Interprofessional Symposium on Spine Care Instructor: Dr. Ronald J. Farabaugh.

Interprofessional Symposium on Spine Care

Instructor:Dr. Ronald J. Farabaugh

Do All Soft Tissue Injuries Heal Within 6-8 Weeks?

A Review of the Literatureand old concepts/myths.

Saal JA, MD. Spine 1997;22(14):1545-1552

The major premise used in the managed care system for the primary care of LBP is based upon the assumption that 90% of patients improve in 6-12 weeks. However, a natural history study by Von Korff found that approximately 60% will recur. In a study of BP in primary care, Von Korff and Saunders found that 60% to 75% improve within the first month, 33% report intermittent or persistent pain at one year, and 20% of patients describe substantial limitations at one year.

Frank, MD. BMJournal 1993; April 3:901-9.

Review of a study in which 373 patients less than 40 years old, with their first onset of back pain, are followed for 10 years. 89% had recurrences and only 33% had no lost time form work from future back problems. Strategies to manage low back pain must be long term and preventive. [Emphasis added.]

Waddel, MD. JMPT 1995;18(9):590-596

Traditional teaching is that 90% of LBP attacks recover within six weeks, but recent natural history studies suggest that this is overly optimistic and over-emphasizes RTW. It now seems that 50% of attacks settle within 4 weeks, but 15-20% have some symptoms for at least 1 year. 70% of patients who have acute back pain will suffer 3 or more recurrences. 20% will continue to have some back symptoms over long periods of their lives.

Jayson, MD, FRCP. Spine 1997;22(10):1053-1056.

At 3 months, only approximately 27% were completely better, 28% improved, 30% had no change, and 14% were worse or much worse. It may well be that in the many studies of acute low back pain, there has been very carefully selected clinical material so that only those patients with acute pain of recent onset and no other confounding factors were included, with the result that these studies do not reflect what actually happens in practice.

Waddell, MD. The Chiropractic Report 1993; July:1-6

Bed Rest: should die as soon as it can. Physical Therapy: There is no adequate evidence of effectiveness. Spinal manipulation: one of two treatments of proven value. Early active exercise: Is the other treatment supported by good evidence. Relief of pain and restoration of function must occur at the same time.Failure to restore function means any pain relief will be temporary andreinforces chronic pain. In the management of occupational back pain,the chiropractic profession is leading the way. The problem is weaknessand loss of function, not disease.

Weisel, MD. Backletter 1996; 11(7): 84 Back pain is a recurrent illness.

Carey’s study emphasizes that BP is typically recurrent and sometimes disabling – in a substantial minority.

Kuritzky, MD. Physician and Sports Medicine 1997;25(1):56-64

97% of BP seen by primary care physicians is mechanical in origin. There is something wrong with the muscles, ligaments, or connective tissues.

Croft P, Macfarland GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of Low Back Pain in General Practice: a

Prospective Study British Medical Journal 1998;316:1356-

1359

Low-back pain is aptly redefined as "a chronic problem with an untidy pattern of grumbling symptoms," with only 25% of patients consulting about the problem reporting full recovery 12 months later. Instead, most patients appear to be enduring their pain but not telling their primary care physician about it.

In fact, after seeing the results, the authors made the following statement:

"By three months after the index consultation with their general practitioner, only a minority of patients with low back pain had recovered. However, most patients with low-back, pain did not return to their doctor about their pain within three months of their initial consultation, and only 8% continued to consult for more than three months."

Croft P, et al. BMJ 1998;316:1356-1359

The authors found that consulting a doctor is not a direct measure of the presence of pain and disability. While patients may stop consulting their doctor, the vast majority will still have some pain and disability 12 months later. Therefore, the authors concluded:

Croft P, et al. BMJ 1998;316:1356-1359

"We should stop characterizing low back pain in terms of a multiplicity of acute problems, most of which get better, and a small number of chronic long term problems. Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences. This takes account of two consistent observations about low back pain: firstly, a previous episode of low back pain is the strongest risk factor for a new episode, and secondly, by the age of 30 years almost half the population will have experience a substantive episode of low back pain. These figures simply do not fit with claims that 90% of episodes of low back pain end in complete recovery."

