Spine
SPINE Volume 39, Number 19, pp 1630-1631 ©2014, Lippincott Williams & Wilkins
L etters TEN YEARS W IT H O U T LO W BACK PAIN Assen Romanov Aleksiev, MD, PhD
“Ten-year follow-up of strengthening versus flexibility exer cises with or without abdominal bracing in recurrent low back pain”—answer from the author of this article Associ ate Prof Assen Romanov Aleksiev to the comments of Leanne Buitendijka, Pieter Vissersa, and Ligia Maxwell Pereira. I am so grateful for the interest in this article. Despite my previous awarded/fancy/high-tech publications, my 10-year follow-up study is the pinnacle of my work and all my life. The greatest reward for me was that I completely got rid of my back pain 10 years ago by following the advices studied in this article. Even better, during the last 10 years, I am helping more patients to get rid of their back pain too by includ ing these simple advices in addition to temporarily relieving them by expensive/state-of-the art medical devices/methods and medicines. No other prevention advice worked signifi cantly for my patients and me. During my 25-year career as a physician, my files have records of more than 20,000 patient visits (including many medical doctors and professors from all medical specialties). I personally analyze, treat, study, and follow-up all cases with spine-related problems (pelvic, back, thoracic, neck, and cervicocranial). It is ironic that namely the pain in my back made me study Medicine. I experienced juvenile recurrent low back pain (LBP) despite my regular sporting activities—swimming every day from the age of 7, skiing from the age of 10+ , playing tennis from the age of 15+ , windsurfing from the age of 18+, and scuba diving from the age of 20+. I was very disappointed that my back pain reappeared periodically despite my “solid” MD education (for 6 yr). Ambitiously, I specialized physical and rehabilitation medicine (+4 yr), but again with no effect on my periodic back pain, regard less of my knowledge and skills in modalities and kinesitherapy. Eagerly, I completed a continuous medical education in manual medicine/therapy (+ 1 yr), which is similar to chiro practic and osteopathy. I am an international lecturer on this highly specialized and dangerous medical specialty, brilliantly manipulating with excellent effect, but only temporal—the back pain was reappearing for my patients and me. Obsessed by the idea to fight to the end with the back pain I defended dissertation on LBP (+4 yr), studying in detail everything currently available about this problem, but my pain was coming back more often, stronger and longer. In addition, I completed (and currently lecturing) other continuous medical
The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No relevant financial activities outside the submitted work. DOI: 10.1097/BRS.0000000000000503
1630
www.spinejournal.com
education trainings (postisometric relaxation, laser-therapy, traction therapy, mesotherapy, electroanalgesia, electrostimu lation, electrodiagnostics, electromyography, biomechanics, and pathological biomechanics of the spine, neuroscience, and health management) (+ 3 yr totally), but again with tem poral results. I did not give up and became a post-PhD visit ing scientist in the Iowa Spine Research Center (+2 yr), where I won 2 prestigious international awards in the same field (as first and second author). Not only did I fail to “save the world” from the back pain, but also I failed to help myself. Even worse— for 2 years in the United States, I became over weight (by 20 kg), got high blood pressure, high blood sugar, headache, tiredness, insomnia at night, sleepiness during the day, edematous ankles, and almost constant and invalidat ing LBP. Upon returning to Bulgaria, I changed my behav ior toward the sedentary life that was killing me, including my spine. Instead of trying to cure something, which I finally realized that could not be cured, I used all my knowledge, skills, and efforts to prevent the next recurrences. Obviously, it is better to prevent than to treat, but it is easier to say than to achieve it. The most difficult part is the scientific proof. The endless preventive recommendations are not effective due to subjective reasons (the “human factor”)— “failed,” “skipped,” “shortened,” “missed,” “wrong,” “inappropri ate,” “difficult,” “overworked,” “lazy,” “impossible,” and many other patients’ excuses. For example, the well-known advice to bend/rise with straightened back is very good, but it is simply impossible during brushing teeth, washing face, shaving beard, washing dishes, etc.-, however, such simple and frequent activities, requiring forward shifting of the center of pressure, are often triggers to LBP episodes in the anamnesis of too many patients. Another excellent idea is the retract able table for office work in sitting and upright posture, but it is used lesser and lesser to the point of no use. The big gest challenge today is to teach the “busy/lazy modern man” very few preventive advices (but no more than 3), which are simple, short, effective, and not interfering with activities of daily living and recreation, so that they can be performed as frequently as possible. It seemed “mission impossible” 10 years ago, when I began to try and study all available pre ventive advices firstly on myself, then on healthy volunteers and finally on patients with LBP, according to all academic and ethical requirements. After 25 years of clinical experi ence and 20 years of increasingly specialized medical train ing, I “reinvented the wheel”—3 well-known advices that are so simple and natural, that it is unbelievable that they are so effective. Most patients expect to hear something fancy/ high-tech/expensive to think that it is helpful. More than 10 years, I am following these advices frequently/shortly/strictly and I have no back pain at all 10 years in a row, although I still practice tennis and skiing. They used to exaggerate my back before but not now, nevertheless that these sports are not recommendable for patients with LBP. S eptem ber 2 0 1 4
