Effectiveness of Pharmacological Therapies and Non Pharmacological Therapies for Low Back Pain
James M. Whedon DC, Andrew W.J. et al: Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Risk of Adverse Drug Events. Journal of Manipulative and Physiologicial Therapeutics, https://doi.org/10.1016/j.jmpt.2018.01.004. Conclusion: Among New Hampshire adults with office visits for low back pain, the adjusted likelihood of an adverse drug event (ADE) was significantly lower for recipients of chiropractic services as compared to nonrecipients. No causal relationship was established between utilization of chiropractic care and risk of an ADE.
Prof Nadine E Foster, Prof Johannes R Anema et al: Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet, Published: March 21, 2018. Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.
Matheus Almeida, Bruno Saragiotto et al: Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018; 208 (6): 272-275. || doi: 10.5694/mja17.01152 April 2018. Main recommendations: Use a clinical assessment to triage patients with LBP. Further diagnostic workup is only required for the small number of patients with suspected serious pathology. For many patients with non-specific LBP, simple first line care (advice, reassurance and self-management) and a review at 1–2 weeks is all that is required. If patients need second line care, non-pharmacological treatments (eg, physical and psychological therapies) should be tried before pharmacological therapies. If pharmacological therapies are used, they should be used at the lowest effective dose and for the shortest period of time possible. Exercise and/or cognitive behavioural therapy, with multidisciplinary treatment for more complex presentations, are recommended for patients with chronic LBP. Electrotherapy, traction, orthoses, bed rest, surgery, injections and denervation procedures are not recommended for patients with non-specific LBP.
Roger Chou, MD; Richard Deyo, MD et al: Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline, Annals of Internal Medicine 2017. Several systemic medications for low back pain are associated with small to moderate, primarily short-term effects on pain. New evidence suggests that acetaminophen is ineffective for acute low back pain, and duloxetine is associated with modest effects for chronic low back pain.
Roger Chou, MD; Richard Deyo, MD et al: Non Pharmacologic Therapies for Low Back Pain: A systematic review for an Americal College of Physicians Clinical Practice Guidline, Annals of Internal Medicine 2017. Several non pharmacologic therapies for primarily chronic low back pain are associated with small to moderate, usually short-term effects on pain; findings include new evidence on mind–body interventions.
Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD et al; For the Clinical Guidelines Committee of the American College of Physicians: Non invasive treatments for acute, subacture, and chronic low back pain: A clinical practice guideline from the American College of Physicians: Annals of Internal Medicine 2017.
Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).
Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select non pharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).
Recommendation 3: In patients with chronic low back pain who have had an inadequate response to non pharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).
Gustavo C Machado,1 Chris G Maher et al: Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis, Ann Rheum Dis 2017;0:1–10. doi:10.1136/annrheumdis-2016-210597. NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo. There is an urgent need to develop new drug therapies for this condition.
Safety of Chiropractic Care
James M. Whedon DC, Yunjie Song PhD, Todd A. Mackenzie PhD et al: Risk of Stroke after Chiropractic Spinal Manipulation In Medicare B Beneficiaries Aged 66 To 99 Years With Neck Pain, JMPT 2015: 38(2). Among Medicare B Beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.
Ephraim W Church, Emily P Sieg et al: Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016 Feb; 8(2): e498
Flexion Distraction Therapy Spinal Decompression Manipulation
Cox, JM, Feller JA, Cox JA: Distraction Chiropractic Adjusting: Clinical Application, Treatment Algorithms, and Clinical Outcomes of 1000 Cases Studied. Topics in Clinical Chiropractic 1996; (3)3:45-59, 79-81. Data from 1000 flexion distraction cases were collected from 30 different clinics. The researchers reported a median 29 days and a median 12 visits for maximal improvement. Less than 9% of cases reached the chronic stage and less than 4% of cases were candidates for surgery after care. The results were separated by conditions to highlight that lumbar disc herniation generally requires more visits and days till maximum improvement than a lumbar sprain/ strain.
Murphy, DR; Hurwitz, EL; Gregory, AA; Clary, R. A non-surgical approach to the management of lumbar spinal stenosis: A prospective observation cohort study. BMC Musculoskeletal Disorders 2096; 7. Study of Cox distraction manipulation on the treatment of lumbar spine stenosis. Lumbar spinal stenosis improved by 76% and disability improved in 73%.
Maruti R. Gudavalli, PhD, Kurt Olding, DC, George Joachim, DC, James M. Cox, DC: Chiropractic Distraction Spinal Manipulation on Post-surgical Continued Low Back and Radicular Pain Patients: A Retrospective Study Series. Journal of Chiropractic Medicine: June 2016 15 1 Number 2: 121-128. Greater than 50% pain relief following chiropractic distraction spinal manipulation was seen in 81% of post-surgical patients receiving a mean of 11 visits over a 49 day period of active care. At 24 month follow up, 79% continued with greater than 50% pain relief. The mean pain relief at the end of active care was 72% and at 24 months was 70%. 24 months after active care, 24 patients (43%) had not sought continued care while 32 required further care (chiropractic for 17 (53%), PT, exercise, injection, medication for 9(28%), surgery for 5 (16%).
