New thinking activates low back pain treatment

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Biomechanics Magazine August 2006

http://biomech.com/showArticle.jhtml?articleID=192700640

New thinking activates low back pain treatment

By: Cary Groner

Elephants don't generally experience a lot of back trouble, as far as

we know. Like all quadrupeds, their backs rest in a relatively

unloaded state as they go about their daily business. The people who

look after them don't get off so easily, however. Humans are

supported by a loaded spine often jangling with pain.

Mikota, DVM, knows something about both of these matters. She

is an elephant veterinarian who has also suffered chronic severe low

back pain. Mikota has spondylolisthesis, a condition in which a

vertebra slips relative to the one above or below it. She spent 2001

in Indonesia, where she healed sick elephants but was unable to do

much for herself beyond taking hefty doses of Advil and codeine.

" It was very bad, and I was convinced I had tried everything, " Mikota

said. But after a scary consultation with a surgeon about spinal

fusion, she decided to try yoga. Within weeks, her torment had begun

to lift. Five years later she is almost pain-free.

" It was phenomenal, particularly because I don't like taking drugs or

going to doctors, " Mikota said. " I still have occasional recurrences,

but it's made a huge difference in my life. I can go on with my work

and manage this. "

Sweeping changes are taking place in the diagnosis and treatment of

low back pain, supported by recent clinical trials. Such mainstream

clinicians as physiatrists, surgeons, and physical therapists

increasingly find their territory overlapping with that of

complementary practitioners including chiropractors, massage

therapists, and yoga teachers. The ultimate goal is an individualized

treatment approach that incorporates any modality likely to benefit

the patient.

Paying the toll

Back pain takes a staggering toll on individuals and society,

accounting for roughly 3% of all physician office visits, second only

to the common cold. Americans spend $50 billion annually seeking

relief from back pain. Annual prevalence varies from 15% to 45% of

the population-individual lifetime incidence is as high as 90%-and

back pain is responsible for up to 15% of all work absences in

developed countries. Although about 85% of people recover from acute

episodes within 12 weeks, those whose pain persists chronically

beyond that point are unlikely to recover fully.1-3

About 70% of acute low back pain results from sprains, strains, or

muscle spasms and resolves with time and minimal intervention. Other,

more serious, conditions may include bulging discs, which can cause

pain by pressing on nerves (and in the extreme case of cauda equina

syndrome, lead to loss of bowel control and permanent neurological

damage); spinal degeneration or stenosis; osteoporosis; skeletal

irregularities such as scoliosis or lordosis; spondylolysis (fracture

of the pars interarticularis) or spondylolisthesis; and fibromyalgia.3

Old theories about bed rest have been largely discredited, at least

after the first day or two. Most clinicians now agree it's best to

keep moving, even if activity causes some discomfort.4 Other

traditional treatment approaches include anti-inflammatory

medications, steroid injections, exercise therapy, and surgery.5

Treating the patient

Twenty years ago practitioners thought new imaging techniques such as

MRI would vastly simplify the diagnosis of low back pain. Studies

soon revealed that a lot of people with positive MRI findings were

symptom-free, however, and that many of those with excruciating pain

had little or no visible pathology.6 Even today, radiography and MRI

reveal the causes of low back pain in fewer than 10% of cases.5

Although a careful history and physical examination remain the

mainstays of an initial diagnosis, more recently clinicians have

developed better ways to determine what's causing pain in a given

patient. These include diagnostic pain blocks, discography, and

electromyography (EMG).

" You have to treat the patient, not their MRI, " said Foye,

MD, an assistant professor of physical medicine and rehabilitation at

the New Jersey Medical School. " You want to identify the pain

generator, the structure responsible for most of the patient's

symptoms, and now we have better tools to do that. "

For example, patients with facet joint arthritis may receive a short-

term painkilling injection, called a medial branch block, in one

joint at a time so practitioners can determine the primary pain

source.

" We are getting increasingly selective with our diagnostic blocks, "

Foye said. " If the patient gets substantial relief from blocking the

nerves to one facet joint, you know at least some of the pain is

located there, as opposed to coming from a herniated disc or

radiculopathy (nerve root irritation). "

In discography, one or more of the patient's discs are injected with

dye. Although any disc will have some associated discomfort,

typically there is much more pain from some discs than others.

" You are looking for concordant pain that matches the presenting

symptoms, and visually you look for leakage of the dye in the

images, " Foye said.

Patients with multiple levels of disc bulging or herniation can be

especially good candidates for approaches such as EMG and nerve

testing, he added, noting that most people over age 40 have a range

of MRI " abnormalities " that may or may not cause symptoms.

" EMG testing may identify that their radiculopathy involves only the

L5 or S1 nerve root, and a selective block using a local anesthetic

can help you be more specific with treatment approaches, " he said.

Sensitivity and specificity

A decade ago clinicians didn't consider it important to isolate which

facet joint was causing symptoms because they had no treatments that

could work at such a specific level. New approaches such as

radiofrequency ablation (RFA) are changing that. If a block indicates

that most of a patient's pain is coming from one location, ablation

can destroy the nerve fibers that carry those signals for several

months by heating them with a targeted burst of energy.

More specific diagnoses can also lead to individually designed

exercise and physical therapy programs, according to Foye.

" It's no longer appropriate to give a patient a preprinted sheet of

low back exercises, because certain problems may be exacerbated by

one position or another, " he said. " Facet joint arthritis, sacroiliac

joint pain, spondylolysis, spondylolisthesis, and spinal stenosis

would all get worse with lumbrosacral extension. By contrast, lumbar

disc herniations, radiculopathy, or osteoporotic compression

fractures could deteriorate with flexion exercises. "

Less enlightened practitioners still sometimes write generic PT

orders for patients with low back pain, Foye said. When their

patients get worse, such doctors often report that they have failed

nonsurgical management.

