The original concept that nerve root compression from a herniated disc produces pain was challenged decades ago when Rosomoff ⁷ presented a series of observations together with clinical and experimental evidence that supported the contention that alternative nonsurgical methods will provide successful treatment even for manifest disc herniations or lumbar stenosis. Physiologic studies demonstrated that, except for a transient painful impulse when the nerve is first impacted, sustained nerve root compression or ‘pinching’ does not produce pain.⁸ There could be numbness or loss of function, but this is not a painful event.

From inspection of human anatomy, it is inescapably clear that all low back injuries must have associated soft tissue abnormalities. Even if the forces causing the injury reach sufficient magnitude to herniate or rupture an intervertebral disc, the force must be transmitted first through the surrounding soft tissue that binds the spine together as a functional unit. These tissues, when injured, undergo a breakdown of the cell membranes to arachidonic acid, from which biosynthesis of prostaglandins and associated products ensues. One important issue in this process is the induction of a state of hyperalgesia, following which a pain signal will evolve when excessive mechanical stimulation occurs or when compounds of reaction to injury, such as histamine or bradykinin, are produced.⁹ The nerve itself does not originate the pain signal; nociceptors are stimulated to initiate the transmission of the signal.

It is our thesis that the disordered musculoskeletal system is responsible for initiating these phenomena.^3,^7,¹⁰ These structures are in the surrounding paraspinal muscles, buttocks, hips, and legs. These peripheral sites are treatable by alternative medical approaches. Treatment will restore function and alleviate pain, often without the need for correcting intraspinal abnormalities that have traditionally been designated as the pain generator. Further, a study carried out in 45 000 patients with low back pain indicated that only 1 in 200 of patients may actually need surgical intervention;¹¹ in our experience the number of patients is 1 in 500.

Muscular and fascial abnormalities are called myofascial syndromes. They have been well described by Travell and Simons.¹² Abnormal movements of the back, restricted ranges of motion in the hips or legs, or the presence of muscle tenderness and/or trigger points, are seen with myofascial syndromes. These can perpetuate mechanical dysfunction, continued strain, muscle fatigue, and pain.

ALGORITHM FOR PAIN REHABILITATION

Although it can be described in discrete phases, rehabilitation is a continuous process of evaluation, treatment, conditioning, and reevaluations. The intensity and duration of each process depends on a variety of parameters including patient’s response, rate of progress, the presence of comorbidities, and the number and type of objectives to be met. The algorithm is depicted in Figure 110.1 and the elements are described below.

Fig. 110.1 Algorithm for pain rehabilitation.

Admission criteria

To enter the system, the patient undergoes evaluation over a 3-day period. The rehabilitation team attempts to identify the medical, behavioral, vocational, financial, social, and other significant problems. The approach is comprehensive and holistic. Patient selection criteria are broad. The patient must have the ability to understand and carry out instructions, must be compliant and cooperative, and must not have aggressive or disruptive behavior that would disturb the milieu. Patients with schizophrenia, manic-depression, or other major psychiatric disorders are not precluded as long as they are receiving treatment which renders them stable. The patient, the family, and significant others, such as the lawyer, the employer, and the insurer must be accepting of vthe program. Worker compensation, liability cases, multiple surgeries, long histories of invalidism, or drug abuse are not exclusionary conditions. Although integral, the financial, legal, and administrative aspects of patient admission are beyond the scope of this chapter.

Upon entry, patients are oriented to the program and are made aware of rules, policies, and expectations. Evaluations and observations are made by the various disciplines in order to:

1. Decide if the patient meets the criteria for inclusion into the program;

2. Determine the appropriate diagnosis based on previous medical records and the additional medical, physical, and psychological assessments;

3. Establish a baseline of abilities, limitations, and goals; and

4. Medication intake, dependence, and use must be determined, particularly as it pertains to narcotics.

The multidisciplinary team consists of physicians, psychologists, occupational and physical therapists, massage therapists, ergonomists, nurses, vocational counselors, and biofeedback therapists. Assessment of the injured individual by these disciplines considers not just the injury history but also the patient’s physical and behavioral status and vocational issues, if applicable.

