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PowerBack Program
WHAT IS IT? | WHY DO IT? | SCIENTIFIC BASIS FOR THE POWERBACK PROGRAM
A Reasonable Solution to Low Back Pain

In the year following implementation of a low back testing and training program, using the same principles on which the PowerBack Program was developed, an industrial mining company saw an 80% decrease in its low back injuries and its monthly workers' compensation liability claims for low back pain plummet from over $14,000 to under $400. That's really astounding, don't you think? If you have employees, clients, patients or just friends who have chronic or recurrent low back pain and those kind of numbers impress you, the following information might also impress you. Please read on about the PowerBack Program.

What is It?



It is a new and unique program in which people are tested, taught, and trained how to get rid of low back pain and prevent it in the future. And it isn't done through any external gimmicks or devices — Each person makes their own torso stronger and resistant to injury. It is a program designed to test anyone (especially potential or current employees) for potential low back injury, train them to prevent it, and help those who have failed other treatments to get rid of it. This Program is inexpensive, uncomplicated, utilizing a series of simple, brief, but focused and intense exercises which are scientifically proven to work. Once learned, it can be done in the comfort of one's home or even business, taking less than five minutes for each exercise session.

Why do It?



Do it because it works. The most common and costliest industrial injury is to the low back, accounting for up to 60% of all medical and indemnity money spent on employee injuries. Low back pain is the leading cause of lost productivity and permanent disability for humans under age 45 years. Great emphasis and expense is focused on treating low back pain, but little on preventing injuries leading to it, a much more reasonable and cost-effective approach. With escalating health care costs, prevention programs are looking more attractive. The main problem is that there has been no scientifically proven method to prevent low back injuries and pain — until the past decade. A new and effective method has been developed which changes the entire focus of how we view low back injury and pain — Focusing on prevention instead of treatment; focusing on the person, not the environment; focusing on training sessions which people will actually do on a regular basis because they are brief, efficent, inexpensive, and they show results!

Scientific Basis for the PowerBack Program


To understand the scientific basis for the clinical and cost effectiveness of the PowerBack Program, please read the following medical article, based on a lecture given by Dr. Parker at the Worldwide Pain Conference, San Francisco, California, on July 20, 2000.

A Clinically and Cost Effective Lumbar Exercise Program

EDSON O. PARKER, MD

Founder of the
Pain Institute of Nevada
Las Vegas, Nevada USA

SUMMARY: Although low back pain (LBP) is a widespread health problem, no consensus exists about consistently effective prevention or treatment methods. Many recent studies document that lumbar extensor muscle strength can be tested to asses LBP 1-16. The equipment (MedX apparatus) used to establish these principles is sophisticated and accurate, but very expensive (over US $30,000). This paper discusses a protocol in which the same principles are used in clinically-effective lumbar extensor testing and training program, but at a fraction of the cost of current lumbar exercise programs which use the MedX apparatus. Furthermore, once people learn the program, they can continue to perform it at their own convenience, on inexpensive, readily available equipment, for sustained conditioning, the only way to maintain genuine long term success.

INTRODUCTION: Little needs to be said about the devastating impact of LBP on our societies. The frustrating point is, since it is such a pervasive medical condition, why haven't we developed more effective methods to accurately diagnose and successfully treat it? As frustrating as it is, a completely accurate diagnosis may continue to elude us due to multifactorial (physical, psychological and social) aspects. The good news is that accurate diagnosis is not and may never be critical to successful treatment in many cases of LBP. As discussed in the recent article by Leggett9, specific diagnosis was not considered a significant factor in the study. The focus was on treating the 'weak link' in the back, the lumbar extensor muscles, and success followed. The key point in this article is that the focus in preventing and treating LBP needs to be on the person, not the environment, and on the low back, specifically, not just on general physical conditioning.

MATERIALS AND METHODS: The several studies which provide the essential data for the results and conclusions will be summarized. The study which illustrates the efficiency of isometric lumbar muscle testing is that of F. Biering-Sorensen, MD, at the University of Copenhagen in 19831. His testing was done on very rudimentary equipment, similar to an exam table, with the test subject holding the unsupported upper body horizontal for a measured period of time, the shorter the time, the weaker the lumbar musculature. This same basic test is done on the much more expensive MedX or Cybex8 devices, but can also be performed on the much less expensive Roman Chair (RC) device (very similar conceptually to Biering-Sorensens's device), with similar clinical results.

