosis resulting in neck extension, whereas sitting erect resulted in relative neck flexion. Postural exercises with neck retractions and correction of lumbar lordosis would therefore be considered an early strategy to obtain functional recovery. Range of motion exercises should be done in a pain-free range in all four planes of motion (flexion/extension, sidebending, and rotation) on a daily basis.
In conjunction with ROM exercises, flexibility exercises should be added to address muscles restricted by the lack of neck motion. Although flexibility exercises have not been specifically described, clearly stretching of the upper trapezius, levator scapula, and scalenes (anterior, middle, posterior) would not be deleterious in most patients with nonspecific neck pain while stretching the quadratus lumborum along with the deeper lumbar musculature and may serve to improve overall ROM and function in the lumbar spine. Hanten et al
50 demonstrated sustained stretching to be superior to active ROM when used as part of a home exercise program.
Caution should be observed in the case of radiculopathy and cervical spondylotic myelopathy where extension or rotatory movements (or both) of the cervical spine may exacerbate symptoms. Isometric strengthening of the cervical spine musculature should be appropriately done, addressing frontal, sagittal, and transverse plane motion. Highland et al
51 demonstrated significant reductions in pain and improved isometric strength and ROM in patients with degenerative disc disease, herniated discs, and cervical strains who were placed on an 8-week program of isometric strengthening and ROM exercises. Caution must be observed in prescribing isometric exercises to anyone with concomitant hypertension or cardiac issues. In such individuals, isotonic strengthening may be preferred. Compared with individuals treated with passive modalities, individuals with disability from neck pain had superior physical functioning with the inclusion of flexibility and strengthening exercises.
17
Jordan et al
52 demonstrated in a group of individuals with chronic neck pain, no significant difference in outcome between groups treated with intensive muscle strengthening, heat or cold modalities, or manipulation at 4- and 12-month follow-up except for a significant increase in endurance in the group treated with intensive strength training.
52 Overall, a comprehensive program incorporating flexibility, ROM, and postural correction with strengthening is clinically supported in the treatment of patients with neck pain and associated disorders.
In the lumbar spine, studies have demonstrated a reduction in aerobic fitness level in patients with low back pain.
53-55 Some raise questions as to which is the cause and which is the effect. Cady and colleagues' study on firefighters is often cited to support the importance of aerobic fitness in the prevention and treatment of acute low back pain.
53 Unfortunately, this study did not measure the incidence of low back pain but instead, analyzed on-the-job low back injury that required missed work. The firefighters with a lower fitness profile had a greater number of missed work days from low back injury. Cady et al
54 did find that the firefighters with improved aerobic fitness did have fewer missed days from work because of low back injury independent of age.
Aerobic exercise may also decrease the psychological impact of low back pain by improving mood, decreasing depression, and increasing pain tolerance.
56 Theoretically, aerobic exercise may help to improve the body's ability to break down scar tissue via tissue plasminogen activator.
57 Improvement of aerobic fitness is a reasonable goal in conjunction with an active exercise program that emphasizes restoration of normal lumbosacral motion, trunk strengthening, and instruction in proper body mechanics. A program of aerobic exercise alone would be overly simplistic, unlikely to benefit most patients, and potentially pain provoking. Deconditioning should be avoided at the onset by limiting bed rest and immobilization. Patients who are significantly deconditioned should be instructed in the basics of aerobic exercise, including a proper warmup, cool-down, and an assessment of target exercise intensity by heart rate or rating of perceived exertion.
Conflicting literature exists on the efficacy of strengthening exercises in the treatment of patients with acute and chronic low back pain.
58-61 Some of this conflicting literature is due to poor study design, difficulty in randomization, and the lack of specific diagnosis in most studies.
60,61 There has also been debate over the merits of flexion versus extension exercises for the treatment of patients with various low back conditions.
62,63 Some studies have shown that flexion exercises are helpful in patients with posterior element dysfunction, such as spondylolysis and spondylolisthesis.
62 Others have demonstrated the efficacy of an extension-based program in patients with discogenic low back pain.
63,64 Unidirectional exercises by themselves are essentially too simplistic to address the multitude of pathophysiologic changes that occur with acute and recurrent low back pain episodes.
Movement of the upper and lower extremities in various planes provides a progressive challenge while patients are in therapy and later during their performance of work and activities of daily living. The overall goal of this comprehensive exercise program is to reduce pain, develop the muscular support of the trunk and spine, and to diminish stress to the intervertebral discs and other static stabilizers of the spine.
Therapy sessions should be actively directed and limited to a number that ensures that patients have a conceptual understanding of the entire program, demonstrate good technique in doing the exercises, and can do them independently at home. In addition, activity-specific training should be incorporated so that patients are instructed to maintain a neutral spine and dynamic muscle support of their spine in all activities of daily living, work, and recreation. These comprehensive programs have now been well documented, and they are commonly used in the treatment of individuals with chronic pain.
61-64