News Category: Lumbar Spine

Degenerative disc disease (DDD) is a common cause of low back pain (LBP) in Worker’s Compensation claims. Ten per cent of the workers aren’t helped by conservative care. This group ends up needing more invasive treatment. But the treatment options are limited. For example, spinal fusion has not proven to be very helpful.

Intradiscal electrotherapy (IDET) is minimally invasive and may be an effective alternative to fusion. IDET involves the placement of a catheter (thin tube) into the disc space. Heat is delivered via a coil inserted through the catheter. The temperature of the disc is increased using thermal (heat) energy.

In this study, the results of using IDET on Worker’s Comp patients are reported. All workers had chronic disc-related LBP. Half of the patients were on narcotics for pain control. Pain and disability were measured before and after treatment. Workers on light-duty or who were off work before treatment were assessed after treatment. Return to work status and productivity were reported.

Patients were divided into three major work groups. The groups were based on degree of physical difficulty. Heavy lifters included construction workers, oil-platform workers, warehouse porters, and army Marines. Moderate laborers included assembly-line workers, maintenance crews, heavy-vehicle drivers, and security workers. The third group was labeled sedentary (desk job) workers.

The authors report significant improvement in both pain and function. Narcotic use dropped from 51 to 13 per cent. Analysis of various factors showed that age and body weight did not affect the results. Pain level and function before treatment were important factors.

Only five per cent of the workers returned to full duty. But almost half of the treatment group were able to return to light duty or full duty with some restrictions on heavy-lifting. This was a major improvement in economic productivity from before treatment. The rest of the workers (47 per cent) did not return to work.

Reports on the results of IDET are few and far between. And the results of those studies don’t agree with each other. The results of this study suggest it is a safe and effective treatment for pain and disability from disc disease.

Differences in results may be based on patient selection, placement of the catheter, and heating temperature used. This was the first long-term study of Worker’s Compensation employees. Younger patients with recent onset of symptoms formed a subgroup of workers. This subgroup really wanted to get back to normal and return to work.

More studies are needed to find the optimal patient and technique for this procedure. It’s possible that different temperatures are needed to destroy pain receptors versus to contract collagen (tissue) fibers. For now, it appears that IDET is safe and useful for carefully selected patients. Worker’s Compensation employees should not be excluded. Age, sex, and obesity do not affect the outcomes.

Mechanical traction to treat back pain has been around for centuries. But its use has fallen out of favor lately. This is because there’s a lack of evidence to support it. A new traction system called vertebral axial decompression (VAX-D) may change that.

With this traction table, the patient is positioned prone (face down). A harness around the pelvis applies a distraction force to the lumbar spine. The upper body is not in a harness or belted in place. Instead, the patient holds a hand grip to stabilize the rest of the body. The surface of the traction table is low-friction so a thoracic (upper body) harness isn’t needed.

In this study, 250 patients with low back pain (LBP) were treated using the VAX-D. All subjects had LBP that limited activity. Each patient had radiographic imaging showing a degenerative or herniated disc. Everyone had tried at least two types of nonoperative treatment without success before using the VAX-D.

Treatment was given five to six times each week for four weeks. Then treatment continued once a week for another four weeks. The traction-relaxation cycle was set at 60 seconds on and 60 seconds off. The force of pull applied was set to the manufacturer’s recommended level in accordance with the patient’s comfort.

Results were measured by comparing pain levels and function before and after treatment. Pain was rated using a number system. Then it was analyzed using lowest, average, and highest intensity on a typical day.

Patients reported great improvement in pain and function after traction. The improvements were still present at 30 and 180 days after the last traction session. The advantages of the VAX-D are that it is noninvasive with a low risk of injury. The down side is that the nature of the unique type of traction pull makes this unit more expensive than conventional traction devices.

Further study is needed before the VAX-D can be recommended. Research is needed comparing this form of traction with standard (conventional) traction. And a group of patients with LBP should be treated with VAX-D and compared to a similar group who do not receive traction treatment.