" Such language implies that the failure was the patient's, " Foye

said. " It also implies that what's needed now is surgery, when really

what's needed is an appropriate, customized exercise or physical

therapy program based on their specific diagnosis. "

The role of muscles

Recent research into different muscle groups is already leading to

better therapeutic regimens. Australian researchers have used EMG and

other approaches to demonstrate the importance of the transversus

abdominis and multifidus muscles in stabilizing the lower spine and

promoting healing. (The transversus abdominis forms a girdle around

the lower abdomen; the multifidi run in several connected segments

along the spine.) Studies have found that activation of the

transversus abdominis is delayed in people with low back pain

compared to those without pain.7,8 Other research discovered that

exercises targeted to strengthening and rehabilitating the

transversus abdominis alone, or in cocontraction with the multifidus,

led to significant improvements in patients' pain scores (e.g., back

pain recurrence of 30% after one year, versus 84% in patients who did

not receive the training).9,10

At the University of California, San Diego, scientists at the

National Skeletal Muscle Research Center have recently reinforced

such findings.

" The lumbar multifidus is crucial in its ability to generate forces;

it's designed to stabilize the lumbar spine, " said Sam Ward, PT, PhD,

biomechanics core director for the center. " To study the lumbar spine

and ignore it would be like studying the knee and ignoring the

quadriceps. Anything you can do to preserve its integrity is

beneficial from a rehabilitation perspective. "

Cutting edge cutting

Preserving the muscle is crucial to Ward's colleague Choll Kim, MD, a

surgeon at UCSD. Kim noted that traditional approaches to back

surgery often damage the multifidi, prolonging recovery and

rehabilitation time.

" In a traditional surgical approach you make a long midline incision

and work on either side of it, " Kim said. " You put in powerful

retractors to open up that space, and you detach all those muscles

from their normal position. The retractors basically crush the

muscle, and if we take out bone and work on nerves, there is often no

place for the muscles to reattach. Even if there is, they're so

damaged they tend not to. "

Such problems may lead to the notorious " failed back surgery

syndrome, " as a result of which surgery has fallen into disfavor as a

solution to many conditions. Some surgeries are necessary, of course.

For patients with severe nerve damage, for example, or with

excruciating pain from a clearly identifiable pathology, according to

Kim. But operating on such patients amounts to treating one evil with

a lesser evil, Kim said.

In other cases, recent research has shown the benefits of surgery to

be questionable. The British Medical Journal reported in 2005 that in

patients with chronic low back pain, surgical stabilization of the

lumbar spine offered no advantages over an intensive rehabilitation

program.11 A 2006 article in Pain reported that lumbar fusion for

chronic low back pain after surgery for disc herniation failed to

offer any benefit over cognitive intervention and exercise.12

Kim and his colleagues are pioneering minimally invasive surgery

(MIS) techniques to maximize surgery's advantages when it is

indicated. For lumbar fusion they typically make a one-inch incision

rather than a four- or five-inch one. They have also developed an

endoscopic discectomy procedure that allows patients to go home the

next day.

" It's early, and we're doing randomized controlled trials, but I can

tell you that my patients who have MIS do much better than those with

traditional approaches in the short term, " Kim said. " In five or 10

years everyone will do it this way, and it will be strange to do a

big, open, midline procedure. "

Old wisdom, new horizons

Patients who can avoid surgery stand to gain a lot from the

increasing acceptance of complementary approaches to pain management

and rehabilitation, and studies support such strategies. A 2005 paper

in the ls of Internal Medicine found that yoga was more effective

than a standard exercise approach for chronic low back pain.13

Another found that yoga led to a significant reduction in disability

and pain versus an educational program.14 Numerous other studies and

meta-analyses have demonstrated the effectiveness of a variety of

exercise and physical therapy regimens, including spinal manipulation

and massage.

For Stallworth, MD, such findings are just common sense.

Stallworth, a physiatrist who directs the inpatient rehabilitation

center at Centennial Medical Center in Nashville, TN, also teaches

yoga.

" In my career I've spent a lot of time studying lumbar stabilization

and McKenzie exercises, and I knew these approaches really helped

patients, " Stallworth said. " When I discovered yoga, I realized this

had been going on for thousands of years, and a lot of the postures

are very similar to things we do with stabilization and extension. "

Not surprisingly, many of Stallworth's patients are also her yoga

students, and even those with conditions such as degenerative disc

disease can become virtually pain-free with an active yoga practice,

she said.

" The research from Australia has shown that the proper engagement of

your transversus and multifidi is critical, " she said. " Gentle range

of motion, core stability, consistency with exercise; these are what

help patients in the long run. "

Stallworth's colleague at the hospital, Pullig Schatz, MD,

authored Back Care Basics, the book that helped Mikota get over

her pain so she could treat her elephants.15 Schatz, who studied yoga

in the U.S. with physical therapist Judith Lassiter, and in India

with B.K.S. Iyengar, was motivated by her own pain, and soon found

herself helping others.

" You have to work with people on their individual biomechanical

issues, " Schatz said. " That's when you see the miracles, because the

program is specific for those people and you are giving them the

right thing from your yoga pharmacopoeia. "

As holistic approaches to low back pain continue to find common

ground with traditional Western medicine, back pain sufferers can

look forward to a twist on the proverbial exercise mantra: No pain,

big gain.

Cary Groner is a freelance writer based in Northern California.

References

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pmr/topic73.htm (WebMD), accessed June 2006.

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www.ninds.nih.gov/disorders/backpain/detail_backpain.htm, accessed

June 2006.

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A version of this story appeared in the April issue of Diagnostic

Imaging, a sister publication to BioMechanics.