Oh H, Lee S, Lee K, Jeong M: The effects of flexion-distraction and drop techniques on disorders and Ferguson’s angle in female patients with lumbar intervertebral disc herniation. J Phys Ther Sci. 2018 Apr;30(4):536-539. doi: 10.1589/jpts.30.536. Epub 2018 Apr 13. Conclusion: Flexion-distraction and drop techniques may be an effective intervention to improve disorders and Ferguson’s angle in female patients with lumbar intervertebral disc herniation.
Gudavalli R, Cambron J, McGregor M et al: A randomised clinical trial and subgroup analysis to compare flexion-distraction with active exercise for chronic low back pain. European Spine Journal 2006; 15: 1070-1082. Both groups improved significantly after treatment. Patients assigned to flexion distraction did better than active exercise. Patients with radiculopathy improved significantly better with flexion distraction therapy.
Cambron GA, Gudavalli MR, McGregor M et al: Amount of health care and self-care following a randomized clinical trial comparing flexion-distraction with exercise program for chronic low back pain. Osteopathy and Chiropractic 2006; 14:19. During a one-year follow-up, participants previously randomized to physical therapy attended significantly more healthcare visits for low back pain than those participants who received chiropractic care. 38% of flexion–distraction patients sought care. 54% of physical therapy patients sought care.
Snow G: Chiropractic management of a patient with lumbar spinal stenosis. JMPT 2001; 24(4): 300-304
- severe, multilevel central canal stenosis in a 78-year-old man
- low back pain and severe bilateral leg pain
- MRI – severe degenerative lumbar stenosis at L3-L4 and L4-L5 and at L2-L3 (less so)
- Treatment – flexion-distraction manipulation of the lumbar spine
- Outcome – decrease in the frequency and intensity of his leg symptoms and a resolution of his low back pain. These improvements were maintained at a 5-month follow-up visit.
Morris CE: Chiropractic rehabilitation of a patient with S1 radiculopathy associated with a large lumbar disk herniation. Journal of Manipulative and Physiological Therapeutics 1999; 22(1):38-44
- 31 y/o man with severe lbp, plantar flexion weakness of left leg, absent Achilles reflex, hypesthesia S1 dermatome, MRI large L5-S1 HNP
- Cox decompression distraction adjustment was part of the treatment resulting in RTW in 27 days.
- Repeat MRI showed no change
- 20 visits over 50 days with total remission. Absent Achilles maintained.
Hayden RA: Multilevel degenerative disc disease: a case study. Georgia Chiropractic Journal 1996; April: 6-7:34
- 61-year-old female with low back, hip and sciatic pain
- five years bedridden or restricted to the sofa
- Onset of the pain was gradual and worsened recently, interfering with work, sleep and rest. Lying flat on her back helped. Pain radiated to both calves at time, left more than right. The physician diagnosed her as having multi-level disc degeneration and degenerative joint disease with significant subluxation of the thoracolumbar spine. She was most symptomatic of a large, medial, contained L5/S1 disc protrusion with S1 nerve root compression.
- After four weeks of Cox® Distraction therapy, she reported no leg or back pain. She is able to walk and function again much to the delight of her family and the confusion of her friends.
Choi J1, Lee S2, Jeon C3. Effects of flexion-distraction manipulation therapy on pain and disability in patients with lumbar spinal stenosis. J Phys Ther Sci. 2015 Jun;27(6):1937-9. doi: 10.1589/jpts.27.1937. Epub 2015 Jun 30. COX FLEXION DISTRACTION EFFECT FOR TREATMENT OF SPINAL LUMBAR STENOSIS OVER OTHER CONSERVATIVE THERAPIES. THE VISUAL ANALOG SCALE SCORES FOR PAIN WERE SIGNIFICANTLY DECREASED IN BOTH GROUPS. IN THE BETWEEN-GROUP COMPARISON, THE DECREASE IN PAIN WAS MORE SIGNIFICANT IN THE FLEXION-DISTRACTION GROUP COMPARED TO PHYSICAL THERAPY. FLEXION-DISTRACTION MANIPULATION APPEARS TO BE AN EFFECTIVE INTERVENTION FOR PAIN AND DISABILITY AMONG PATIENTS WITH LUMBAR SPINAL STENOSIS.
Occupational Health, Safety & Ergonomics
Wiholm, C, Richter, H, Mathiassen, SE, & Toomingas, A. (2007). Associations between eyestrain and neck-shoulder symptoms among call-center operators. Scandinavian Journal of Work, Environment & Health, 54. Conclusions: The results from this study suggest an association between self-reported eyestrain and shoulder-neck symptoms. However, no causal relations could be derived due to the cross-sectional design.
Kallings, L. V., Blom, V., Ekblom, B., Holmlund, T., Eriksson, J. S., Andersson, G., Wallin, P., & Ekblom-Bak, E. (2021). Workplace sitting is associated with self-reported general health and back/neck pain: a cross-sectional analysis in 44,978 employees. BMC Public Health, 21(1), 875–875. https://doi.org/10.1186/s12889-021-10893-8. Conclusions: Sitting almost all the time at work and not taking breaks is associated with an increased risk for self-reported poor general health and back/neck pain. People sitting almost all their time at work are recommended to take breaks from prolonged sitting, exercise regularly and decrease their leisure time sitting to reduce the risk for poor health.