Spine
L etters
Finally, I found peace and fulfilled my mission as a patient with LBP and as a doctor. What interests me more now is to share my experience and help more people, absolutely free, because I already “know how.” This is more important than all my accomplishments till now—100 publications, 500 cita tions, international awards, a Head of a clinic, an academic teacher (of MD students, MD graduates, MD postgraduates, MD specialists, GPs, etc.), a national consultant in physical medicine and rehabilitation, an honorary member of national and international societies, a national reviewer, honorary posts of my CV in international bibliographic data bases, etc. Simply, I am trying to convince my patients to exercise more frequently but without any luck except for those that learned to brace. Most of the patients with LBP “do not like to exercise.” The pain is a natural reminder to do something. Unfortunately, it is too late to do anything after the pain reap peared. Most patients immobilize themselves during exacer bation. Very few (mostly those that learned to brace) increase the frequency of bracing and/or exercising due to their previ ous experience that it helps more than the immobilization. They report that it is easier and with less pain to do any daily task with bracing. I always explain them that the frequent bracing and exercising is more important as prevention dur ing the pain-free episodes rather than as treatment during the recurrence. The patients always agree and promise to do it all their life; however, the whole scenario usually is repeating. By now, I have not found any preventive advice (except bracing), that increases the exercise frequency during the pain-free epi sodes of patients with LBP. Answer to comment 1. The eligibility criteria, derived from the patient’s anamnesis and the conventional for my clinical analysis (neurological status, orthopedic status, kinesiologic analysis, etc.), were not only the age, but anamnesis of at least 2 episodes of recurrent nonspecific LBP in the past 12 months, each episode lasting more than 24 hours, preceded and sepa rated by a period of at least 1 month without LBP. Exclusion criteria were neurological deficits, structural anomalies, spi nal cord compressions, severe osteoporosis, acute infections,
S p in e
tumors, and severe cardiovascular, pulmonary, hepatic, renal, or metabolic disorders. The baseline level of pain was not set as part of the inclusion/exclusion criteria. Most of my patients usually have more severe pain probably due to the highest level of service in the oldest and the biggest University hospital in Bulgaria that I am working in. In addition, I am a national consultant in the field, so usually the worst cases come to me. The moderate and the minor cases commonly are covered by the peripheral health system. Answer to comment 2. Helping patients with spine prob lems is my passionate hobby and I am doing it for free (includ ing the research). My patients relay on me as an expert and a trustful friend. They consult with me (24 hr, daily) as a first choice physician irrespective of the medical problem they may have. My specialty requires knowledge in the whole human medicine—there is no disease that cannot be rehabilitated. I am not looking for patients—they are looking for me and are participating voluntarily in my voluntary research. Answer to comment 3. The time course for the pain dura tion was equal to the duration of the last exacerbation during the year that passed. The reasoning is that the patient still remembers the duration of the last exacerbation, but not always the previous ones. The pain intensity reflected a single moment of maximal pain, which was usually at the begin ning of the last exacerbation during the year that passed. This way, the multiple comparisons are more correct. The reason ing is that at the end of each consecutive year there are dif ferent time intervals since the last recurrence. If the pain was measured at the moment of the visit, the pain was lower. The time course for the pain frequency was 1 year—it reflected the number of recurrences during the year that passed. Assen Romanov Aleksiev, M.D., PhD Associate Professor Bulgarian National consultant in Physical Medicine and Rehabilitation, Head o f the Clinic o f Physical Medicine and Rehabilitation at the University Hospital “Alexandrovska”, and lecturer at the Medical University, Sofia, Bulgaria
w w w .s p in e jo u rn a l.c o m
1631
Copyright of Spine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