Researchers around the world are trying different forms and combinations of exercise and other treatment approaches to solve the problem of chronic low back pain (CLBP). This study was done in the Netherlands by a group of psychologists and rehab specialists.

They divided adults with CLBP into four groups. Each group received a different treatment. Group one had 10 weeks of aerobic training along with strengthening of the back extensor muscles. This was called active physical treatment (APT).

Group two had 10 weeks of physical activities and problem solving training (PST). The physical activities were geared to the patient and slowly increased over time. Problem solving was designed to help patients find ways to do more despite their pain. This treatment was called graded activity plus problem solving or GAP.

Group three had both APT and GAP. This was referred to as combination treatment (CT). A physical therapist supervised patients in the first three groups. A psychologist or social worker provided the PST. Patients in group four (control group) were on a waiting list for services. They received no treatment during this 10-week period of time.

The results showed that combining treatments didn’t work any better than single treatment approaches. Patients were tested at six and 12 months after treatment. Levels of pain, depression, and levels of disability were not different among the treatment groups.

The authors could not account for these results. They offered suggestions for future studies. For example, there may be subgroups of patients identified by certain characteristics who would benefit the most from one specific form of treatment. Or perhaps treatment could be more fine-tuned for certain types of problems.

Treatment for CLBP is often focused on improving strength and aerobic capacity. The goal is to restore functional abilities and allow patient to resume normal activities. Experts agree that combining several treatment modes works better than doing nothing. This study has added to our knowledge of what works and what doesn’t.

Studies over time have resulted in changes in the surgical treatment for disc herniation. At one time, the entire disc was removed but not replaced. In 1977, the microdiscectomy was introduced as a more minimal approach to disc removal. With this procedure, the disc is removed using a very small incision. There is minimal disruption of the ligaments and bony structure.

Today, sequestrectomy has been suggested as a modification to microdiscectomy. With sequestrectomy, only the loose fragments of disc material in the intervertebral space are removed. The disc space is not entered at all. The advantages of sequestrectomy over microdiscectomy are reported in this study.

Two groups of patients with a single-level lumbar herniation were compared. None of the patients had a previous spine surgery. One group had a standard discectomy. All disc material at the affected level was removed. The second group had a sequestrectomy: only free-floating disc fragments were taken out.

The short-term results (four to six months) for these two groups were reported in an earlier study. Long-term results after two years were the focus of this report. Outcome measures included pain, self-rated quality of life, and rate of reherniation. Both groups had good improvement in pain. Over time, the microdiscectomy group reported worse symptoms and increased use of pain medication.

Improved function was observed in the sequestrectomy group and did not decline over time. On the other hand, function declined in the microdiscectomy group. Function was measured in terms of sleep, work, and play (sports). After two years, the reherniation rate was the same for both groups.

The authors conclude that sequestrectomy is a superior treatment over microdiscectomy for disc herniation. Removing only the disc fragments that are pressing on the spinal nerve root is all that’s needed for good results. Concern about reherniation after sequestrectomy was not supported by this study. For the best results, surgeons should continue to remove as little disc material as possible. Healthy disc tissue should not be touched.

There are many different ways to treat chronic low back pain (LBP). Not all work equally well. Some seem to fit certain patients better than others. There is a wide range of symptoms and response to treatment observed with the many people affected by chronic LBP.

In this report, the use of functional restoration (FR) as a treatment approach is reviewed. Evidence to support its role in treatment is presented. FR is a method used to treat chronic pain patients. It is a holistic approach that takes into account social, psychologic, and physical factors affecting pain and disability.

FR was first developed in the late 1980s. It provided an alternative way to manage chronic LBP. Many physical therapists, occupational therapists, and rehab specialists adopted this treatment idea. It is a team approach based on the idea that the individual treatment methods work better when combined together at the same time.

Physical capacity and other measures of function were included in the FR assessment. Goals of the program included decreased pain and decreased use of medication. Restoring activities of daily living (ADLs) and getting the patient back to work were also important.

The program was designed to make sure the patient had enough physical capacity to return to work. There should be no danger of re-injury or the need for further health-care related to this episode of back pain.