Holm, in The Cervical Spine, Lippincott, 1989, p. 440

  “Follow-up roentgenograms taken an average of 7 years after

injury in one series of patients without prior roentgenographic evidence of disc disease indicated that 39% had developed degenerative disc disease at one or more disc levels since injury. It was pointed out that available evidence indicated an expected incidence of 6% degenerative change in a population with this mean age of 30 years. Thus, it appeared that the injury had started the slow process of disc degeneration.”

“In another follow-up study of patients with similar injuries but with preexisting degenerative changes in the neck it was observed that after an average of 7 years 39% had residual symptoms, and roentgenographic evidence of new degenerative change at another level occurred in 55%.”

Symptoms vs. Function

As a result of these and other studies there has been a shift in thinking away from the traditional "symptom" approach, towards contemporary thinking of "function".

For many patients with recurrent back pain, staying functional is a "process" more so than a "result" based on a predictable healing time or average.

Diagnostic Test Accuracy

A Review of the Literature

Haldeman, DC, PhD, MD. Spine 1990;15(7):718-723.

The pathology model cannot explain back pain ordisability. It is not possible to look at pathology anddetermine the symptoms a patient may be suffering.It also is not possible to look at a patient with back

painwith no neurologic deficits and determine the nature ofthe pathology. About 30% of asymptomatic subjectsshow abnormalities in the lumbar spine by myelogram,CT and MRI. There is a large percent of symptomaticpatients with severe complaints in whom testing fails

toreveal any structural lesion.

Jensen, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. NEJM

1994;331(2)July 14:69-73

98 people: only 36% had a normal disc at all levels. 52% bulge at least one level 27% protrusion 1% extrusion 38% had abnormality at more than one level

Summary: Finding may be frequently coincidental

Cervical Discogenic Pain. Prospective Correlation of MRI and Discography in Asymptomatic Subjects and Pain Sufferers.

Schellhas, Smith, Gundry, and Pollei, Spine 1996 Feb. 1;21(3):300-11; Discussion by James Zucherman, 311-12.

Methods:

Ten lifelong asymptomatic subjects and 10 nonlitigious chronic neck/head pain patients underwent discography at C3-C4 and C6-C7 after magnetic resonance imaging. Disc morphology and provoked responses were recorded at each level studied.

 Results:  In the pain patients, 11 discs appeared normal at MRI and 10 of

these proved to have anular tears discographically.  Discographically normal discs were never painful in either

groups. 

Cervical Discogenic Pain. Spine 1996 Feb. 1;21(3):300-11; Discussion by James Zucherman, 311-12.

(cont’d)

Conclusion:  Significant cervical disc annular tears often

escape magnetic resonance imaging detection, and MRI cannot reliably identify the source(s) of cervical discogenic pain.

“But the x-ray is negative! How can there be an injury?”

Question: Are diagnostic tests such as x-ray, MRI, EEG, EMG, etc, reliable indicators for the potential for injury?

Answer: NO

Wickstrom et al….

Experiments produced tears of the ALL so severe that they were often seen in conjunction with avulsions of the disc of vertebrae (rim lesions).

Yet, they were not seen on radiographs

MRI…(1) Goldberg et al. (2) Davis et al. Visualization of ALL

Jonsson MD. Journal of Spinal Disorders 1991;4(3):251-263.

Study of cervical spine of 22 patients who died of fatal skull fractures in MVAs. X-rays were evaluated by an expert orthopedic radiologist. Only 1 of 10 gross ligamentous disruptions were even suspected on X-rays. 198 lesions were missed. Multilevel soft-tissue injuries were common. Very few injuries were detected or even suspected on radiograms. The vast majority was not recognized. Plain radiograms cannot detect soft-tissue lesions unless they are associated with vertebral body malalignment. Conclusions: the majority of lesions are soft-tissue injuries. Plain radiograms show virtually no soft-tissue lesions.

 Side note:As a result of these types of studies, it has become apparent that a

thorough physical examination is more important, in combination with functional assessments, than traditional diagnostic evaluations to determine the presence or absence of soft-tissue injuries.

Liebenson, DC, Oslance. Rehabilitation of the Spine. Williams and Wilkins, Baltimore. 1996:73.

“80% of patients have no identifiable structural pathology and require treatment based on evaluation of functional deficits. In the majority of cases, patients have soft tissue injuries and functional changes are the only objective findings on which to base treatment and judge progress. Outcomes assessments including objective functional tests give the third party payers, patients and doctors a way to measure progress over time, and evaluate the prescribed treatment. Overemphasis on treatment of structural pathology results in a failure to identify or focus on functional loses and work demands. [Emphasis added.]”

