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     a. Conditioning - Work Hardening & Home Program issues  
     b. Non-Physical Inference 
     c. Validation and Reflection to Seeking Options    
     d. Caught in the Contest  
     e. Defensible Opions and Impairment Guide Considerations 
Now it is time to be convincing to prevent chronic disability. After exhausting diagnostic and or surgical procedures for slow recovery or continuing care for improving patients, we return to a treatment paradigm with minor changes in emphasis to avoid chronic disability as displayed in Table: Disability Prevention below.  Whether due to the period of reduced activity or to changes in the motion segment, the focus of gaining comfortable activity tolerance turns now to conditioning. At this point nothing should stand in the way of the needed conditioning (Patient Handout # 3). (For further understanding why the goals must change see Psychological factors and treatment concerns about chronic disability
Table Disabiilty Prevention - overcome activity intolerance 
Now the major emphasis is to build comfort by improving the activity tolerance through conditioning. 
Why Conditioning: Consider the following non-confrontational dialogues designed to increase understanding through analogies and simple explanations. 
    A. When will the pain go away?  For increased understanding, review an analogy of the knee. 
"It makes no difference whether knee surgery is required or not.  Recovery only comes after conditioning the thigh muscles to the point of compensating for whatever knee problem remains.  With adequate conditioning of the protective muscles, some patients can return to rigorous professional athletics, not because the knee is normal but because there is adequate muscular compensation to tolerate the required activity.  This commonly requires the protective muscles to be conditioned beyond what they were before the knee problem.  Until reaching that point, the knee continues to be painful, doesn't tolerate activity, can be set off by any minor mishap and even gets red and swollen with use it until the muscular capacity improves.  It is similar with the spine." 
B. Why not just treat the pain? If the goal is only to treat the pain, clinicians often become trapped into avoiding activities that may be bothersome.  Obviously, inactivity can make the conditioning problem worse from a physiological standpoint but also elongate the period of reduced activity tolerance then risking livelihood where being off work increases the risk of death before age 65 years by 50%. See (Off Work Risks
Until muscles can do their normal protective compensatory job, every task is like gardening the first time in spring after resting all winter.  It isn't necessarily painful when we start, but after we tire or specific muscles begin to fatigue, we pay for it that night, the next day or even right away.  The pain is not from doing something dangerous or having a serious problem.  It is the result of the winter rest.  It usually takes days of working in the garden before muscles become conditioned well enough to tolerate the activity comfortably. 
C. Conditioning Suggestions:  Helps patients understand how a lack of general stamina can prolong symptoms and how the training of specific spine muscles provides protection from future problems. "Our best science indicates that conditioning involves addressing two weak links that can keep protective muscles from reacting fast enough to keep your spine from being irritated.  The most obvious is fatigue of the specific back muscles.  When fatigued, they react slower and can't do their normal dampening with activity.  Also, if the owner of those muscles becomes even a little tired, the spine muscles react slower.  Fatigue robs us of our coordination and reactions." (see Why Conditioning). 
Medical Basis: Nothing, surgical or non-surgical, makes the back young again after a few weeks of limiting symptoms or significant sciatica.  For 1/3 of us by 30 and all by age 50, the key to treatment is to gain enough muscular compensation to reduce the frequency and severity of future episodes of back problems.  
 D. Simple Safe Home Conditioning Program: 
The Safe conditioning process can simply start with completion of: 
1. General endurance training to build comfortable activity tolerance beginning 3-5 days per week for six weeks with a pulse rate in healthy individuals above 120 beats per minute (if >40 y/o) and 130 beats per minute (if <40 y/o). This is especially important to avoid debilitation should a patient decides to limit regular activity. This is accomplished either with continuously walking or stationary cycling for 30 minutes, or working up to jogging 15-20 minutes 5 days per week (Conditioning Handout I).   
2. Specific back muscle conditioning can be started after only a few weeks of general endurance training.  The aim is to gain specific muscular protection by achieving continuously holding the weight of the trunk up against gravity fro 4 minutes daily for 4 weeks (Conditioning Handout II). 
Table Proven impact Specific Erector Spinae Conditioning  
Fig. Specific Erector Spinae Conditioning 
Raise chest and limbs from position A to B holding lumbar curve in a neutral position similar to standing. 
Begin holding with back in neutral position 1 1/2 minutes and work up to 4 minutes over about 2 weeks. 
       [Do not go up and down - hold!]    Back muscles must burn 30 or more seconds each time to progress. 
Further exercises are not really treatment of the spine but a "spring training" or "basic training" attempt to get back what is lost when inactive due to back symptoms.  Thus, this is really re-conditioning and eventually maintenance of arms, legs and abdominal muscles.  Dips, for the arms, can be performed in an armchair.  Leg exercises can include either squats at the sink or the old ski conditioning exercise of assuming the sitting position against a wall without a chair.  The abdominal muscle conditioning can be gentle on the back.  All of these can be performed in less than 5 minutes of effort and usually can be added after 4 weeks of specific spine muscle conditioning or made much more elaborate. 