SPINE Volume 39, Number 19, pp 1630-1631 ©2014, Lippincott Williams & Wilkins
L etters TEN YEARS W IT H O U T LO W BACK PAIN Assen Romanov Aleksiev, MD, PhD
“Ten-year follow-up of strengthening versus flexibility exer cises with or without abdominal bracing in recurrent low back pain”—answer from the author of this article Associ ate Prof Assen Romanov Aleksiev to the comments of Leanne Buitendijka, Pieter Vissersa, and Ligia Maxwell Pereira. I am so grateful for the interest in this article. Despite my previous awarded/fancy/high-tech publications, my 10-year follow-up study is the pinnacle of my work and all my life. The greatest reward for me was that I completely got rid of my back pain 10 years ago by following the advices studied in this article. Even better, during the last 10 years, I am helping more patients to get rid of their back pain too by includ ing these simple advices in addition to temporarily relieving them by expensive/state-of-the art medical devices/methods and medicines. No other prevention advice worked signifi cantly for my patients and me. During my 25-year career as a physician, my files have records of more than 20,000 patient visits (including many medical doctors and professors from all medical specialties). I personally analyze, treat, study, and follow-up all cases with spine-related problems (pelvic, back, thoracic, neck, and cervicocranial). It is ironic that namely the pain in my back made me study Medicine. I experienced juvenile recurrent low back pain (LBP) despite my regular sporting activities—swimming every day from the age of 7, skiing from the age of 10+ , playing tennis from the age of 15+ , windsurfing from the age of 18+, and scuba diving from the age of 20+. I was very disappointed that my back pain reappeared periodically despite my “solid” MD education (for 6 yr). Ambitiously, I specialized physical and rehabilitation medicine (+4 yr), but again with no effect on my periodic back pain, regard less of my knowledge and skills in modalities and kinesitherapy. Eagerly, I completed a continuous medical education in manual medicine/therapy (+ 1 yr), which is similar to chiro practic and osteopathy. I am an international lecturer on this highly specialized and dangerous medical specialty, brilliantly manipulating with excellent effect, but only temporal—the back pain was reappearing for my patients and me. Obsessed by the idea to fight to the end with the back pain I defended dissertation on LBP (+4 yr), studying in detail everything currently available about this problem, but my pain was coming back more often, stronger and longer. In addition, I completed (and currently lecturing) other continuous medical
The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No relevant financial activities outside the submitted work. DOI: 10.1097/BRS.0000000000000503
1630
www.spinejournal.com
education trainings (postisometric relaxation, laser-therapy, traction therapy, mesotherapy, electroanalgesia, electrostimu lation, electrodiagnostics, electromyography, biomechanics, and pathological biomechanics of the spine, neuroscience, and health management) (+ 3 yr totally), but again with tem poral results. I did not give up and became a post-PhD visit ing scientist in the Iowa Spine Research Center (+2 yr), where I won 2 prestigious international awards in the same field (as first and second author). Not only did I fail to “save the world” from the back pain, but also I failed to help myself. Even worse— for 2 years in the United States, I became over weight (by 20 kg), got high blood pressure, high blood sugar, headache, tiredness, insomnia at night, sleepiness during the day, edematous ankles, and almost constant and invalidat ing LBP. Upon returning to Bulgaria, I changed my behav ior toward the sedentary life that was killing me, including my spine. Instead of trying to cure something, which I finally realized that could not be cured, I used all my knowledge, skills, and efforts to prevent the next recurrences. Obviously, it is better to prevent than to treat, but it is easier to say than to achieve it. The most difficult part is the scientific proof. The endless preventive recommendations are not effective due to subjective reasons (the “human factor”)— “failed,” “skipped,” “shortened,” “missed,” “wrong,” “inappropri ate,” “difficult,” “overworked,” “lazy,” “impossible,” and many other patients’ excuses. For example, the well-known advice to bend/rise with straightened back is very good, but it is simply impossible during brushing teeth, washing face, shaving beard, washing dishes, etc.-, however, such simple and frequent activities, requiring forward shifting of the center of pressure, are often triggers to LBP episodes in the anamnesis of too many patients. Another excellent idea is the retract able table for office work in sitting and upright posture, but it is used lesser and lesser to the point of no use. The big gest challenge today is to teach the “busy/lazy modern man” very few preventive advices (but no more than 3), which are simple, short, effective, and not interfering with activities of daily living and recreation, so that they can be performed as frequently as possible. It seemed “mission impossible” 10 years ago, when I began to try and study all available pre ventive advices firstly on myself, then on healthy volunteers and finally on patients with LBP, according to all academic and ethical requirements. After 25 years of clinical experi ence and 20 years of increasingly specialized medical train ing, I “reinvented the wheel”—3 well-known advices that are so simple and natural, that it is unbelievable that they are so effective. Most patients expect to hear something fancy/ high-tech/expensive to think that it is helpful. More than 10 years, I am following these advices frequently/shortly/strictly and I have no back pain at all 10 years in a row, although I still practice tennis and skiing. They used to exaggerate my back before but not now, nevertheless that these sports are not recommendable for patients with LBP. S eptem ber 2 0 1 4
