Low back pain treatment launches resistance movement

[Guest guest]

October 2006 Biomechanics Magazine

http://www.biomech.com/showArticle.jhtml?articleID=193200645

Low back pain treatment launches resistance movement

By: Clare PT, MSPT, PsyD, MTC

Low back pain is a major public health problem. LBP affects 80% of

the general U.S. population at some point with sufficient severity

to cause absence from work. It is the second most common reason for

visits to primary-care doctors, and is estimated to cost the

American economy $75 billion every year. Lifetime incidence of LBP

ranges from 60% to 90% with a 5% annual incidence.1 One of the

problems for practitioners treating LBP has been the need for

empirical proof of the efficacy of intervention. As effective

treatments for LBP have been quite elusive (especially for patients

with chronic pain), many techniques and interventions have been

attempted.2

A fairly new treatment technique that has been generating excitement

among practitioners using it is the concept of active therapeutic

movements (ATM), which are short, full-strength movements against an

isometric resistance in the direction of a previously painful

movement. The ATM concept was discovered by accident by a physical

therapist while treating a back patient. A device called the ATM2

was developed to most effectively implement the ATM concept. Despite

the effectiveness of the ATM2 reported by some physical therapists,

chiropractors, and team trainers, no clinical studies have been

published. This case study was undertaken to begin generating

empirical data concerning the effectiveness of the ATM2.

Case study

To recruit a subject for this case study, a notice was placed in a

local daily newspaper, advertising a treatment for LBP. Inclusionary

criteria included any kind of movement impairment due to low back

pain and age between 18 and 75. Exclusionary criteria were

pregnancy, smoking habit, current pain medication protocol, and

current care protocol for the problem. The objective of the trial

was to compare lumbar muscle activation levels in a normal relaxed

stance and in an upright, anatomically correct position before and

after an ATM-concept treatment using the ATM2 system.

Equipment used included the ATM2-Pro, by BackProject, and the

MyoVision sEMG with the Baseline 3D sEMG protocol.

A 60-year-old woman was chosen from among several respondents as a

preliminary subject. She was cleared by her physician to participate

in the trial and on screening was deemed appropriate for the study

and signed an informed-consent agreement.

The subject was a part-time teacher who indicated that she began to

have LBP in late December of 2005. She could not recall any incident

or injury to her low back but indicated that she had been doing her

customary four to seven-mile walks three times a week and thought

maybe her pain had something to do with the cold weather prior to

its onset. She also suggested that lifting her grandchild might have

set off her back pain, although she never felt any pain at any time

while lifting her grandson. She thought maybe carrying her water

bottle while walking was to blame so she tried alternating her

carrying side but her LBP persisted.

She described her pain as tense, achy, and cramping. The pain was

located about two inches above her waist. It came on after five to

10 minutes of walking and did not appear to be affected by flat

versus hilly terrain. She described her pain level as a nine (out of

10) that eased immediately when she stopped walking. She denied any

sleep disturbance and the only other activity that she indicated

caused her back to ache was sitting, but only occasionally and only

after sitting for a long time (a couple hours or more).

The subject was quite fit. Besides walking, she regularly did

Pilates, had built a home with Habitat for Humanity in Africa the

previous summer, and a couple years previously had completed Avon's

Walk for Breast Cancer, which involves walking 60 miles in three

days. The subject denied any prior history of LBP and indicated that

other than taking medication for hypothyroidism, her health was

excellent.

The subject was evaluated on Jan. 23 to determine which direction of

lumbar movement most closely reproduced her complaints. Backward

bending reproduced her LBP, so it was determined that she would be

set up on the ATM2 facing the unit (Figure 1). With this setup, the

subject could perform the ATMs into the direction of her pain.

Subject's backward bending motion was also measured at this time and

she was determined to have 17 degrees of extension.

Before performing the movements, the subject was prepped for

application of surface electrodes (skin was cleaned with alcohol,

shaved, and abraded).