Mooney, MD. J. Musculoskeletal Medicine 1995; Oct:33-39.

“Common acute back pain is due to chemical abnormalities created by soft tissue tear. The tear represents a mechanical disruption, which is usually microscopic. X-rays demonstrate no changes before and after an acute back injury.”

 Again, function is more important in the evaluation and treatment of

back pain than structural pathology. A "negative" x-ray has limited value in the determination of medical necessity since one cannot evaluate "function" from an x-ray. Similar findings concerning other imaging findings was also demonstrated in a paper by Davis, DC. JNMS 1996;4(3):102-115.

 In general, imaging studies are not useful in determining the origin of

pain. However, they are a useful diagnostic tool used in the detection of structural deformities or pathology, which may prevent the application of appropriate manipulative procedures.

Jarvik et al. Rapid Magnetic Resonance Imaging vs Radiographs for Patients with Low Back Pain. JAMA

2003;289:2810-2818.

Conclusion: Rapid MRIs and radiographs resulted in nearly identical outcomes for primary care patients with low back pain. Although physicians and patients preferred the rapid MRI, substituting rapid MRI for radiographic evaluations in the primary care setting may offer little additional benefit to patients and may increase the costs of care because of the increased number of spine operations that patients are likely to undergo.

Association between pain in the hip region and radiographic changes for osteoarthritis: results

from a population-based study. Birrell et al. Rheumatology 2005 44(3):337-341.

Objectives: The relationship between hip pain and radiographic change in the population is unclear due to lack of agreed definition for hip pain and difficulties in obtaining radiographs from asymptomatic random samples.

Our objective was to assess the

relationship between hip pain and radiographic changes in OA in a population sample aged over 45.

Association between pain in the hip region and radiographic changes for osteoarthritis: results from a

population-based study. Cont’d

Conclusion: Hip pain is relatively infrequent in the general population compared with the published reports of other regional pain syndromes.

Mild/moderate radiographic change is very frequent and not related to pain, whereas severe change is rare but strongly related.

In younger males, severe radiographic change is much less likely to be associated with pain.

Symptoms vs. Function

As a result of these and other studies there has been a shift in thinking away from the traditional "symptom" approach, towards contemporary thinking of "function".

For many patients with recurrent back pain, staying functional is a "process" more so than a "result" based on a predictable healing time or average.

Summary

Since 1956…dozens of studies

“Natural Healing Time”……Myth

Mechanical Back Pain…predominant issue

Restoration and maintenance of “function” is critical

Chronic PainMyth: SMT indicated for acute or

chronic…..or both?

A Review of the Literature

Meade Study: BMJ 1990

A British ten year study concluded that chiropractic treatment was significantly more effective, particularly with patients with chronic and severe pain

Giles LG, Muller R. JMPT 1999

Study compared spinal manipulation, needle acupuncture, and NSAIDs for the treatment of chronic back pain.

After 30 days, spinal manipulation was the only intervention to achieve statistically significant improvement.

Intervention by way of acupuncture or NSAIDs did not result in significant improvements in any of the outcome measures.

Manual Medicine 1986

CMT is both subjectively and objectively, more effective at relieving low back pain than a manual placebo treatment. 

SPINE 1997 Maurits W. van Tulder, et al

“…strong evidence for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short term results.”

Additionally, the study found that no single therapeutic intervention was demonstrated to be effective in the treatment of chronic LBP.  

SPINE 1995 Triano, McGregor, et al

“There appears to be clinical value to treatment according to a defined plan using manipulation even in low back pain exceeding 7 weeks’ duration”

CHIROPRACTIC MORE EFFECTIVE THAN MEDICAL CARE FOR LBP; JMPT – March 2004;27:160-9.

Investigators pooled data on 60 chiropractic patients from 51 chiropractic clinics and 11 patients cared for by general practitioners from 14 medical clinics. All subjects had acute or chronic LBP.

  Findings showed that chiropractic care had significant advantages over medical

care. Specifically, “a clinically important advantage for chiropractic patients was seen in chronic patients in the short-term (>10 [visual analog scale] points), and both acute and chronic chiropractic patients experienced somewhat greater relief up to 1 year.” Patients with leg pain below the knee appeared to have the greatest advantage from chiropractic care.