Dry Needling/ Acupuncture
Tekin L, Akarsu S, Durmus O et al: The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial. Clin Rheumatol. 2013 Mar;32(3):309-15. doi: 10.1007/s10067-012-2112-3. Epub 2012 Nov 9. The objective of this study was to test the hypothesis that dry needling is more effective than sham dry needling in the treatment of myofascial pain syndrome (MPS). This was a prospective, double-blinded, randomized-controlled study conducted in an outpatient clinic. Thirty-nine subjects with established myofascial trigger points were randomized into two groups: study group (N = 22) and placebo group (N = 17). Dry needling was applied using acupuncture needles, and sham dry needling was applied in the placebo group. The treatment was composed of six sessions which were performed in 4 weeks; the first four sessions were performed twice a week (for 2 weeks) and the last two, once a week (for 2 weeks). The visual analog scale (VAS) and Short Form-36 (SF-36) were used. When compared with the initial values, VAS scores of the dry needling group following the first and sixth sessions were significantly lower (p = 0.000 and p < 0.000, respectively). When VAS scores were compared between the groups, the first assessment scores were found to be similar, but the second and third assessment scores were found to be significantly lower in the dry needling group (p = 0.034 and p < 0.001, respectively). When SF-36 scores of the groups were compared, both the physical and mental component scores were found to be significantly increased in the dry needling group, whereas only those of vitality scores were found to be increased significantly in the placebo (sham needling) group. The present study shows that the dry needling treatment is effective in relieving the pain and in improving the quality of life of patients with MPS.
Eric Gattie, Joshua A. Cleland, Suzanne Snodgrass: The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: A systematic Review and Meta-analysis. Journal of Orthoaedic & Sports Physical Therapy. Vol. 47: Issue 3: Pages 133-149, March 17. Very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling, and other treatments for reducing pain threshold in patients presenting with musculoskeletal pain in the immediate to 12 week follow up period. Low-quality evidence suggests superior outcomes with dry needling for functional outcomes when compared to no treatment or sham needling. However, no difference in functional outcomes exists when compared to other physical therapy treatments.
Kang JI, Kwon HM, Jeong DK, Choi H, Moon YJ, Park JS: The effects of postural control and low back pain according to the types of orthoses in chronic low back pain patients.J Phys Ther Sci. 2016 Nov;28(11):3074-3077. Epub 2016 Nov 29. Conclusion: The results of the present study showed that wearing soft lumbosacral orthoses was more effective than wearing rigid lumbosacral orthoses.
Hiroaki Nakashima, Minoru Yoneda, Tokumi Kanemura et al. Conservative treatment of spondylolysis involving exercise initiated early and sports activities resumed with a lumbar-sacral brace. Journal of Orthopaedic Science, 2021, ISSN 0949-2658, https://doi.org/10.1016/j.jos.2021.01.013. Conclusions: Sufficient bony union can be achieved by conservative treatment with early exercise and a lumbar-sacral brace in cases of very early and early spondylolysis.
Surgical vs Conservative Spinal Treatment
Zaina F MD, Tomkins-Lane C PhD, Carragee E MD, Negrini S MD: Surgical versus non-surgical treatment for lumbar spinal stenosis, Spine: 15 July 2016 – Volume 41 – Issue 14 – p E857–E868. We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects. High-quality research is needed to compare surgical versus conservative care for individuals with lumbar spinal stenosis.
Weber: Spine Update: the natural history of disc herniation and the influence of intervention. Spine 19(19). 90% of patients with 4 months of sciatica respond to non surgical energetic non-operative care. 60% of surgical interventions are unnecessary.
Gamache FW. Neurological Surgery, New York Presbyterian-Weill/ Cornell, New York, NY, USA. 26. The value of “another” opinion for spinal surgery: A prospective 14 month study of one surgeon’s experience. Surg Neurol Int. 2012; 3(Suppl 5: S350-4. November 2012. Author recommended no surgery for 69 (44.5%) patients on second opinion.
Froholdt A; Reikeraas O; Holm I; Keller A; Brox JI. No difference in 9 year outcome in chronic low back pain patients treated with lumbar fusion versus cognitive intervention and exercises. European Spine Journal, Vol 21 Nov 12, 2012.
Albert, Hanne B. PT, MPH, MPH, PhD; Manniche, Claus MD, PhD, Med Sci. The efficacy of systematic active conservative treatment for patients with severe sciatica: A single-blind, randomized, clinical, controlled trial. Spine: 01 April 2012 – Volume 37 – Issue 7 – p 531-542. Paper shows non surgical care for surgical disc herniation patients is equal to surgery. 181 consecutive patients with radicular pain below the knee were examined at the baseline, at 8 weeks, and at 1 year after the treatment. All were surgical candidates for lumbar disc surgery.
Foulongne E, Derrey S, Ould Slimane M et al. Department of orthopaedics, Rouen University Hospital, 1, Rue de Germont, 76091 Rouen cedex, France. Lumbar spinal stenosis: Which predictive factors of favourable functional results after decompressive laminectomy? Neurochirurgie. 2012 Dec 13. pii: S0028-3770(12). The long term results of surgical treatment of lumbar spinal stenosis were moderate with an improved outcome in 49.5% of cases in this study.
Memo PA, Nadler S, Malanga G: Lumbar disc herniations: a review of surgical and non surgical indications and outcomes. J of Back and Musculoskeletal Rehabilitation. 2000; 14(3): 79-88. Non surgical treatment of radicular pain may be superior to surgery based on cost, morbidity, complications.