The success of such programming has been verified by various studies. And the results are better than with less intensive programs or with usual (standard) care. Studies show that the results are equally good around the world.

Patients in different countries with different economic and social conditions had comparable positive outcomes. The FR approach has even been shown to help prevent chronic disability in patients with LBP.

However, the cost may seem higher than standard or traditional care. Third party payers have resisted paying for such programs. Further studies have shown that FR patients are less likely to use pain-relieving medications. They are more likely to return to work compared with the treatment-as-usual group. The overall cost of the treatment-as-usual group was actually twice as much as the FR group when measured over a year’s time.

The authors conclude that FR is a good choice for patients with chronic LBP who have not been helped by other, less expensive programs. FR is also recommended after surgery for patients who have not regained enough function to return to work. Patients must be motivated to manage their pain and work toward goals of full recovery and return to work.

Patients looking for nonoperative ways to treat chronic low back pain (CLBP) might want to consider cognitive behavioral therapy (CBT). CBT is a way to change behavior by changing the way a patient thinks about his or her back pain. In this review of CBT, experts in psychology at the University of Texas (Arlington) offer a summary of CBT.

Patients find many different ways to cope with illness, injury, and disease. But these coping skills and the emotions, thoughts, and behaviors that come with them aren’t always healthy or rational. CBT addresses the psychosocial aspects of CLBP and can help reduce pain and anxiety that comes with it.

Many different techniques are used as a part of CBT. These can include imagery, positive self-talk, biofeedback, and various methods of self-induced relaxation. Patients are taught how to set realistic goals and reach them. Negative and self-defeating thoughts are identified. The patient is educated about ways to overcome them.

Breaking the cycle of maladaptive coping behaviors isn’t easy. Many patients with CLBP also have issues around alcohol and other drug abuse. Depression and anxiety can lead to withdrawal from daily activities, including work. But CBT can be successful if patients are motivated and willing to do their homework exercises between sessions.

Studies show that CBT works well when it is part of a multidisciplinary team approach to pain management. Treatment that focuses on both the biologic and psychosocial aspects of pain may cost more in the short-term, but they have better long-term results. Patients have fewer relapses and visit their physicians less often than those who are treated by a single approach of surgery, medications, exercise, or massage, etc.

Overall research shows that CBT reduces pain and pain behaviors. Activity level increases and social functioning improves. Patients report less distress and anxiety on a daily basis. These improvements may lead to less pain or at least the perception of decreased symptoms and less suffering.

Treatment of chronic pain conditions has moved away from monotherapy (a single approach to pain). CBT should be combined with other treatment tools such as physical therapy to address deconditioning, instability, and loss of function that further contribute to the chronic pain cycle. Medications for pain relief and other treatment methods that address all aspects of biologic, psychologic, and social factors are still important.

The cost of health care is rising every year in the United States. And part of that economic burden is the management of chronic low back pain (CLBP). Efforts are being made to find out what kind of nonoperative treatment might work best for CLBP. In this report, doctors and therapists from Mayo Clinic bring us up to date on traction therapy. Does it work? How? What’s the evidence to support this treatment approach?

Traction to treat spinal disorders has been around for a long time (since at least 1800 BC). It became very popular in the late 20th century for the treatment of lumbar disc lesions with back and leg pain (sciatica). High-dose traction with manipulation has become the most commonly prescribed type of traction used today. High-dose refers to using a pull of 30 to 50 per cent of the body weight.

Mechanical traction should not be used for anyone with severe osteoporosis (brittle bones), ligamentous instability, local infection, or bone cancer. Patients with fractures, hernias, or high blood pressure are also excluded from the use of traction. Traction for the lumbrosacral spine is not advised during pregnancy. It is used most often for patients with subacute or CLBP.

Overall, the evidence points against the use of traction as a treatment for CLBP. Research has not been done to show who (if anyone) might benefit the most from this treatment. Studies comparing traction to other treatment (hot packs, manipulation, exercise) have not had consistent results. Since traction can be applied in different ways with different positions and force, it’s not surprising outcomes vary from study to study.