  “Study findings were consistent with systematic reviews of the efficacy of spinal

manipulation for pain and disability in acute and chronic LBP,” write the study’s authors. “Patient choice and interdisciplinary referral should be prime considerations by physicians, policymakers and third-party payers in identifying health services for patients with LBP.”

Waddell, MD. The Chiropractic Report 1993; July:1-6

Bed Rest: should die as soon as it can. Physical Therapy: There is no adequate evidence of effectiveness. Spinal manipulation: one of two treatments of proven value. Early active exercise: Is the other treatment supported by good evidence. Relief of pain and restoration of function must occur at the same time.Failure to restore function means any pain relief will be temporary andreinforces chronic pain. In the management of occupational back pain,the chiropractic profession is leading the way. The problem is weaknessand loss of function, not disease.

Bronfort. DC et al. JMPT 1996; 19(9): 570-582

…compared the efficacy of five weeks of: (1) spinal manipulation (SM) with trunk strengthening exercises (TSE); (2) SM combined with trunk stretching exercises; and (3) NSAIDs with TSE all followed by 6 weeks of supervised exercise alone.

For the management of chronic low back pain, trunk exercise in combination with spinal manipulation or NSAIDs seems beneficial and worthwhile.

Summary

The benefit of chiropractic manipulation (in addition to exercise) over single intervention treatments like acupuncture, exercise, and NSAIDs for patients with chronic pain syndromes is clear and supported by scientific study.

Manipulation is certainly the safest and most effective treatment to keep a spine functional and the chronic pain patient employed.

Adjustments Don’t Have to Make Noise to Work. Archives of Physical Medicine and Rehabilitation – July 2003;84:1057-60.

“There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with non-radicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment.”

Manual Therapy for patients with stable angina pectoris: a nonrandomized open prospective

trial. JMPT. Nov. 2005;28(11):654-661. Christensen, et al.

275 pts……..stable angina 50 dx w/ cervicothoracic angina (CTA), the

treatment group. Remaining pts. in control group. CTA….8 tx of manual therapy/HVLA in 4 wks,

and trigger points/massage. Result: 70% of CTA improved. 96% thought DC tx was beneficial. Quality-of-life questionnaires provided the

most revealing evidence of the benefits of chiropractic care.

Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized

double-blinded clinical trial of active and simulated spinal manipulation.

Spine Journal 2006. Published online 2/3/06. Santilli, et al.

102 adults seen in 2 medical centers in Rome. Two groups: active and simulated. Active: max. of 20 tx in 30 days. CMT: Examining the ROM, soft tissue

manipulation, followed by “brisk rotational thrusting away from the greatest restriction.”

Assessed at 15, 30, 45, 90, and 180 days. Results: 55% of active group were free of

radiating pain, compared to only 20% of simulated pts.

Less local pain, pain, and less NSAIDs.

Cox et al. Distraction Manipulation Reduction of an L5-S1 Disk Herniation . Journal of Manipulative and

Physiological Therapeutics Volume 16, Number 5, June, 1993

Conclusions: Chiropractic distraction manipulation is an effective treatment of lumbar disk herniation, if the chiropractor is observant during its administration for patient tolerance to manipulation under distraction and any signs of neurological deficit demanding other types of care.

Cassidy et al. Side Posture Manipulation for Lumbar Intervertebral Disk Herniation. JMPT. Volume 16,

Number 2, February, 1993

Conclusions: The treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective.

Cassidy et al. Cont’d

Points of Interest:        Normal disks withstood an average of 22.6 degrees of rotation before failure,

while the degenerated disks withstood an average of 14.3 degrees.         When disk failure occurred, it presented as peripheral annular tears and not

herniation or prolapse.        Posterior facet joints of the intact lumbar motion segment allow only a small

range of rotation at the lower levels.        Therefore torsional failure of the lumbar disk first requires fracture of the

posterior joints, which can then result in peripheral annular tears.        Bottom line: The bony architecture of the lumbar spine prevents excess

rotation that would have damaged the peripheral annular fibers. Therefore it remains unlikely that side posture spinal manipulation would damage a disk.

Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: a preliminary study. Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teasdale N. J Manipulative Physiol

Ther. 2004 Oct;27(8):509-14. Related Articles, Links

OBJECTIVE: To document the potential role of maintenance chiropractic spinal manipulation to reduce overall pain and disability levels associated with chronic low-back conditions after an initial phase of intensive chiropractic treatments.