Table Pain and Activity Tolerance Changes with Home Conditioning 
     Above is a charted experience with 405 visits of 116 patients for whom activation was recommended.  Note that patients with both acute back problems and chronic back problems of more than 3 months respond about the same the greatest change of VAS rating both pain and activity tolerance after completing 4 weeks of Specific Back Muscle Conditioning, better than just completing the General Endurance Training. 
     An additional simple Specific Back Muscle Conditioning for upper back and neck is also available (Conditioning Handout Phase II arm circles).  Once an individual's shoulders will tolerate 100 continuous small arm circles slowly, the small circles are performed as rapidly as possible to recruit the upper back and neck muscles.  Canned goods (tuna to pears) and even weights can be added to gain further needed conditioning for young mesomorphs.   
Work Hardening should be reserved, if at all possible, for gradual return to work activities at work. The basic concept is to observe the patient performing as many repetitions of a specific limited task as tolerated. If unable to tolerate a full circuit, then repetitions need to be built with a portion of the load (3/4 or 2/3 the requirement) until one circuit of problem tasks can be completed. Then begin 3/4 to 2/3 of full load while building the repetitions beyond what is required, then gradually increasing the load to the normal level. The speed of progression and eventual endpoint can be predicated by many physical and non-physical factors. A work hardening approach performed in the normal work milieu increases the chance of success, aided by peer pressure encouragement to overcomes many more fears and reduces potential costs to the patient.  
Home Conditioning Considerations 
A back problem can reduced the comfort level at work and at home.  For most people comfortable tolerance of work activities initially comes from adapting to regularly doing the work activities.  Improving the comfort level at work is similar to more extreme circumstances like spring training to comfortably tolerate the regular season or boot camp to more comfortably tolerate the rigors of being a foot soldier.  Closer to home, only by continuing to garden can we restore comfortable gardening tolerance, should the long winter's rest makes the first spring efforts uncomfortable.   
Our intention is to provide proven effective activity recommendations for those not carrying out regular daily activities. This can safely be carried out to the reliable literature (see AHCPR Guide #14 and  Malmivaara 2/9/95 NEJM). with activities less stressful on the back than sitting on the side of the bed before rising. Thus, safe activities to improve comfortable activity tolerance can be explained and should be part of a home program that is welcomed by those confident enough to be interested. Thereafter the patient can decide as to whether (s)he is having enough difficulty now to do this safe conditioning. Only the individual can decide whether the present situation is comfortable enough. If so, then the patient will have a safe conditioning program available for use whenever needed to be more comfortable.  
Data indicates that the "only activity-begets-activity" paradigm is even more important the older we get and after we have had an episode of back symptoms that affects our comfortable activity tolerance.  Knowing there is no way to make anyone's spine feel young again after experiencing a few weeks of back pain or an episode of sciatica, we want to help our associates be more comfortable at work and home.  The best data we have been able to find in the literature relates to activity such as work or exercise to build general activity tolerance and exercise for specific back muscle endurance for future protection.   
Eye Inflamation Analogy Other reason to stay active — to be more comfortable!  We want is to be sufficiently active so that pain lingers no longer than necessary (as found in multiple studies).  We commonly hurt whether we are active or not. Science indicates that exercise may well help us with symptoms beyond speeding recovery of comfortable tolerance of activity. 
Illustrations: Painful eye inflammation & nerve root irritation - something in common! 
You can hardly touch your eye when extremely inflamed with conjunctivitis and blephoritis. Yet, when our eye is not inflamed we can rub it vigorously without discomfort.  The impact of inflammation appears to be similar for nerves in the spinal canal. When inflamed, nerve seems less tolerant of mechanical stimulation. Recovery from inflammation better explains the rapid recovery from back symptoms and sciatica better than any noticeable reduction in mechanical stimulation. 
An "eye inflammation" analogy for rapid changes in back and/or sciatica symptoms.   
Commonly patients report back problems after a abruptly returning to a specific activity.  We have some hints that back problem’s initial recovery and recurrent episodic nature may relate to normal occurring inflammatory substances that can irritate back nerves.  The concept of our irritated back or nerve roots may be analogous to an  “inflamed eye".  Some natural occuring nerve irritating substances have been found in the disk. Perhaps the frequency and severity or initial and recurrent episodes can be best explained by these natural occurring irritants building up to a toxic level with inactivity before then being mechanically dislodged in higher concentrations that can inflame nerves with an abrupt increase in activity.  Regular continuous physical activity may keep these “irritating substances” sufficiently diluted to not then reach a neurotoxic concentration capable of inflaming nerves.  Like the inflamed eye, inflamed sciatic or local nerves become more sensitive to mechanical irritation of Stenosis or disk material similar to inflamed eye being rubbed or touched.  
The inflammation may explain the relatively rapid abatement of sciatica symptoms while a large herniated disk remains unchanged on the MRI scan. We can use the "eye inflammation" analogy to explain to patients why they should find daily activities, e.g., walk, jog, jump rope, bike, climb stairs etc., not only to build activity tolerance and a more restful sleep but if done regularly help minimize symptoms by perhaps diluting those irritating “irritating substances” so their concentrated remain insufficient to inflame nerves. (see chemical irritation of nerves) 
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