The authors conclude there is a need for further study of traction before discontinuing its use. Patients should be studied based on age, weight (or body mass index), and type of back pain or spinal disorder. The treatment variables should also be tested for number of treatments needed, length of treatment, and type of traction provided.

Pain is often the focus of patients with chronic low back problems. Finding a way to relieve the pain has become a major challenge for pain specialists. When there’s no cure for the condition, the goal is to improve function. One way to do that is to decrease the pain.

Treatment begins with anti-inflammatory and/or or analgesic (pain relieving) drugs. Exercise and physical activity are advised. When these measures don’t help, then spinal injections, opioid drugs, or surgery may be tried. In this article, doctors from the San Francisco Spine Institute in California and The Cleveland Clinic Center for Spine Health in Ohio review the place opioid analgesics have in managing chronic low back pain (CLBP).

Opioids are narcotic pain-relievers. They come in a wide range of forms from short-term to long-term and short-acting to sustained-release. Evidence for or against the use of these drugs has been lacking. Current studies have brought evidence that has given doctors a reason to re-think the use of opioids.

Information about average dose needed for good pain control is available now. Several safe and effective opioid analgesics are available for long-term use. Others have been developed to treat breakthrough pain. Opioids also come in different formulations now. Some are taken orally (pill form). Others come in patch form. The patch is changed every two to three days.

The authors provide a brief summary of many opioid analgesics useful for chronic pain. Duration of pain relief and special remarks about each one are reported. Some patients don’t respond to opioids. It appears that whether or not opioids are helpful may depend on the patient’s genetic predisposition. The prescribing physician must titrate the opioid for each patient. This means they find the optimal dose for each person based on symptoms and side effects.

Opioids work by binding to opioid receptors in the central nervous system. This makes it impossible for pain messages to get through from the body to the spinal cord and up to the brain. Concerns about dependence and addiction are important and should be taken into consideration.

The North American Spine Society has published a special issue of their journal on nonsurgical ways to treat chronic low back pain (CLBP). The goal was to bring us up-to-date on many types of treatments that have some clinical benefit to patients. In this article, medicine-assisted manipulation (MAM) was reviewed.

MAM refers to the use of spinal manipulation after any type of pain control has been given. The pain control may be from pills or injections. When injections are used, this treatment is called manipulation under anesthesia (MUA).

As a broad concept, MAM takes on several forms. The spinal joint can be numbed and then manipulated. Steroid injection into the epidural space can bring pain relief through anesthesia. The spine may be manipulated after epidural injection.

The patient could be under general or conscious anesthesia while the surgeon manipulates the spine. Sometimes a special X-ray called fluoroscopy is used. Fluoroscopy allows the surgeon to see inside the spine. This tool guides the surgeon’s placement of the needle for injection of the steroid or anesthetic.

In all MAM procedures, manipulation takes on several forms as well. While the patient is sedated, the manual therapist (usually a physical therapist) stretches the muscles and joints. The connective tissue is stretched or massaged to release fibrous adhesions. Various forms of traction may be used to the lumbrosacral region.

MAM has become popular in some areas of the U.S. because it seems to decrease pain, spasm, and muscle guarding. With greater relaxation of the joints and muscles, the therapist can then apply manual techniques more effectively. The end result is greater flexibility and motion with less force. The overall results seem positive.

MAM is used with patients who have loss of motion and who have not responded to other conservative methods of treatment. It is advised that four to eight weeks of soft tissue mobilization should be tried first before MAM. Patients who have had a failed back surgery or who have nerve entrapment or muscle contracture are also good candidates for this treatment.

There is not enough evidence to support or deny the value of MAM. Many of the studies done are of poor quality or too small to rely upon. Most of the studies were done back in the 1930s when this technique was first started. The methods used today are very different. There are no reported ongoing studies in this area at the present time.

There is a strong need for studies to support the theories behind MAM. Patient satisfaction and the clinician’s belief that the treatment has a positive benefit is not enough in today’s evidence-based medicine.