The outcome of the exhaustive assessment is a constructed, formalized care plan detailing problem areas, treatment strategies, and expected outcomes. Due to the large number of possible findings upon initial assessment, a set of ‘key indicators’ is used to monitor progress towards the final goals. Key indicators may include (1) pain level; (2) number of hours of sleep; (3) pain medications; (4) lifting, carrying, sitting, standing, walking tolerances; (5) ranges of motion of the neck and trunk; (6) straight leg raise; (7) composite hip range of motion; (8) posture; (9) strength; (10) gait; (11) and key behavioral and vocational problems. These indicators are updated on a weekly basis.

Phase I may take 2–3 days for interviews and/or evaluations. A team meeting is then held, findings are discussed, and team recommendations are presented to the Medical Director. In a multidisciplinary conference, the Medical Director discusses the findings with the patient and significant other. Team recommendations, clarification of medical concerns, and diagnosis are addressed. Patient questions, misconceptions, and expectations are also discussed. Admission to the program is contingent upon the patient’s full consent to participate in the process, including tapering from narcotics or other dependence-producing substances.

Activation and physical restoration

During this phase, treatment is initiated. A variety of therapeutic approaches are used to restore ranges of motion, resolve trigger points, taper off narcotic medications, and begin the process of education and relearning. Stretching, physical agent modalities, body mechanics training, and behavioral interventions are used to guide the patients through what is probably the most difficult phase of the program. Patients must surmount hurdles of fear, anger, mistrust, and past misconceptions about diagnosis in order to proceed with confidence and acceptance. Education includes topics such as myofascial pain syndrome, relaxation, stress management, and healthy lifestyles. Simultaneously, the patient’s medication is reviewed and a rigorous management program is initiated and monitored, including tapering from narcotics or other dependence-producing drugs. The use of ice and other modalities to alleviate pain are introduced.

A daily treatment schedule is designed to accommodate the various treatments and disciplines. A typical treatment schedule for one patient is shown in Table 110.1. The contents of each patient’s schedule vary on a daily basis depending on the stage (week) in treatment, level of activation, and progress.

Table 110.1 Typical daily treatment schedule

Patient name___________________
Time	Activity
8:00–8:30	Movement therapy, warm up, low-impact aerobics
8:30–10:00	Physical therapy, stretching, modalities, back exercises, functional electrical stimulation, active exercises, gait training, flare-up procedures
10:00–11:30	Occupational therapy, body mechanics training, biofeedback, functional circuits, pacing, walking, climbing, lifting, carrying, pushing/pulling, reaching, safety, joint protection, ADL training
11:30–12:00	Psychological counseling, family counseling, stress management, breathing exercises, hypnosis, vocational counseling, vocational preparation, case management
12:00–1:00	Lunch break
1:00–1:30	Strength and cardiovascular training
1:30–2:00	Neuromuscular massage therapy
2:00–3:00	Occupational therapy, upper extremity activities exercises, educational activities, work simulation
3:00–4:00	Group activity, educational sessions
4:00	Evening activities, recreational activities

Treatment is provided on a daily basis including Saturdays. At nighttime, patients are assigned ‘homework’; i.e. evening self-paced exercises determined by the treating therapist and monitored by nursing staff.

A very effective tool in this phase is the concept of daily goals, final goal setting, and self-monitoring. Computerized modeling is used to determine optimal pathways a patient should follow during rehabilitation. The model utilizes statistical projection methods, which take into consideration the patient’s initial performance level and the desired goals.¹³ This nonlinear model derives its coefficients from retrospective data collected from over 1000 patients with chronic pain who successfully completed the 4-week rehabilitation and functional restoration program, and who have returned to a productive lifestyle. Once initial levels of performance have been measured and treatment goals have been determined, the daily goals are assigned to provide a personalized print-out of the expected ‘daily’ performance. The daily goals program provides daily increments for the patient’s therapeutic activities. The optimal progression print-out from initial tolerances to final goals is used by the patient and the treating staff to determine effects needed to achieve the desired daily performance throughout treatment.