Concerning training, the Legget9, Mooney12, and Nelson13,14 studies provide more more than ample evidence that focused lumbar extension exercises can prevent low back injury and pain and subsequent disability. The MedX machine was used in each of those studies, and the exercise protocol required lumbar exercises only once or twice per week, for 10 to 20 weeks. In my own clinical program, I use the RC equipment, as it meets the primary essential criteria in the above studies: Stabilization of the pelvis during the exercise, so that the lumbar extensor muscles are isolated, i.e. specifically excluding the major muscles of the buttocks and hamstring (personal communication with Charles E. Kelly, MD, one of the co-authors with B.W. Nelson, MD13,14). Therefore, using the RC equipment can accomplish the same objective as the much more expensive MedX or Cybex devices, at a small fraction of the cost

The specific program I have developed, which I call the PowerBack Program (PBP), utilizes a modification of the Biering-Sorensen method for testing and a totally new protocol for training, using modifications of several of the study methods described above, which heretofore have never been adapted to an inexpensive type of exercise equipment, such as the RC. Thus, the PBP protocol is much less expensive, yet no less effective, than current protocols, using techniques and equipment which have much more practical applicability than programs using the MedX or Cybex equipment. Companies and patients can afford to purchase the less expensive RC equipment and perform the exercises in their business or homes after the formal training is complete. Thus, once trained, employees and/or patients can continue to exercise to keep their backs strong for as long as they are inclined to do so, without continuous use of the medical system or costs for recurrent formal training. The testing is equally straightforward, using the simple inexpensive RC equipment, which employers can purchase for their own screening of employees. The PBP also employs abdominal muscle exercise as an integral part of the emphasis on overall trunk strengthening

Testing under the PBP involves strictly measured timing of two testing trials at the same clinic visit. Patients are required to hold their unsupported upper body within 10° of horizontal (using a modified inexpensive bubble goniometer device) for as long as possible. The holding time in seconds corresponds to lumbar strength, the less the time, the weaker the lumbar area, and the more susceptible to low back injury, and vice versa. This method has obvious utility in preemployment screening. It is reproducible and can also be used to measure progress with strength training. Testing takes from 20 to 30 minutes, including the instruction, warm up, and time interval between test periods.

Training is performed at least once, but ideally, at least twice per week. Each session takes only about 10 to 15 minutes, including warm-up stretching and abdominal crunch exercise preceding the actual lumbar exercise. After several minutes of stretching, the patient performs one set of abdominal crunches, which takes from 1 to 2 minutes. Then the patient mounts the RC, and hangs the upper body vertical for 15 to 30 seconds to stretch the lumbar muscles, followed by one set of lumbar extensions (raising the upper body from the vertical to the horizontal position, then lowering to vertical is one repetition), to volitional fatigue or 'failure' (can't do anymore repetitions), followed by another 15 to 30 seconds of hanging vertical to stretch the lumbar muscles, prior to dismounting the RC. Under the PBP, that training protocol can be performed for five sessions (Introductory Program), for 10 sessions (Limited Program) or 20 sessions (Standard Program), depending on the physical status and motivation of the patient. The maximum cost for even the longest Program (testing and 20 training sessions) is less than 25% of the cost of other currently available programs, obviously being very cost effective.

RESULTS: The results of training are quite dramatic. In the Mooney study, a 20 week study with subjects exercising only once per week on the MedX apparatus, lumbar strength doubled, the incidence of back injuries in the exercise group decreases from 2.94 to .55 per 200,000 employees hours, a decrease of over 80%, and the average workers' compensation liability dropped from $14,430 per month to $380 per month for the study year, a decrease of over 97%. His understated conclusion was that "The significant increase in strength associated with the exercise program correlated with the greatly reduced incidence of back claims." Other studies of focused lumbar exercise reflect similar results to that of the Mooney report: An exercise program of focused intense training on the lumbar extensor muscles, even for only a few minutes once per week, elicits consistent, reproducible, and dramatic increases in strength and decreases in injury, disability, and utilization of health care resources. My own ongoing clinical work, using the Roman Chair device in the PBP, shows similar results.

CONCLUSIONS: A review of the literature1-16, several recent clinical studies9,12,13,16, and my own personal and clinical experience provide strong evidence that the most effective method to prevent low back injury resulting in LBP and to treat chronic LBP is active exercise. Education, workplace modifications, and general exercise provided in standard physical therapy protocols are not adequate. Active exercise is required, and it must be exercise focused on muscles in the trunk, specifically in the lumbar area, the area most often neglected and most often injured. The reason that focused exercise on the lumbar area is so successful is that it is an area of the body rarely exercised, thus relatively weak and unprepared for the severe episodic stresses placed on it. Thus, focused intense strengthening exercise, even as limited as once per week, can have dramatic positive results on increasing strength and decreasing pain and/or risk of injury. The Mooney study showed a doubling of strength in a 20 week program and Pollock15 states that 200 to 300% increases can be achieved. The reason is postulated to be that lumbar extensor muscle strength is not normally developed or maintained with routine lifestyles or with existing exercise methods, i.e., the lumbar muscles atrophy from chronic disuse. With the pelvis stabilized and the lumbar muscles isolated, they can be fully developed with relatively brief, but intense exercise. And, although the MedX and Cybex exercise machines are excellent devices and have been essential to establish the critical information necessary to develop the training protocols, they are very expensive and are not necessary to actually conduct clinically-effective lumbar muscle testing and training.