Millhouse PW1, Schroeder GD, Kurd MF et al. Microdiscectomy for a Paracentral Lumbar Herniated Disk. J Spinal Disord Tech. 2015 Dec 24. Patients with lumbar disc herniations causing radiculopathy often associated with leg pain see the vast majority improve with nonoperative care. Surgical intervention is reserved for patients who have significant pain that is refractory to at least 6 weeks of conservative care, patients who have a severe or progressive motor deficit, or patients who have any symptoms of bowel or bladder dysfunction.
Hazel J. Jenkins MChir PhD, Aron S. Downie MChir PhD et al.: Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. The Spine Journal https://doi.org/10.1016/j.spinee.2018.05.004. Conclusion: Inappropriate imaging is common in LBP management, including both overuse in those where imaging is not indicated and underuse of imaging when it is indicated. Appreciating that both underuse and overuse can occur is fundamental to efforts to improve imaging practice to align with current guidelines and best evidence.
Webster BS et al: Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilisation outcomes, J Occup Environ Med. 2010. The majority of cases had no early MRI indications. Results suggest that iatragenic effects of early MRI are worse disability and increased medical costs and surgery, unrelated to severity.
Prevalence of Spinal Degeneration & Disc Bulges
Brinjikji W, Luetmer PH, Comstock B, Breshahan BW et al.: Systematic literature review of imaging features of spinal in asymptomatic populations, Am Journal of Neuroradiology, 2015 Apr;36(4):811-6. Results: Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria. The prevalence of disk in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. Conclusions: Imaging findings of spine are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient’s clinical condition.
Nakashima, Hiroaki MD; Yukawa, Yasutsugu MD et al. Cervical Disc Protrusion Correlates With the Severity of Cervical Disc Degeneration: A Cross-Sectional Study of 1211 Relatively Healthy Volunteers. Spine: 01 July 2015 – Volume 40 – Issue 13 – p E774–E779doi: 10.1097/BRS.0000000000000953. IN 1211 PEOPLE AGED 20 TO 70, PFIRRMANN CLASSIFICATION OF DISC DEGENERATION SHOWED THAT MILD DISC DEGENERATION WAS VERY COMMON, INCLUDING 98.0% OF BOTH SEXES IN THEIR 20’S. THE SEVERITY OF CERVICAL DISC DEGENERATION SIGNIFICANTLY INCREASED WITH AGE IN BOTH SEXES AT EVERY LEVEL. THE DISC DEGENERATION PREDOMINANTLY OCCURRED AT C5–C6 AND C6–C7.
Boos: The diagnostic accuracy of MRI, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine 20(24). 76% of asymptomatic patients show MRI disc herniations. 96% of symptomatic patients show MRI disc herniations.
Prevalence and Economic Costs of LBP and musculoskeletal conditions
Prof Jan Hartvigsen, Mark J Hancock et al: What low back pain is and why we need to pay attention, The Lancet, Published: March 21, 2018. Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause—eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.
Rainville: Ortho Cl NA 27(4). Back injuries in USA have an annual cost of 86 billion.
Carey: Care seeking individuals with chronic low back pain. Spine 20(3). 25% of chronic low back pain patients absorb 95% of the cost.
Taimela S: The role of physical exercise and inactivity in pain recurrence and absenteeism from work after active outpatient rehabilitation for recurrent or chronic low back pain. A follow up study. Spine 2000; 25(14). Recurring persistent pain and work absenteeism is less among those who maintain regular exercise habits after an active treatment for recurrent chronic low back pain. Less favorable outcome in those who do not exercise.
Andronis, L., Kinghorn, P., Qiao, S. et al. Appl Health Econ Health Policy (2016). doi:10.1007/s40258-016-0268-8. Cost-effectiveness of non-invasive and non-pharmacological interventions for low back pain: a systematic literature review. The identified evidence suggests that combined physical and psychological treatments, medical yoga, information and education programs, spinal manipulation and acupuncture are likely to be cost-effective option for low back pain.
Aspegren D, Enebo BA, Miller M, White L, Akuthota V, Hyde TE, et al. Functional scores and subjective responses of injured workers with back or neck pain treated with chiropractic care in an integrative program: a retrospective analysis of 100 cases. J Manipulative Physiol Ther. 2009 Nov-Dec; 32(9):765-71. CONCLUSIONS: The study identified positive effects of chiropractic management included in integrative care when treating work-related neck or back pain. Improvement in both functional scores and subjective response was noted in all 3 time-based phases of patient status (acute, subacute, and chronic).
Waddell, Gordon. Preventing incapacity in people with musculoskeletal disorders. Brittish Medical Bulletin. 2006. Musculoskeletal disorders are among the most common causes of sickness absence, long-term incapacity for work and ill-health retirement. The number of Incapacity Benefit (IB) recipients in the United Kingdom has trebled since 1979, despite improvement in objective measures of health. Most of the trend is in non-specific conditions (largely subjective complaints, often with little objective pathology or impairment). Understanding incapacity requires a biopsychosocial model that addresses all the physical, psychological and social factors involved in human illness and disability. Rehabilitation should be directed to overcome biopsychosocial obstacles to recovery and return to work. These principles are fundamental to better clinical and occupational management and minimizing incapacity. Sickness absence and incapacity from non-specific musculoskeletal conditions could be reduced by 33–50%, but that depends on getting all stakeholders onside and a fundamental shift in thinking about these conditions— in health care, in the workplace and in society.