Spine
L etters
Finally, I found peace and fulfilled my mission as a patient with LBP and as a doctor. What interests me more now is to share my experience and help more people, absolutely free, because I already “know how.” This is more important than all my accomplishments till now—100 publications, 500 cita tions, international awards, a Head of a clinic, an academic teacher (of MD students, MD graduates, MD postgraduates, MD specialists, GPs, etc.), a national consultant in physical medicine and rehabilitation, an honorary member of national and international societies, a national reviewer, honorary posts of my CV in international bibliographic data bases, etc. Simply, I am trying to convince my patients to exercise more frequently but without any luck except for those that learned to brace. Most of the patients with LBP “do not like to exercise.” The pain is a natural reminder to do something. Unfortunately, it is too late to do anything after the pain reap peared. Most patients immobilize themselves during exacer bation. Very few (mostly those that learned to brace) increase the frequency of bracing and/or exercising due to their previ ous experience that it helps more than the immobilization. They report that it is easier and with less pain to do any daily task with bracing. I always explain them that the frequent bracing and exercising is more important as prevention dur ing the pain-free episodes rather than as treatment during the recurrence. The patients always agree and promise to do it all their life; however, the whole scenario usually is repeating. By now, I have not found any preventive advice (except bracing), that increases the exercise frequency during the pain-free epi sodes of patients with LBP. Answer to comment 1. The eligibility criteria, derived from the patient’s anamnesis and the conventional for my clinical analysis (neurological status, orthopedic status, kinesiologic analysis, etc.), were not only the age, but anamnesis of at least 2 episodes of recurrent nonspecific LBP in the past 12 months, each episode lasting more than 24 hours, preceded and sepa rated by a period of at least 1 month without LBP. Exclusion criteria were neurological deficits, structural anomalies, spi nal cord compressions, severe osteoporosis, acute infections,
S p in e
tumors, and severe cardiovascular, pulmonary, hepatic, renal, or metabolic disorders. The baseline level of pain was not set as part of the inclusion/exclusion criteria. Most of my patients usually have more severe pain probably due to the highest level of service in the oldest and the biggest University hospital in Bulgaria that I am working in. In addition, I am a national consultant in the field, so usually the worst cases come to me. The moderate and the minor cases commonly are covered by the peripheral health system. Answer to comment 2. Helping patients with spine prob lems is my passionate hobby and I am doing it for free (includ ing the research). My patients relay on me as an expert and a trustful friend. They consult with me (24 hr, daily) as a first choice physician irrespective of the medical problem they may have. My specialty requires knowledge in the whole human medicine—there is no disease that cannot be rehabilitated. I am not looking for patients—they are looking for me and are participating voluntarily in my voluntary research. Answer to comment 3. The time course for the pain dura tion was equal to the duration of the last exacerbation during the year that passed. The reasoning is that the patient still remembers the duration of the last exacerbation, but not always the previous ones. The pain intensity reflected a single moment of maximal pain, which was usually at the begin ning of the last exacerbation during the year that passed. This way, the multiple comparisons are more correct. The reason ing is that at the end of each consecutive year there are dif ferent time intervals since the last recurrence. If the pain was measured at the moment of the visit, the pain was lower. The time course for the pain frequency was 1 year—it reflected the number of recurrences during the year that passed. Assen Romanov Aleksiev, M.D., PhD Associate Professor Bulgarian National consultant in Physical Medicine and Rehabilitation, Head o f the Clinic o f Physical Medicine and Rehabilitation at the University Hospital “Alexandrovska”, and lecturer at the Medical University, Sofia, Bulgaria
w w w .s p in e jo u rn a l.c o m
1631
Copyright of Spine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
