Physical Treatments

An examination of the initial phase treatments reveals the following:
                                           
Physical Therapy: According to a recent study by Feline and Lund of McGill University, there is little evidence that physical therapy and physical therapy modalities provide any long-term efficacy greater than placebo.

The therapies that were examined included exercise, ultrasound, thermal agents, acupuncture, low-intensity laser therapy, electrical stimulation, and combination therapies for a variety of musculoskeletal pain conditions including chronic back pain.  The authors reported, "our results suggest that none of the therapies under review cause improvements in symptoms of chronic musculoskeletal pain or in quality of life that outlast the therapy...including placebo."

Van den Hoogen et al published the results of a study involving 269 patients. It was concluded that receiving physical therapy was associated with a longer duration of low back pain.  The authors reported, "at every moment in time, patients receiving physical therapy had a 51% less chance to recover in the following week than patients not receiving physical therapy."

The AHCPR Guideline for Acute Low Back Problems in Adults concurs: "The use of physical agents and modalities in the treatment of acute low back problems is of insufficiently proven benefit to justify their cost”. “Only two studies evaluated physical agents and modalities in patients with acute low back pain. Neither found significant differences in self-rated pain relief or other outcome measures between patient groups receiving physical agents and modalities (including diathermy, ultrasound, flexion/extension exercises, massage, and electrotherapy) and groups receiving a placebo."

Skargren et all reported the results of a study involving 323 patients who were assigned to care by a physiotherapist or a chiropractor. Those receiving chiropractic treatment received primarily manipulation. Those in the physiotherapy group received a variety of treatment modalities. The mean number of chiropractic visits was 7. The mean number of PT visits was 7.9. The conclusion: "No differences in the outcomes for either primary treatment in effectively reducing the symptoms. No differences in outcome, or direct or indirect costs between the two groups could be seen, nor in subgroups defined as duration, history, or severity."

TENS: A study of 324 patients found no differences in outcomes in those receiving three different types of TENS and those given a sham TENS unit with indicator lights but no output.

Ultrasound:  Gam and Johannsen reviewed 293 papers published since 1950, to assess the evidence of the effect of ultrasound for musculoskeletal disorders. The conclusion of this review was: "None of the methods gave evidence that pain relief could be achieved by ultrasound treatment."

Exercise:  One of the central strategies in most current guidelines for initial treatment is a program that focuses on improving aerobic fitness and on increasing strength and flexibility. Although exercise may seem like a logical answer to the patient’s recovery, physical activities that increase the patient’s intradiscal pressure will make the pain and pathology worse over time.   This treatment is not designed to address or alter the pathology or prognosis of discogenic and degenerative disc disorders.

A study by Faas A. Et al concluded that “prescribing ‘exercise’ more specifically flexion exercise – for acute back patients actually increases absence from work”.  This study was an offshoot of an award winning randomized study of 473 patients that concluded, “exercise is ineffective as a treatment for acute back pain”.  The authors stated that.” Overall, patients in the exercise group had a higher level of absenteeism than the other groups. Patients who appeared to comply with the exercise recommendations did not do any better than patients who didn’t.”

The results of the above studies were concordant with a similar randomized study by Gilbert et al.  which concluded that “patients who performed flexion exercises actually did worse” and “the exercises were not useful for acute low back pain”.

Acupuncture:   Acupuncture has been utilized for mitigation of mild to moderate pain (associated with back or neck problems). Acupuncture does not address the pathology associated with low back pain nor will it change the prognosis for the patient.

Epidural Steroid Injections: Epidural corticosteroid injections have been used have been used for nearly half a century and are widely used in everyday clinical practice. They may be helpful for reducing tissue inflammation and short-term pain relief in a patient with an acute radicular low back problem who is unable to participate in an active treatment program because of severe leg pain and/or neuromotor deficit.

In randomized, double blind trials, patients were given up to three epidural injections of corticosteroids versus saline .  After three months, there were no significant differences between the groups.  The authors concluded that “although epidural injections may afford short-term  improvement in leg pain, this treatment offers no significant functional benefit, nor does it reduce the need for surgery.”

A recent randomized double-blind trial published in the Annals of Rheumatic diseases (2003) concluded that steroid injections for sciatica are no better than saline.  These findings are consistent with those of another definitive trial presented at the recent American College of Rheumatology meeting.

Lumbar Support Belts:  According to a large new prospective cohort study conducted by researchers at the National Institute of Occupational Safety and Health, lumbar support belts do not prevent back pain or back pain disability.    In the largest prospective study of back belt use, adjusted for multiple individual risk factors, neither frequent belt use nor a store policy that required belt use was associated with reduced incidence of back injury claims or low back pain. The study found no beneficial effect of belt use in any group: among employees with and without a history of back injury, employees with consistent belt-wearing habits, or employees with the most strenuous jobs.

Results based on multiple studies all converge to a common conclusion: back belt use is not associated with reduced incidence of back injury claims or low back pain in material handlers.

Surgery

A large study by Dvorak J. et al. reviewed the long-term results of patients that had received surgery for lumbar disc herniations .  They reported that of the 575 patient’s studied, 70% still complained of back pain; 83% complained of constant heavy pain; 45% have a residual sciatica; 35% are still under some kind of treatment; 47% are receiving a disability pension and 17% required repeat surgeries.

The authors stated “Based upon the criteria given by Spine as related to justified or unjustified indication, there was no statistical difference in long-term results for surgery as compared to conservative care”.  “The so-called justified indication for disc herniation neurosurgery does not necessarily imply a good long term result.”

The overuse of surgery has been perhaps the single most damaging medical intervention for back pain sufferers. Bigos and Battie reported, “Surgery seems helpful for at most 2% of patients with back problems, and its inappropriate use can have a great impact on increasing the chance of chronic back pain disability.

In a Volvo award winning paper, Waddell reports, “Dramatic surgical success unfortunately only applies to approximately 1% of patients with low back disorders. Our failure involves the remaining 99% . . . for whom the problem has become progressively worse.”   

Saal and Saal supervised care for a group of patients referred by neurologists for surgery. They attempted rehabilitation for these patients and made the following observations: “Surgery should be reserved for those patients for whom function cannot be satisfactorily improved by a physical rehabilitation program .   Failure of passive non-operative treatment is not sufficient for the  decision to operate.”  They also reported that, “the premise that operative patients fare better in the first year is contrary to our results, and the notion that surgery is necessary in a patient with a large   disk extrusion is not supported in the literature.  The presence of a disk extrusion does not adversely effect the outcome of non-operative treatment and should not be used as overwhelming evidence that surgery is necessary”.

In 1983, Weber reported that, even in properly selected patients, there is no difference in outcome between surgically and conservatively treated patients at two years.

In 1992, Bush et al  stated that, “86% of patients with clinical sciatica and radiologic evidence of nerve root entrapment were treated successfully by aggressive conservative management.”  They reported that, “the intervertebral disc pathomorphology that might seem best suited to surgical resection is in fact that which shows the most significant incidence of natural regression. . .these results confirm that if the pain can be controlled, nature can be allowed to run its course with the partial or complete resolution of the mechanical factor . . .lumbar herniated nucleus pulposus can be treated non-operatively with a high degree of success.”

Bush et al also stated that ‘Surgery clearly has its place in the treatment of lumbar spine disorders. Conservative care practitioners must be able to select the patients who satisfy the criteria for surgical intervention. These criteria are more strict than previously believed.