Australian Institute of Health and Welfare. (2015). Australian Burden of Disease Study Impact and causes of illness and death in Australia. https://www.aihw.gov.au/getmedia/c076f42f-61ea-4348-9c0a-d996353e838f/aihw-bod-22.pdf.aspx?inline=true. The leading causes of total burden in order were coronary heart disease, back pain, COPD, lung cancer and dementia.
Prognosis of LBP
Jayson MIV: Presidential Address: Why does acute back pain become chronic? Spine 22(10). At 3 months, prognosis is 27% completely better, 28% improved, 30% no change, 14% worse.
von Korff: Spine 21(24). 66-75% patients have pain at 1 month after treatment ends.
Mathews: Arth Rheum 39(9). 175 of 513 low back pain patients had pain 15 years after onset.
Yuen: Sciatic neuropathy: clinical and prognostic features in 73 patients. Neurology 44. Return of motor strength after damage of the sciatic nerve was 10% within 6 months, 30% by 1 year, 50% by 2 years and 75% by 3 years.
Epidural Injections for LBP
Valat JP: Epidural corticosteroid injections for sciatica: a randomized, double blind controlled clinical trial. Annals of Rheumatic Diseases 2003: 62(7). 3 epidural injections of 2ml prednisolone acetate or saline were given to sciatica patients with herniated nucleus pulposus. Same relief with both.
Deplort et al: Archives of Physical Medicine and Rehabilitation 85(3), March 2004. Epidural steroid injections provide 32% of patients sustained pain relief.
Caneiro JP, O’Sullivan PB, Roos EM, Smith AJ, Choong P, Dowsey M et al. Three steps to changing the narrative about knee osteoarthritis care: a call to action. Br J Sports Med. 2020;54:256-258. Knee osteoarthritis (OA), characterised by knee pain and functional limitation, is widely understood to imply that symptoms are due to structural damage. This view leads to the belief that non-surgical approaches are futile and the structural damage needs to be ‘fixed’. In contrast, contemporary evidence supports knee OA as a ‘whole person condition’ in which knee health is influenced by the interaction of different biopsychosocial factors that modulate inflammatory processes and tissue sensitivity, as well as behavioural responses that lead to pain and disability. This contrasting view reinforces the critical role of non-surgical approaches to manage knee OA.
Platelet-Rich Plasma (PRP) Injections
Singh, H., Knapik, D. M., Polce, E. M., Eikani, C. K., Bjornstad, A. H., Gursoy, S., Perry, A. K., Westrick, J. C., Yanke, A. B., Verma, N. N., Cole, B. J., & Chahla, J. A. (2022). Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis: A Systematic Review and Network Meta-analysis. The American Journal of Sports Medicine, 50(11), 3140–3148. https://doi.org/10.1177/03635465211029659. Conclusion: Platelet Rich Plasma yielded improved outcomes when compared with Platelet Rich Growth Factors, Hyaluronic Acid, Corticosteroids, and placebo for the treatment of symptomatic knee OA at a minimum 6-month follow-up. Further investigations evaluating different intra-articular injections and other nonoperative treatment options for patients with knee OA are warranted to better understand the true clinical efficacy and long-term outcomes of nonsurgical OA management.
Kuan-YuLin M.D, Chia-ChiYang PhD, Chien-JenHsu M.D, Ming-Long Yeh PhD, Jenn-Huei Renn M.D PhD. Intra-articular Injection of Platelet-Rich Plasma Is Superior to Hyaluronic Acid or Saline Solution in the Treatment of Mild to Moderate Knee Osteoarthritis: A Randomized, Double-Blind, Triple-Parallel, Placebo-Controlled Clinical Trial. Volume 35, Issue 1, January 2019, Pages 106-117, The Journal of Arthroscopic & Related Surgery. Intra-articular injections of leukocyte-poor PRP can provide clinically significant functional improvement for at least 1 year in patients with mild to moderate osteoarthritis of the knee.
Hussain, Nasir, Johal, Herman, & Bhandari, Mohit. (2017). An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature. SICOT-J, 3, 57–57. https://doi.org/10.1051/sicotj/2017036. Thus far, the evidence appears to suggest that PRP may provide some benefit in patients who present with knee osteoarthritis or lateral epicondylitis. On the other hand, evidence appears to be inconsistent or shows a minimal benefit for PRP usage in rotator cuff repair, patellar and Achilles tendinopathies, hamstring injuries, anterior cruciate ligament (ACL) repair, and medial epicondylitis.
Laudy ABM, Bakker EWP, Rekers M, Moen MH. Efficacy of platelet-rich plasma injections in osteoarthritis of the knee: a systematic review and meta-analysis. Br J Sports Med. 2015 May 1;49(10):657–72. Conclusions: On the basis of the current evidence, PRP injections reduced pain more effectively than did placebo injections in OA of the knee (level of evidence: limited due to a high risk of bias). This significant effect on pain was also seen when PRP injections were compared with hyaluronic acid injections (level of evidence: moderate due to a generally high risk of bias). Additionally, function improved significantly more when PRP injections were compared with controls (limited to moderate evidence). More large randomised studies of good quality and low risk of bias are needed to test whether PRP injections should be a routine part of management of patients with OA of the knee.