METHOD: 2 groups; (1) 12 tx in 1 mo., no tx for 9 mo. (2) 12 tx in 1 mo., 1 tx every 3 weks for 9 mo.

RESULTS: Both groups maintained their pain scores at levels similar to the postintensive treatments throughout the follow-up period. For the disability scores, however, only the group that was given spinal manipulations during the follow-up period maintained their postintensive treatment scores. The disability scores of the other group went back to their pretreatment levels.  CONCLUSIONS: Intensive spinal manipulation is effective for the treatment of chronic low back pain. This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective postintensive treatment disability levels.

Dabbs, D.C. and Lauretti, D.C., A Risk Assesment of Cervical Manipulation vs. NSAIDs for the Treatment of Neck Pain. Journal of Manipulative and Physiological Therapeutics. Vol. 18, number 8 Oct. 1995; 18:530-6.

“The best evidence indicates that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times. There is no evidence that indicates NSAID use is any more effective than cervical manipulation for neck pain.”

Death rate for NSAID-associated GI problems at 0.04% per yr amoung OA patients receiving NSAIDs, or 3,200 deaths in the US per year.

  He (Brandt) also noted that there are several animal

studies and human clinical studies that have actually implicated NSAIDs in the acceleration of joint destruction.

Chiropractic Care Staves Off Pregnancy-Related Back Pain

University of Bridgeport College of Chiropractic 17 cases of pregnant women with LBP Pain scale: 5.9 reduced to 1.5 Average time to clinically important pain relief:

4.5 days. Average # of visits: 1.8 16 of 17 improved. No adverse effects. Conclusion: DC tx was safe and effective.

Source: Journal of Midwifery and Women’s Health. Jan 2006;51:e7-10

Goals of Chiropractic Spinal

Manipulation for Chronic Pain

1. Pain Relief2. Improve Fx3. Decrease Reliance on drugs4. Keep the patient employed

SMT and Headaches

A Review of the literature

Vernon et al. Spinal Manipulation and Headaches of Cervical Origin.  

Journal of Manipulative and Physiological Therapeutics, Volume 12,  

Number 6, December, 1989.  

ABSTRACT: The role of the cervical spine in headache remains controversial. Often confused as tension or common migraine headache, headaches arising from the neck pose a diagnostic and therapeutic challenge.

Recent writers addressing this issue, including Bogduk (2-4), Edmeads (50, Farina et al. (6) and Sjaastad and his colleagues (7-9), have added much to our current understanding. However, even these authors appear to have included only a small portion of the supportive literature in their reports, leaving a diminished sense of the historical attention and the current clinical importance of this category of headaches.  

Hurwitz et al. Manipulation and Mobilization of the Cervical Spine: A Systematic Review of the

Literature

Literature 1966 to present

Conclusion: Cervical spine SMT and mobilization probably provide at least short-term benefits for some patients with NP and headaches.

Woodward, Cook, et al. (1996). “Chiropractic Treatment of Chronic Whiplash.” Injury 27 (9): 643-5

“The accumulated literature suggests that 43% of patients will suffer long-term symptoms following ‘whiplash’ injury. If patients are still symptomatic after 3 months then there is almost a 90% chance that they will remain so. No conventional treatment has proven to be effective in these established chronic cases.”

“The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic ‘whiplash’ injury.”

  Following the chiropractic treatment, 93% of the

patients had improved.

A Symptomatic Classification of Whiplash Injury and the Implications for Treatment. Khan, Cook, Gargan, and Bannister, University Department of Orthopaedic Surgery, Bristol, UK. The Journal of Orthopaedic Medicine 21[1]1999.

Objective: To determine which patients with chronic whiplash will benefit from chiropractic treatment.

93 patients, 68 female.  Conclusion: Whiplash injuries are common. Chiropractic is the

only proven effective treatment in chronic cases. Our study enables patients to be classified at initial assessment in order to target those patients who will benefit from such treatment.

  57% make full recovery.  Resolution of symptoms will have occurred within 2 years of injury.  8% will remain disabled by their symptoms.

Chronic pain

Current Concepts

Receptive Field EnlargementSynaptogenesis/Neuroplasticity

Neurological Wind-up

A Glimpse into an Evidence-based

Practice

1. Clinical Vignettes

2. Evidence/Best Practices

3. Performance Measures and Value-based medicine.

Copyright © 2012 Dr. Ronald J. Farabaugh