Sports activities in general only have limited effect on chronic pain conditions

Several studies have demonstrated that lack of physical activity leads to an increasing instability in the spine and increases risks for future back pain (Teichthal et al., 2015b). This correlation seems to even be higher with increasing with age (Dahlqvist et al., 2017; Hicks et al., 2009). Despite this clear connection, it has been shown that physical activity as therapeutic measure only has limited efficiency. Studies on high-level athletes have revealed multiple cases with paraspinal atrophies and chronic back pain. It seems that high frequencies of physical activity and the presence of well-developed skeletal muscles do not prevent from developing chronic back pain (Hides et al., 2008; Wassermann et al., 2018). It can thus be concluded that for successful rehabilitation treatment options need to focus on targeting the deep paraspinal back muscles. 

Isolated training of paraspinal back muscles using a fixation system

The results of multiple studies have shown that exercise programs that strengthens the paraspinal muscles are capable to relief the pain symptoms (Hides et al., 2008; Steele et al., 2015b). Due to its primary function for upright positioning and stabilizer for the spine, paraspinal back muscles cannot be contracted voluntarily. Therefore, isolated training performed with high intensities is very challenging. Other muscle groups such as the hip extensors commonly carry big parts of the load so that training stimulus for the paraspinal muscles is significantly minimized (Steele et al., 2015b). During the last two decades intensive research has been performed in order to develop training machines that decrease the activity of other muscle groups. Optimal results were achieved using a fixation system that is the basis of the Dr. Alfen therapy devices. Via a dorsal pelvic stabilization and through semi-sitting positioning the hip extensors and lower limb muscles are deactivated (da Silva et al., 2009; San Juan et al., 2005; Larivière et al., 2010). The same principles were applied in the development of the training devices for the neck region (Schomacher & Falla, 2013; Pollock et al., 1993). It seems that maximal training stimulus leading to local muscles exhaustion can only be achieved using this fixation system. Information on current strength levels and potential deficits can be gained from isometric strength tests (Graves et al., 1990a,b; Robinson et al., 1992) 

For optimal results and low-risk training protocols need to be adapted to the patients’ diagnoses

Due to acute pain it is often not possible to exercise with high intensities und within a large range of motion (ROM). Therefore we strongly recommend adapting the ROM and the training weights to the current symptoms and the underlying morphological changes in the spine. Interestingly, this does not lead to a reduced efficiency. Studies have shown that training within a limited ROM does eventually have therapeutic effects on the full ROM (Graves et al., 1992; Steele et al., 2013). Therefore, training protocols can be adapted to the underlying diagnoses. From our experience the right choice and optimal progression of ROM and weights are essential for optimal rehabilitation. We have developed a system (Alflexus Software) that contains pre-settings for more than 240 spinal diagnoses. Using this system, a therapist can optimally guide training progression and at the same time guarantee low risk for the patient. That is especially crucial when the patient has advances structural changes in the spine (disk herniation, stenosis, spondyle arthristis etc.).

Training frequency and intensity

According to the literature available, 1-2 high intensity training sessions a week and maximum muscle fatique are sufficient to achieving ideal therapy results (Steele et al., 2015a,b; Graves et al., 1990b; Pollock et al., 1989). Intriguingly enough, the number of sets is irrelevant, so one high intensity set each training session is sufficient to reaching maximum exhaustion. However the current pain condition and wellbeing has to be considered when increasing the weight. Also the therapy has to be started with submaximum intensity. To achieve lasting results, the patient has to complete all 18 training sessions. However as previously described, the adjustment of the patient to structural modifications is a crucial factor in achieving a successfull rehabilitation. Patients that suffer from a disc prolapse for example, have to be trained differently than patients suffering from degenerative spine diseases. 

Clinical outcome

Scientifically it is evident that isolated extension resistance training provides superior results for rehabilitating patients from back pain than any other type of exercise (Steele et al., 2015a). It appears to be sufficient and effective for significant and meaningful improvements in perceived pain and disability (Steele et al., 2017; Pollock et al., 1993; Evans et al., 2002). This clinical outcome is associated with increased isometric lumbar extension strength (Steele et al., 2018). These findings are supported by a recent study by Steele and co-workers in which it has been shown that intervertebral discs can heal and regenerate with medical strengthening therapy (Steele et al., 2015c).