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3. Activity as Treatment for lost activity intolerance due  = Regaining and Maintaining Comfortable Activity Tolerance. 
 
Remember the old Groucho Marx joke -         
"Doctor, doctor, after surgery will I be able to play the violin?" Doctor: "I would hope so." Response: "Good! Cause I could never play it before".   
Surgery, manipulation, injections, medication or rest do not train you to play the violin, run a marathon, do strenuous activity or return comfortably to your normal activity after being away from it for a while. Only conditioning allows you to again comfortably tolerate activities.  Hurt does not mean harm. Conditioning activities do not prolong symptoms and need not be more stressful on the back than sitting at bedside before rising in the morning. Remind the patient that though changes in activity may not be totally comfortable, nothing will be recommended that is dangerous to the spine. Dangers are far greater with inactivity. Unfortunately, there is no way to maintain or build activity tolerance without conditioning (see Why Conditioning in section IV). Once activity tolerance is lost due to de-conditioning, only conditioning can regain or improve comfortable performance. Any activity limitations should be approached very carefully as they can have very untoward impact on both the individual's body and livelihood but mortality before age 65 years. See Risks of Limiting Activity data that make it imprudent for the clinician to focus treatment on pain as the risks pale in comparison. Reliable studies do not find avoiding work or other activity to improve health, shortening time of symptoms, reduced surgical rates or improves future back health. 
 
The Three parts of Suggested Activity Progression   
      a.   Resume normal work activities immediately or soon as possible (See Activity Paradigm Confirmed). Limiting further debilitation with a home program to maintain endurance and progress to Specific Conditioning.  
      b.  General Conditioning for Stamina  
      Speed Walking or Stationary Cycling for 30 continuous minutes (minimum heart rate of 120 for those over age 40 or of 130 for those under age 40) or Jogging for 10-20 minutes. If you really want to save time, jump rope (500 repetitions/day). Begin the chosen activity five days per week. If a problem do morning, evening, skip a day, morning, evening etc., to get 18 hours between workouts. NOTE: Consider swimming for the severely debilitated or those with severe lower extremity joint problems as limiting impact or load does little to prepare us for daily activity or missteps. (Conditioning Handout Phase I). 
   After 5 days per week of conditioning for 6 weeks, general stamina can be maintained thereafter with 2 sessions per week of 30 minutes each (like an airplane, it takes much more energy to get up to altitude than stay there - 2 days a week of conditioning is usually enough to maintain it). 
      c. Specific Conditioning of Spine Muscle -   
      Conditioning the protective trunk muscles is based upon the work of Finn Biering-Sorensen (1985) who found those who could use their back, gluteal muscles and hamstrings to hold their trunk up against gravity for 3-4 minutes seemed to have the best protection against back problems the next year. Gundewall et al, (1993) used this epidemiological data to develop spine muscles training which reduced number new episodes in nurses to 1/10th and days off work for back symptoms to 1/5th compared to the untrained. The job of these specialized nurses was to lifted patients all days. The therapeutic goal was to begin holding the trunk up for 2 minutes, working to 4 minutes per day of spine muscle conditioning (Table 13 or Conditioning Handout Phase II
 
4. Education & Reassurance for those slower to recover  
      Reiterate the initial assurances of no hints of anything serious and expectations of rapid recovery, the importance of conditioning and reassure that that special studies will be considered to help explain the continued limitations if not significantly better by the end of 4 weeks  (Patient Discussion Handout #1). 
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Table 6: Initial Care Summary 
 
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TREATMENT beyond the first month.  Should the patient not be completely asymptomatic but improving and functioning reasonably, then continue active care to prevent disability and limit future symptoms (see post Procedural Care).  Should there be a significant worsening or emergence of a Red Flags then diagnostic considerations can always be addressed as needed -- function is the key since a lack of total comfort can result from many factors, physical and non-physical (see Non-Physical interference). 
 
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