There are commercially-available programs which conduct such testing and training, but they are expensive ($2000), one reason being they use the expensive MedX equipment. The high cost of these programs and some equipment often prohibits participation by the average person, precisely the one who should be targeted for this type of treatment. The most cost effective piece of exercise equipment available to conduct an effective lumbar exercise testing and training program is the Roman Chair, of which there are several commercially-available models, with no moving parts, ranging in price from US$99 to $200. The RC can be used not only for active exercise, but also for stretching and traction, being even more cost effective by eliminating the need for an additional lumbar traction machine, most of which cost at least $300. Some RC type models, with rotating mechanisms, cost three times more than the fixed RC, and are not necessary for effective results. The fixed RC is uncomplicated, durable and will last a lifetime.

Numerous articles describe the failure of passive methods to effectively prevent or treat LBP. Although much effort and money are being spent on workplace modifications to prevent injury to the low back, including the use of lumbar support belts, they are not consistently effective: First, workers do not reliably or properly utilize them. Second people spend the majority of their lives, about 75%, away from work, and most injuries to the low back actually occur outside of the workplace. The obvious conclusion is that education, passive methods, and workplace modifications do not reliably prevent injury to the low back, with its resultant pain and disability.

The solution to the enormous problem of LBP is to modify the primary element involved in the problem, the low back of each individual person. By strengthening the area of the body most susceptible to disabling injury, the low back, each individual person can be made resistant to lumbar injury, at any time, in any activity, be it at work, at home, or in recreation. Instead of depending on an unreliable external device, such as a lumbar support belt, people protect themselves from injury by enhancing their own internal body structural support (muscles, ligaments, tendons, even vertebral bodies). It is a simple, straightforward concept, and it is effective. Efficacy can be documented by measuring improvement in psychosocial function, decrease in utilization of the health care system, even to the extent of avoiding spine surgery for which people were candidates14. The primary obstacle we must overcome is changing behavior to get people to continue the exercise program on their own, after being tested and trained, which is essential to maintain long term protection from injury. The good news is, with new and efficient protocols, such as the PowerBack Program, utilizing readily available inexpensive equipment, we now have tools with which we can reach many more people in a successful effort to defeat the widespread dilemma of low back pain.

REFERENCES :

1.  Beiring-Sorensen F. Physical measurements as risk indicators for low back trouble over a one-year period. Spine 9: 106-119, 1984
2.   Cady LD et al. Strength and fitness and subsequent back injuries in firefighters. J Occup Med 21: 269-272, 1979
3.    Graves JE, et al. Quantitative assessment of full range of motion isometric lumbars extensor strength. Spine 15: 289-294, 1990
4.   Graves JE, et al. Effect of training frequency and specificity on isometric lumbar extension strength. Spine 15: 504-509, 1990
5.     Gundewall B, et al. Primary prevention of back symptoms and absence from work, Spine 18: 587-589, 1993
6.    Ito T, et al. Lumbar trunk muscle endurance testing: An inexpensive alternative to a machine for evaluation. Arch Phys Med Rehab 77: 75-79, 1996
7.   Keyserling WM, et al. Isometric strength testing as a means of controlling medical incidents on strenuous jobs. J Occup  Med 22: 332-336, 1980
8.   Lee, JH et al. Trunk muscle weakness as a risk factor for low back pain. Spine 24: 54-57, 1999
9.   Leggett S, Mooney V, et al. Restorative exercise for clinical low back pain. Spine 24: 889-898, 1999
10.   Li Y, et al. Lumbar extension strength training: Should patients train once or three times per week? The Back Letter 13: 74, 1998
11.   Manniche C, et al. Intensive dynamic back exercises for chronic low back pain: A clinical trial. Pain 47: 53-63, 1991
12.   Mooney VM, et al. The effect of workplace based strengthening on low back injury rates: A case study in the strip mining industry. Occup Rehab 5: 157-167, 1995
13.   Nelson BW, et al. The clinical effects of intensive, specific exercise on chronic low back pain: A controlled study of 895 consecutive patients with 1 year follow up. Othopedics 18: 971-981, 1995
14.   Nelson BW et al. Can spinal surgery be prevented by treating surgical candidates with aggressive strengthening exercises? A prospective study of cervical and lumbar patients. Arch Phys Med Rehab 80: 20-25, 1999
15.   Pollock MI, et al. Effective resistance training on lumbar extension strength. Am J Sports Med 17: 624-629, 1989
16.   Risch SV, et al. Lumbar strengthening in chronic low back pain. Spine 18: 232-238, 1993

 


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