Lopes Luis AI, Casimiro MV, Reizinho C. Efficacy of Radiofrequency Neurotomy for Lumbar Facet Syndrome and Sacroiliac Joint Pain Neurosurgery. 2015 Aug;62 Suppl 1, CLINICAL NEUROSURGERY:203-204. RADIOFREQUENCY NEUROTOMY WAS USEFUL FOR THE TREATMENT OF LUMBAR FACET SYNDROME AND SACROILIAC JOINT PAIN. DESPITE OF GRADUAL LOSS OF EFFICACY, AT 2 YEARS 40% OF PATIENTS MAINTAINED A 50% REDUCTION OF PAIN INTENSITY. THEREFORE THIS PROCEDURE COULD BE USED FOR TREATMENT OF CAREFULLY SELECTED PATIENTS WITH CHRONIC LBP.
Muscle De-conditioning in LBP
Asian Spine J. 2016 Jun;10(3):516-21. doi: 10.4184/asj. 2016.10.3.516. Classification of Chronic Back Muscle Degeneration after Spinal Surgery and Its Relationship with Low Back Pain. Ohtori S1, Orita S1, Yamauchi K1, Eguchi Y1, Aoki Y1, Nakamura J1, Ishikawa T1, Miyagi M1, Kamoda H1, Suzuki M1, Kubota G1, Inage K1, Sainoh T1, Sato J1, Shiga Y1, Abe K1, Fujimoto K1, Kanamoto H1, Inoue G1, Takahashi K1. AFTER SPINE SURGERY, MRI REVEALED MUSCLE DEGENERATION IN ALL PATIENTS. MODIC CLASSIFICATION WAS USED TO DESCRIBE IT. AFTER SURGERY (TYPE 1, 6%; TYPE 2, 82%; AND TYPE 3, 12%).
Mitsutake T1, Sakamoto M, Chyuda Y, Oka S, Hirata H, Matsuo T, Oishi T, Horikawa E. Greater Cervical Muscle Fat Infiltration Evaluated by Magnetic Resonance Imaging is Associated with Poor Postural Stability in Patients with Cervical Spondylotic Radiculopathy. Spine (Phila Pa 1976). 2015 Oct 15. FAT INFILTRATION WITHIN MUSCLE COULD LEAD TO INHIBITION OF NORMAL ACTIVITY OF MUSCULATURE. FAT WITHIN CERVICAL MULTIFIDUS MUSCLE COULD DIRECTLY CAUSE POSTURAL INSTABILITY IN STATIC STANDING, EVEN THOUGH THE PROPRIOCEPTIVE INFORMATION HAS NORMAL LOWER LIMBS. GREATER CERVICAL MUSCLE FAT INFILTRATION EVALUATED BY MAGNETIC RESONANCE IMAGING IS ASSOCIATED WITH POOR POSTURAL STABILITY IN PATIENTS WITH CERVICAL SPONDYLOTIC RADICULOPATHY.
Adolescent Idiopathic Scoliosis
Asian Spine J. 2016 Jun;10(3):570-81. doi: 10.4184/asj.2016.10.3.570. Epub 2016 Jun 16. Postural Rehabilitation for Adolescent Idiopathic Scoliosis during Growth. Weiss HR1, Moramarco MM2, Borysov M3, Ng SY4, Lee SG5, Nan X6, Moramarco KA2. LONG-TERM FOLLOW-UP OF UNTREATED PATIENTS WITH ADOLESCENT IDIOPATHIC SCOLIOSIS (AIS) INDICATES THAT, WITH THE EXCEPTION OF SOME EXTREMELY SEVERE CASES, AIS DOES NOT HAVE A SIGNIFICANT IMPACT ON QUALITY OF LIFE AND DOES NOT RESULT IN DIRE CONSEQUENCES. IN VIEW OF THE RELATIVELY BENIGN NATURE OF AIS AND THE LONG-TERM COMPLICATIONS OF SURGERY, THE INDICATIONS FOR TREATMENT SHOULD BE REVIEWED. FURTHERMORE, RECENT STUDIES HAVE SHOWN THAT SCOLIOSIS-SPECIFIC EXERCISES FOCUSING ON POSTURAL REHABILITATION CAN POSITIVELY INFLUENCE THE SPINAL CURVATURES IN GROWING ADOLESCENTS. THERE IS AT PRESENT LEVEL 1 EVIDENCE FOR THE EFFECTIVENESS OF SCHROTH SCOLIOSIS EXERCISES IN THE MANAGEMENT OF AIS.
McGill, Stuart. Low- Back Disorders: Evidence-Based Prevention and Rehabilitation, 2nd Ed. Champaign: Human Kinetics Publishers, 2007. CONCLUSIONS: Supervised Schroth exercises provided added benefit to the standard of care by improving SRS-22r pain, self-image scores and BME. Given the high prevalence of ceiling effects on SRS-22r and SAQ questionnaires’ domains, researchers hypothesize that in the AIS population receiving conservative treatments, different QOL questionnaires with adequate responsiveness are needed.
den Boer WA, Anderson PG, Limbeck JV, Kooijam MAP: Treatment of idiopathic scoliosis with side shift therapy: an initial comparison with a brace treatment historical cohort. Eur Spine J 1999:8;406-10. Exercise for scoliosis are for strengthening the convex side of the curve and ensuring its mobility, the same goals for adjusting scoliosis. We are not looking to necessarily correct the curve or reverse it, but rather ensure its mobility. Mehta Exercises are excellent tools the patient can do alone or, optimally, with a helper.