On a weekly basis or sooner, if necessary, a team conference reviews the patient’s progress and level of participation; and the team determines if the program should be continued, modified, or terminated. Behavioral issues are addressed early. The patient must be in agreement with the treatment plan. The building blocks for the postdischarge maintenance program also start during this phase.

Rehabilitation for lifestyle and work restoration

Job simulation is an important concept with respect to return to work. In conjunction with the vocational counselor, job tasks are reviewed with the patient to determine which must be simulated if there is to be a successful return to work. Conferences with the employer and job site visits may be necessary to form the plan. Once the simulation demands are determined, the patient is taught to perform tasks safely to restore confidence and prevent reinjury. This allows the treating physician to certify that the patient can safely handle the job.

If a patient’s care plan does not include return to work, functional circuits and realistic lifestyle simulations are utilized to return the patient to those functional levels that will allow comfort and safety.

EVALUATION OF FUNCTIONAL DISABILITY

Objective measurements are utilized to determine physical condition, functional abilities, behavioral health, vocational parameters, and other patient attributes relevant to the rehabilitation process. Methods of measuring functional capacity fall under three main categories: (1) patient’s self-report of functional levels, which provides information about the perception of how much the patient believes he can or cannot do; (2) medical examination to provide an estimate of medical impairment; and (3) assessment of abilities or limitations producing quantifiable measures reflecting the level of performance, in comparison with performance levels of healthy subjects (e.g. norms) or the match to job/task demands.

Physician evaluation

The entry to evaluation and treatment is through the physician. The physician must obtain a detailed, accurate history. The mechanism of injury and the precise location of the pain at onset are critical. A neurologic examination evaluates reflexes, muscle strength, and sensory status to document the presence or absence of neurologic deficits.¹⁴ Although neurologic screening is essential, it is most often not significantly positive. In fact, only 1% of individuals have neurologic dysfunction which is reversible usually and, therefore, should not be considered as a pathological deficit. The soft tissue examination must be sophisticated and thorough.¹⁵ All musculoskeletal and myofascial abnormalities must be identified. This is particularly important, since myofascial syndromes may simulate neurological syndromes, particularly radiculopathies. The straight leg raising (SLR) test may produce leg pain considered to be indicative of irritated nerve roots, but this occurs even more regularly with myofascial syndromes. Contractures of the hip musculature, particularly the hip rotators, are common and disabling with standing or walking, so that restricted ranges of motion about the hips are not necessarily an indicator of articular disease. Palpable soft tissue tenderness by itself, again, is thought by some to be less specific or reliable, but, to reiterate, tender/trigger points and restricted ranges of motion are the hallmark of myofascial syndromes and must be sought so they can be identified and treated. They are, in fact, objective findings.

Simple laboratory tests, including blood count and erythrocyte sedimentation rate, are sufficiently inexpensive and efficacious for use as initial tests when there is suspicion of back-related pathology, such as tumor or infection. Lastly, special tests such as radiographs, imaging techniques, electrodiagnostics, thermography, and discography should be reviewed or recommended, if deemed necessary, but should be interpreted with extreme caution.¹⁰

Motor dysfunction evaluation

This is a method developed to identify and effectively treat ‘motor’ dysfunction in patients with chronic pain conditions.¹⁶ This innovative testing utilizes on-line computerized electromyographic (EMG) methods to study recruitment of muscles involved in a chain of motor activities.¹⁷ This method may detect functional muscular abnormalities that cannot be identified by clinical examination, even by experienced observers. The EMG signals of the various muscles are examined for baseline activity, symmetry, magnitude, frequency contents, synchrony, timing, and patterns. Patients’ behaviors are also observed. Motor dysfunction evaluation (MDE) findings are then compared to relevant clinical findings. Patient-specific, as well as condition-specific, multidisciplinary approaches are then generated to deal with the problems during daily treatment. The overall objective is to improve function and accelerate restoration. This is accomplished through using EMG and other electrically assisted methods to increase sensory perception of muscles and joints; increase neuromuscular recruitment; increase strength and endurance; and reestablish synchrony, symmetry, pattern, and synergy of muscle activity, thereby increasing functional capacities and reduction of pain.