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Low back pain and the Reconditioning Phase, Step 2: Adaptation

Musculoskeletal disorders are the biggest cause of disability. Despite the billions spent, the problem is just getting worse. Latest medical guidelines strongly recommend exercise therapy as the first-line-treatment for musculoskeletal disorders instead of much more expensive surgeries.

By Geoffrey Mackay, getback Clinical Director and Co-Founder

Following the important first step of Reconditioning (Co-ordination), when the patient relearns how to control the multifidus muscle as it shortens and lengthens under load, the Therapist subtly moves the patient into the second training step: Adaptation.

In the getback programme, Adaptation refers to the ability of the targeted muscles to adjust to increased load with the aim of strengthening them.

During the Adaptation step the coordination and metabolism of the target muscles are further improved. It is very important that the right amount of resistance is prescribed, and that this resistance is specific to the muscle action being targeted.  

The Adaptation step is where the biomechanical properties of the getback devices come to the fore. The resistance applied by getback devices is constant through the full range of motion and places less pressure on surrounding structures. 

Anyone who has experienced back pain understands how tentative you can become when different forces are associated with movement. At this stage of training, we know that patients are generally reporting a decrease in pain and positive comments about posture and stability. The last thing we want to do is upset this improved feeling of wellbeing.

getback patients experience a sense of safety when exercising on the devices because the amount of resistance, range and speed of movement are precisely targeted and controlled. 

A subtle increase of resistance triggers the beginning of the Adaptation step and the range of movement and resistance are gradually increased, as tolerated, to 40 per cent of the predetermined range. 

This increase of the range of movement is important so that every segment of the spine is gradually opened, allowing the muscle to progressively and safely control the movement. These segmental movements are enhanced by the biomechanical properties of the devices, which sequentially control the movement of each segment of the spine. 

Important metabolic changes start to happen at a micro muscle level during the Adaptation step. It is important that the right amount of overload is prescribed to the targeted muscle to ensure there is carry over between sessions. 

In exercise based treatment there is a vast difference between just following a programme and moving and exercising at a very specific intensity. The more specific the prescription and delivery of the exercise, the greater amount of carryover there is between sessions. Along with with the level of specificity that the devices allow, getback programmes target the correct metabolic stimuli to promote optimal metabolic changes. 

‘Exercise is medicine’ at a macro level describes the myriad benefits exercise has on health. The Adaptation step is a good example of how correctly prescribed exercise stimulates muscles at a micro level to re-establish a normal functional state.  

Examples of patient compliance graphs

 

Flexion device, 2nd visit

Patient presented with pain aggravated while bending forward. The above compliance graph is consistent with a Step 1: Orientation. Starting at the bottom of the graph, the red lines show their movement was rushed and uncomfortable. Through the middle of exercise where the graph turns yellow, the patient’s trepidation was evident – the movements were slow with pauses between repetitions.

 

Flexion device 4th visit

After four visits, the same patient’s movements were comfortable. Hesitation and fear of movement was no longer apparent and the patient demonstrates good control for the majority of the exercises. This is the point where the therapist can consider moving the patient to the Step 2: Adaption.

The patient also reported that pain had decreased significantly, and their perceived effort had also dropped. This graph represents only one movement (the patient’s most difficult) – with all other movements the patient is reporting similar, if not better, results. 

 

Left Rotation device, 6th visit 

The graph demonstrates a patient who is clearly in the 2nd phase of the getback programme. Resistance is increasing, the range of movement is larger and other than the initial repetitions, the patient has good control with all contractions.

 

Left Rotation device, 9th Visit

During the 2nd phase of the getback treatment, if the patient demonstrates control consistently above 90% they can be introduced to Track Training. Track Training allows for advanced prescription and progressions and further challenges the patient’s control and coordination.

 

Case Graph showing the first two phases (11 sessions)

The  case graph above plots the patient’s journey over the initial getback appointments. 

To interpret this graph:

Red dots – represent a pain rating out of 10 the patient reported at the start of each treatment

Green dots – represents how hard the patient perceived each treatment session to be out of 5

Orange block – represents the change in resistance across the treatment programme

Grey block – represents the change in range of motion (how far the patient is moving in each treatment session). 

The light resistance (Orange) and the small movement (Grey) is the first step. 

As the resistance starts to increase, the patient is progressing towards the second step, with increased movement range and higher resistance. 

This patient is progressing well through the getback treatment programme.