Active correction by sideshift: an alternative treatment for early idiopathic scoliosis, In: Warner JO, Mehta MH. Scoliosis prevention. Proceedings of the P. Zorab scoliosis symposium 1983: Praeger, New York pp 126040. Side shift therapy should be considered as an additional treatment for idiopathic scoliosis in adolescents with an initial Cobb angle between 20 and 32 degrees.
Dunn A, Baylis S, Ryan D: Chiropractic management of mechanical low back pain secondary to multiple level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report. J Chiropractic Medicine. 2009 Sep; 8(3): 125-30. Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.
Schneiderman: Spine 20(16): Cause of pain in spondylolisthesis. Pars interarticularis is source of pain in spondylolisthesis.
Cox Jm: Chiropractic treatment of lumbar spine synovial cysts: a report of two cases. J Manipulative Physiol Ther. 2005 Feb;28(2):143-7. Chiropractic distraction manipulation and physiological therapeutic care relieved 2 patients with low back and radicular pain attributed to MRI-confirmed synovial cysts of the lumbar spine. This treatment may be an initial conservative treatment option for synovial cysts with careful patient monitoring for progressive neurologic deficit which would necessitate surgery. Distraction manipulation may be a safe and effective conservative treatment of synovial cyst causing radicular pain; further data collection of clinical outcomes is warranted.
Khan, AM; Girardi, F . Spinal lumbar synovial cysts. Diagnosis and management challenge. EUROPEAN SPINE JOURNAL 15 (8). AUG 2006. p.1176,1177-1182 SPRINGER, NEW YORK. STILL RECOMMENDING SURGERY FOR SYNOVIAL CYST?? Occur in females mostly in 6th decade of life. Incidence <0.5% of the general symptomatic population. Symptoms: radicular pain and neurological deficits. Level: commonly found at L4-5, the site of maximum mobility. Unilateral or bilateral and at one or multilevel. MRI is considered the tool of choice for its diagnosis. Etiology spinal instability, facet joint arthropathy and degenerative spondylolisthesis. Synovial cysts resistant to conservative therapy should be treated surgically. Resection and decompression with or without fusion and instrumentation remains an appropriate option. Synovial cysts may recur following surgery.
Tepe, S; Kara, M; Iplikcioglu, AC. Spontaneous Disappearance of Lumbar Synovial Cyst. JOURNAL OF NEUROLOGICAL SCIENCES-TURKISH 29 (1). 2012. p.154-158. CONSERVATIVE TREATMENT OF LUMBAR SYNOVIAL CYSTS IS RECOMMENDED DUE TO DISAPPEARANCE WITHOUT SURGERY.
Martha, JF; Swaim, B; Wang, DA; Kim, DH; Hill, J; Bode, R; Schwartz, CE. Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients. SPINE JOURNAL 9 (11). NOV 2009. p.899-904. LUMBAR FACET JOINT STEROID INJECTION WITH ATTEMPTED SYNOVIAL CYST RUPTURE IS CORRELATED WITH AVOIDING SUBSEQUENT SURGERY IN HALF OF 101 TREATED PATIENTS.
Bozzao A et al: Relapsing remitting bilateral synovial cysts of the lumbar spine. Neuroradiology 2001:43:1076-8. 33% of synovial cysts associated with degenerative spondylolisthesis and instability of the involved joint found in 61% of cases. Suggests that segmental joint play is a role in development of synovial cyst.
Chemical Inflammation & Neuropathic Pain
Eur Cell Mater. 2016 Jul 19;32:123-36. Reduced tissue osmolarity increases TRPV4 expression and pro-inflammatory cytokines in intervertebral disc cells. Walter BA1, Purmessur D, Moon A, Occhiogrosso J, Laudier DM, Hecht AC, Iatridis JC. REDUCED TISSUE OSMOLARITY, LIKELY FOLLOWING PROTEOGLYCAN DEGRADATION, CAN INCREASE TRPV4 SIGNALLING AND ENHANCE PRO-INFLAMMATORY CYTOKINE PRODUCTION, SUGGESTING CHANGES IN TRPV4 MEDIATED OSMO-SENSATION MAY CONTRIBUTE TO THE PROGRESSIVE MATRIX BREAKDOWN IN DISEASE.
Ogon I1, Takebayashi T, Iwase T, Emori M, Tanimoto K. Sympathectomy and sympathetic blockade reduce pain behavior via alpha-2 adrenoceptor of the dorsal root ganglion neurons in a lumbar radiculopathy model. Spine (Phila Pa 1976). 2015 Jul 10. NEUROPATHIC PAIN IS DUE, AT LEAST IN PART, TO ENHANCED SYMPATHETIC NORADRENERGIC TRANSMISSION WITHIN THE DRG. SUPPRESSION OF SYMPATHETIC ACTIVITY BY REDUCING ADRENERGIC RELEASE IN THE DRG MAY RELIEVE NEUROPATHIC PAIN.
