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Lower Back Pain: Hurt Doesn't Mean Harm

Exercise -- Despite Pain -- Means Faster Return to Work
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Rewarding the "Good," Ignoring the "Bad" continued...

The physical therapists were specially trained to ignore complaints about pain. The idea here is not to be callous, but to keep the focus off of the "bad" and on the "good." They rewarded patients for completing each task, and showed them encouraging graphs that demonstrated their progress.

"We started the tasks at a very low level of difficulty so that the patients would establish a record of success," Mechelen says. "It is this feeling of success -- and neglecting all signs of pain by the physical therapist -- that builds confidence. Only by reinforcing "good" do we help the patient. We teach the physical therapists not to focus on what is "bad."

Did it work? Most patients who got normal care returned to work after three months. Most of those who went through the "graded activity" program went back to work after two months -- nearly a month sooner. And there was no difference between groups in the number who re-injured their backs.

The study, which appears in the Jan. 20 issue of the Annals of Internal Medicine, only lasted six months. But van Mechelen says the one-year results are very similar.

Hurt Doesn't Mean Harm

It's a good plan, James Weinstein, DO, says in an editorial accompanying the study.

"Patients learn that the exercises do not cause harm even though they may cause pain. [They] gain confidence that they can work safely despite back pain," he writes. "In so doing, they unlearn behaviors in which they had associated freedom from pain with physical inactivity or absence from work."

Heidi Prather, DO, chief of physical medicine and rehabilitation at Washington University School of Medicine, also praises the approach.

"This is behavioral management, which says, 'Let's not focus on your pain level, let's focus on your function,'" Prather tells WebMD.

Weinstein points out that professional athletes -- and most "weekend warrior" amateur athletes -- regularly play with pain. So what's the difference between them and injured workers?

"Athletes and other professionals are highly motivated, have high self-esteem, are not depressed, and have a strong motivation to keep doing what they always do," he suggests. "Can we imbue the injured worker with some of the ideals and motivation of the injured athlete?"

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