Five sEMG electrodes were used on the patient's back, one placed on

either side 1 to 2 inches from the spine at L1 and L5 and the fifth,

a ground, placed near the bottom of the scapula (Figure 2).

The subject was instructed to stand in her normal relaxed stance

with her back to the wall, but not touching it for about 15 seconds,

then transition to an anatomically correct position by leaning flat

against the wall, with her back, hands, and head touching the wall

for an additional 15 seconds.

The subject was next strapped into the unit and the straps were

ratcheted tight until she was able to bend backward without any

pain. The movement is rendered pain-free as a result of the passive

repositioning and stabilization facilitated by the ATM2 system. She

performed 10 ATMs. While still held by the device, she completed the

10 hip extensions for each leg that were also prescribed.

After she finished all movement repetitions, the belts around her

pelvis were gently loosened and she was asked to walk around for a

moment. She was then asked to repeat the backward bending movement

free of the ATM2 and she reported that her pain level had gone from

a nine of 10 to a zero of 10. Her backward bending was measured

again and determined to be 22 degrees of extension, a 29.4% increase

from her pretreatment measurement. Her pain-free state lasted for a

couple of days, even after a walking trial of two and a half miles.

The subject was seen two more times, once in January and once in

February. At each session she repeated the protocol exactly except

that at the final intervention she did not perform the hip extension

movements but instead (still in the holding position), she performed

10 flexion movements to each side (about 45 degrees ).

Results

The patient underwent three interventions, with one week between

each intervention. After each treatment, measurable improvement was

documented.

Session 1. Prior to the first intervention, notable differences in

muscle activation levels were observed between subject's left and

right sides in both the normal stance and anatomical posture.

Postintervention, sEMG results indicated immediate calming and

normalization of muscle activation levels during normal stance, but

no significant changes in the anatomical posture (leaning flat

against the wall).

Session 2. Prior to the second intervention, significantly less

difference in muscle activation levels than prior to the first

intervention were observed between left and right sides in the

normal stance. No significant changes were observed in the

anatomical posture. Postintervention, sEMG results indicated

immediate calming and normalization of muscle activation levels

during the normal stance, but again no significant changes in the

anatomical posture.

Session 3. Prior to the third intervention, significantly less

difference in muscle activation levels were observed between left

and right sides in the normal stance than before the second session.

There were still no significant changes observed in the anatomical

posture.

Postintervention, normal stance remained low and normalized, but

sEMG results indicated immediate calming and normalization of muscle

activation levels during the anatomical posture.

The subject reported that after the first intervention and with each

successive intervention she was able to increase her walking mileage

without any increase in pain. When contacted by phone for follow-up

at the end of March, she reported that her pain was very mild and

noticeable only because she was now being asked about it. She

reported that she had returned to her prior level of walking, which

is five to six miles at a time, including hills. She stated that she

was very pleased with the results.

Discussion and conclusion

Although ATM2 has come to be widely used by healthcare practitioners

as a treatment for LBP, no clinical studies have been published to

establish the efficacy of the unit. This case study was conducted to

begin to establish empirical evidence of the device's efficacy.

Results indicated that for this case study, the subject had an

overall decrease in LBP significant enough to allow her to return to

full activity. In addition, the subject's ROM improved and recorded

sEMG levels decreased. At the end of the study trial EMG readings

indicated a normalization of muscle activation levels in the

anatomical posture while normal stance activation levels remained

low and normalized. Based on the results of this case study, the

ATM2 appears to be an effective treatment for LBP with objective

measures to quantify the results.

Clare , PT, MSPT, PsyD, FAAOMPT, MTC, is an associate professor

of physical therapy at California State University, Sacramento.

References

1. Hills EC. Mechanical low back pain. eMedicine Web site,

www.emedicine.com/pmr/topic73.htm. Last updated 4/8/05.

2. Nourbakhsh MR, Arab AM. Relationship between mechanical factors

and incidence of low back pain. J Orthop Sports Phys Ther 2002;32

(9):447-460.