Wang J1, Wang XW2, Zhang Y3, Yin CP3,Yue SW3. Ca2+ influx mediates the TRPV4-NO pathway in neuropathic hyperalgesia following chronic compression of the dorsal root ganglion. Neurosci Lett. 2015 Jan 6. pii: S0304-3940(15)00015-4. doi:10.1016/j.neulet.2015.01.010. CHRONIC COMPRESSION OF THE DORSAL ROOT GANGLION (DRG) (CCD) IN RATS IS A TYPICAL MODEL OF NEUROPATHIC PAIN.
Wang J1, Wang XW2, Zhang Y3, Yin CP3,Yue SW3. Ca2+ influx mediates the TRPV4-NO pathway in neuropathic hyperalgesia following chronic compression of the dorsal root ganglion. Neurosci Lett. 2015 Jan 6. pii: S0304-3940(15)00015-4. doi: 10.1016/j.neulet.2015.01.010. CHRONIC COMPRESSION OF THE DORSAL ROOT GANGLION (DRG) (CCD) IN RATS IS A TYPICAL MODEL OF NEUROPATHIC PAIN. NEUROINFLAMMATION IS CAUSED BY LOCAL AND SYSTEMIC EXPRESSION OF PROFLAMMATORY CYTOKINES AS MEDIATORS OF PAIN. AMONG THESE CYTOKINES, TNF-Α, IL-1Β AND IL-6 ARE ESPECIALLY NOTABLE ATTRIBUTED TO THEIR HYPERALGESIC IMPACTS AFTER NERVE DAMAGE. THIS STUDY COMPARED THE TISSUE LEVELS OF INTERLEUKIN-1Β(IL-1Β), INTERLEUKIN-6 (IL-6), INTERLEUKIN-10 (IL-10) AND TUMOR NECROSIS FACTOR-Α (TNF-Α) IN SUBLIGAMENTOUS AND FREE FRAGMENT TYPES OF DEGENERATED INTERVERTEBRAL DISC AT ACUTE AND CHRONIC PERIODS FROM 49 PATIENTS (24 WOMEN, 25 MEN) WITH AN AVERAGE AGE OF 38.2±4.9 TREATED SURGICALLY BY MEANS OF MICRODISCECTOMY. LEVELS OF IL-1Β, IL-6, IL-10 AND TNF-Α WERE ASSESSED IN TISSUE SAMPLES PREPARED FROM NUCLEUS PULPOSUS TISSUE OBTAINED DURING MICRODISCECTOMY PROCEDURE.
Chen YM1, Shen RW2, Zhang B3, Zhang WN4. Regional tissue immune responses after sciatic nerve injury in rats. Int J Clin Exp Med. 2015 Aug 15;8(8):13408-12. EXPRESSION OF INTERFERON-Γ(INF-Γ), INTERLEUKIN-10 (IL-10) WAS SIGNIFICANTLY ELEVATED ONE WEEK FOLLOWING NERVE INJURY, BUT GRADUALLY DECREASED THEREAFTER. OUR FINDINGS DEMONSTRATE THAT IMMUNE RESPONSES AND INFLAMMATORY CELL ACTIVATION ARE INVOLVED DURING RECOVERY FROM SCIATIC NERVE INJURY.
Rydevik: Spine 9(2). Intraneural edema results in ischemia of nerve at 20-30 mm pressure which results in numbness. Axonal transport is blocked at or over 30mm of pressure. Axons regenerate 1 mm per day. Peripheral nerves require 30-50mm pressure to cause damage.
Takahashi K: Nerve root pressure in lumbar disc herniation. Spine 24(1). Average nerve root pressure of herniated nuclear pulposis was 53 mm Hg. 10 mm reduced circulation and impairs nutrition. 20 mm paraesthesia results in no neuro deficits. Edema of the nerve root at 50 mm for 2 minutes. Neurological deficits has 60mm pressure. Trunk list at 82.1 mm. Paralysis, foot drop, cauda equine syndrome at 104-256 mm.
Weinstein: Spine 11(10). Neuroactive peptide produced in brain, spinal cord and dorsal root ganglion. 80% is produced in the dorsal root ganglion. Produced in posterior longitudinal ligament, facet capsule annulus fibrosis. It stimulates nociceptors and proprioceptors. Stimulated by mechanical or chemical irritants.
Cavanaugh: Lumbar facet pain: biomechanics, neuroanatomy and neurophysiology. J Biomechanics 1996; 29(9). Facet joint is heavily inner acted by small nerve fibers and free and encapsulated nerve endings that produce Substance P. Under inflammation, chemical irritants are secreted by the facet capsule that result in low back pain.
Freemont: Backletter 12(7). Damaged discs have nociceptors grow into them.
Kikuchi: Spine 19(1). Facet indents the dorsal root ganglion in 71% of cases studied.
Curcumin derived from Tumeric
Neurology Research International. 2016;2016:9468193. doi: 10.1155/2016/9468193. Epub 2016 May 19. The Potential of Curcumin in Treatment of Spinal Cord Injury. Sanivarapu R1, Vallabhaneni V2, Verma V3. Curcumin, the active ingredient in turmeric, a spice known for its medicinal and anti-inflammatory properties, has been validated to harbor immense effects for a multitude of inflammatory-based diseases. Curcumin shows superior results over corticosteroids. Curcumin has shown improvements from current standards of care in other diseases with few true treatment options (eg. Osteoarthritis), there is immense potential for this compound in treating spinal cord injury. Awareness of the incredible potential that curcumin shows for spinal cord injury in a patient population that direly needs improvements on current therapy.