Lower Back Pain: Hurt Doesn't Mean Harm

Exercise -- Despite Pain -- Means Faster Return to Work

From the WebMD Archives

Jan. 20, 2004 -- Trying to get back to work after suffering lower back pain? Regaining confidence -- not ending pain -- seems to be the key, experts say.

Yes, it hurts. After headache, lower back pain is the most common reason people miss work. In most cases, there's no lasting physical problem. But the pain often persists -- and as any sufferer can tell you, it's very real indeed.

Once upon a time, doctors recommended bed rest until back pain went away. Now doctors reject that idea in favor of getting back to normal activities as soon as possible. That's easier said than done. But now a Dutch research team finds that a "graded activity program" gets people back to work much faster than standard care.

The program doesn't make the pain go away. But it does restore patients' confidence that a little pain won't harm them. That confidence lets them return to their normal lives, says study researcher Willem van Mechelen, MD, PhD, professor of social medicine at VU University Medical Center, Amsterdam, Netherlands.

"Hurt is not harm," Mechelen tells WebMD. "People with lower back pain can work despite their pain. They can be active. Pain won't cause any damage."

Rewarding the "Good," Ignoring the "Bad"

Van Mechelen's team taught their "graded activity program" to several physical therapists. They then enrolled 134 employees of KLM Royal Dutch Airlines who were out of work for at least a month because of nonspecific low back pain. Half the workers got standard care. The other half entered the graded activity program. Neither group was told which was which.

Here's how the program works. First the patients undergo medical tests to reassure them that there's no ongoing physical problem with their backs.

Then they go to hour-long, twice-weekly exercise sessions. The exercises included tasks -- such as lifting suitcases -- that were part of the workers' normal tasks. After three weeks, the workers were asked to set a date for returning to work. Based on that date, the physical therapists set up an exercise program that began with easy, confidence-building tasks that gradually increased in difficulty from session to session. All of the tasks have to be completed regardless of pain.


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?"


Based on the van Mechelen team's study, the answer appears to be "yes." Their program changes how disabled workers see -- and cope with -- their lower back pain.

This approach doesn't mean physical therapists and doctors don't care about how much their patients hurt. Prather says it's still important for doctors to try to find -- and treat -- the root cause of patients' pain.

"I wouldn't jump to the big conclusion that we are telling everybody we don't care about their pain. That is not part of treating humans." Prather says. "Everybody interprets pain differently. And everybody is required to do a different job. So if the focus is on function, the end point is going to be different for everybody."

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SOURCES: Staal, J.B. Annals of Internal Medicine, Jan. 20, 2004; vol 140: pp 77-84. Weinstein, J. Annals of Internal Medicine, Jan. 20, 2004; vol 140: pp 142-143. Willem van Mechelen, MD, PhD, professor, department of social medicine, VU University Medical Center, Amsterdam, Netherlands. Heidi Prather, DO, chief, section of physical medicine and rehabilitation, department of orthopaedic surgery, Washington University School of Medicine, St. Louis.
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