Neck, Back Pain: Clinical evaluation of treatment modalities.


Abstract: From the most ancient time, mechanical disorders of the spine were one of the major concerns of mankind. Perhaps no other disease has initiated so many different treatments, during the history of Medicine. All these methods are said to be efficient, if not the most efficient, by their promoter. It is interesting to note that each of these methods acts upon a different mechanism. It is therefore Understandable if one asks himself how is it possible to cure one disease with such a variety of treatments. The explanation may be: The disease is self limiting and self repairing, none of the treatments are curative, perhaps some of them will accelerate the self reparation. Thousands and thousands of articles have been published on the treatment of low back pain and cervical pain. One of the most important study in this field is the Report of the Quebec Task Farce on Spinal Disorders in 1987. From 7000 articles related to spinal disorders form 1972, 721 were selected according to their quality. After analysis of these articles treatments were classified in 5 categories: 1- Useful, demonstrated by scientifically acceptable controlled randomized trial. This category represented the strongest scientific proof. 2- Useful, by scientifically acceptable nonrandomized controlled studies. This category represented the second most scientific proof. 3-Considered useful, in current practice without any scientific proof. 4- Not been demonstrated useful in the scientific literature and it is not currently used in practice. 5- The method is contraindicated, because scientific evidence demonstrated it either harmful or more harmful than beneficial. The treatment modalities were: 1- Bed rest. 2- Systemic medication. 3- Local medication. 4- Cryotherapy. 5- Thermotherapy. 6- Massage. 7- Exercises. 8- Functional training. 9- Back school. 10- Biofeedback. 11- Spinal orthosis. 12- Spinal support. 13- Electroanalgesia. 14- ­Mobilization. 15- Manipulation. 16- Traction. 17- Pain Clinic. 18- Acupuncture. 19- ­Psychopharmacology. 20- Psychotherapy. 21- Spinal arthrodesis. 22- Chemonucleolysis. 23- Discectomy. 24- Denervation. The analysis of articles demonstrated that the only treatment methods scientifically proven to be useful by randomized controlled methods were the bed rest, the Back School, the chemonucleolysis, and the surgery. Bed rest for 2 days or less was effective for the following conditions: LBP, LBP radiating to posterior thigh, and LBP radiating to calf. The bed rest was efficient on acute and sub acute forms not exceeding 7 weeks of duration. Wiesel et al, in 1980 demonstrated that 10 days of bed rest allowed better recovery than no rest. The study of Dayo et al, in 1985 demonstrated that the result of 2 days bed rest was equivalent to 7 days. Bed rest for more than 2 days: The Weber's Study, in 1983 demonstrated that 2 weeks of bed rest was efficacious on radicular compression. In few exceptions more than 2 weeks of bed rest will be useful. Back School: Is a structured intervention program aimed at a group of individuals and providing them general information on the spine, recommended postures and physical activities, prevention, and exercise for the back. The program of back school varies from center to center, however the essence is the same (Aberg 1982, Berquist and Ullman 1977). What about other treatments? The second category of treatments are those that their usefulness were not scientifically proven, however they were shown to be useful by non randomized controlled trials: Systemic medications to decrease the pain in all stages and all forms of LBP, systemic medication to decrease the muscle spasm in acute forms of LBP not exceeding 7 days (with or without irradiation), systemic medication to decrease local inflammation in acute and subacute forms of LBP, with or without irradiation, not exceeding 7 weeks. Local injections of anesthetic drugs or anti inflammatory drugs are controversial. Strengthening exercises in LBP without irradiation or irradiating to calf, in the chronic forms of more than 7 weeks duration. Although these exercises increase the strength, they have not been proven to increase endurance. The third category of treatments are those that are of common practice without any scientific proof of efficacy. In this category we can mention: Back supports, cold and heat therapy, massage, traction, mobilization and manipulations, biofeedback, acupuncture, pain clinic. The above mentioned points were a summary of the conclusions obtained by the Quebec "Task Force on Spinal Disorders upon the medical literature up to 1986. Other works have been done after the Quebec Task Force report. Swezey in an exhaustive review confirms the conclusions of the Quebec Task Force. Form the analysis of 13 articles published from 1987 to 1992, he classified the various treatments in 4 categories for their ability to relieve pain: Proven, probable, possible, and doubtful. For each method the risks were calculated as: Non; low, and moderate. For each method the cost was calculated as: Low, moderate, and high. Proven methods were: Short term bed rest (no risk, no cost), analgesics (low risk, low cost), NSAIDs (low risk, low to moderate cost), muscle relaxant (low risk, low to moderate cost), manipulations (moderate risk, moderate cost). Tsang in a review based on 11 articles published from 1991 to 1992 analyzed the treatment modalities. The major points were: The axiom "let the pain be your guide" seems to provoke disuse-induced deconditioning. A scheduled physical exercise in which pain is not a limit of activity improved the spinal mobility, trunk muscle strength, and lifting capacity (Estlander et al.). Same conclusions were made by Rainville et al. and Lindstrom et al. The volume of herniated nucleus pulposus can decrease and even disappear in some patients with conservative treatments (Delauche-Cavallier et al,. Maigne et al., Thelander et al.). Koes et al. reviewing 35 randomized clinical trials comparing spinal manipulation with other treatments concluded that the efficacy of manipulation had not been convincingly established. Besides the 3 extensive reviews few other works merit to be cited. Gardel et al. obtained a high satisfaction index with back school. Sullivan et al. in 1992 conclude that the prevalence of major depression in patients with chronic low back pain is 4 times the general population. The tricyclic antidepressants and cognitive-behavioral approaches may be effective beside other treatments for pain.Lawrence et al. 1992, use the measurement iterative loop as a conceptual framework to examine the economics of common therapies for acute non specific low back pain. They conclude that among treatments with some support from randomized controlled study, bed rest appears to be economically superior to others. HOW TO APPLY THE ABOVE RULES IN DAILY PRACTICE: It is impossible to classify accurately all LBP cases. The following classification may be a guideline. LBP with no irradiation: 1) Acute: 2 days bed rest. Adequate medication. Gradual return to normal activities. Adequate exercises Basic principles of what to do and what to not do in the daily activities (simplified form of back school). 2) Subacute: a) Presence of objective physical symptoms: To manage as the acute form. b) Absence of objective physical symptoms: Gradual return to normal activities. Adequate exercises. Basic principles of what to do and what to not do in the daily activities (simplified form of back school). 3) Chronic. Back school. LBP with nerve root pain: As LBP with no irradiation. However the bed rest must be adjusted to the need, usually not exceeding 2 weeks. 1) Acute forms not responding to conservative treatment: Re-evaluationof the patient. If important physical signs, chemonucleolysis or surgery may be considered. If minor physical signs, back school and/or psychiatric help. Tricyclic medication may be considered? 2) Acute forms with motor deficit: There is no hurry for surgery, conservative treatment is to be considered first. Re-evaluation of the patient 2 weeks later if aggravation surgery is to be considered. If stable: Continuation of the conservative treatment, re-evaluation of the patient every 2 to 4 weeks, If no improvement after 2 to 3 months surgery may be considered. If improvement: Continuation of the conservative treatment, there is no need for surgery. 3) Subacute forms not responding to conservative treatment: Re-evaluation of the patient: If important objective physical signs surgery may be considered. If minor objective physical signs: Back school. If no physical signs: Back school, psychiatric evaluation. 4) Chronic forms not responding to treatment: Back school, psychiatric evaluation. It is important to keep in mind that not every patient will fit in to this simplified frame. Adjustment per case and use of other methods, even if not scientifically proven to be effective, may be needed as painted out by Swezey.