More and more, the role of psychosocial factors in chronic low back pain (LBP) has become apparent. The interaction of biologic factors with psychologic and social factors is the focus of new research.

In this report, a three-step approach to the assessment and treatment of spine patients is presented. Studies to support the use of this evaluation method are ongoing. Using a three-step approach like this may help improve outcomes. Evidence is still needed to prove this.

The first step in the biopsychologic exam in the initial screening. The screening process helps find patients with psychosocial and functional distress. This information is useful when planning rehab. It can also be used when surgery is scheduled.

Specific tests in the screening exam include the Medical Outcomes Study 36-Item Short Form [SF-36] and the visual analog scale (VAS). Surveys to assess disability and depression (e.g., Beck Depression Inventory, Pain Disability Questionnaire) are also included.

Step two is the psychosocial interview. A psychologist or psychiatrist conducts this part of the exam. Questions are asked to look for possible barriers to recovery.

The examiner begins with family history of mental illness, personal stress, and work history. Further testing may be needed based on the results of this portion of the exam. Special tests include the Minnesota Multiphasic Personality Inventory, PRIME-MD Patient Health Questionnaire, and the 56-item Multidimensional Pain Inventory.

The third and final step is the presurgical evaluation. Anyone who is planning to have spine surgery must undergo a psychologic exam first. This assessment helps identify patients at risk for failure due to significant biopsychosocial issues.

Using the results of testing, an overall risk score is determined. Patients are placed in one of three groups: low risk for surgery, high risk for surgery, or uncertain at this time. Anyone at high or uncertain risk may be sent to a special rehab program before surgery.

Many of these at-risk patients are able to proceed ahead with surgical treatment once they’ve completed the rehab program. It’s unclear if the patients at high risk will ever be ready for surgery. Pre- and postsurgical rehab may be needed for this group. Without enough proof that surgery can benefit this group, they just may not be candidates for surgery.

The latest craze in exercise programs is core training, also known as core stabilization or lumbar stabilization. But what does it do? And does it really work? Doctors and physical therapists at the University of Washington in Seattle reviewed available research to find out some answers.

Core training or lumbar stabilization is aimed at the muscles of the trunk, abdomen, and pelvis. The goal is to improve motor control, strength, and endurance.

Specific muscles targeted include the transverse abdominis (TrA), lumbar multifidi, and iliopsoas (hip flexor). Other spinal abdominal, and pelvic muscles are also affected by core training.

The basis of core training is the contraction (at the same time) of the deep trunk muscles. This concept is called co-contraction. Applied appropriately, co-contraction leads to core stability. In the patient with low back pain (LBP), this can mean less pain and more function.

Many studies and reviews have been published on the topic of lumbar stabilization exercises. The focus is on patients with low back pain. The results show no significant differences in long-term outcomes for patients treated with stabilization versus other treatment choices.

One reason for these results may be that all of the studies used a mixed group of patients with nonspecific chronic low back pain. The next step is to see if a specific subgroup within the patient groups would benefit from stabilization exercises more than other subgroups.

This idea of treatment based on subclassification has become well understood. Researchers looking for answers to the problem of chronic LBP are taking this approach now. Until we know exactly which patients to apply spinal stabilization exercises to, this treatment will persist as a popular approach to all patients with acute and chronic episodes of LBP.

Scientists haven’t been able to prescribe the perfect exercise program for everyone with low back pain (LBP). That may be because there is a wide range of exercises that can be done for the back. And no one has been able to nail down how much exercise, how often, or the intensity with which they should be done.

Many studies combine two or more types of exercises together. The results can’t be compared to other studies of single exercise types. Different approaches to LBP use different exercise strategies. These can include:

There are many treatment approaches to chronic low back pain (CLBP). One effective but less commonly used technique is called prolotherapy. Dextrose (a sugar compound) along with a numbing agent (lidocaine) and phenol are injected into the spinal ligaments. The body responds with an inflammatory reaction. Scar tissue is formed and helps stiffen up loose joints.

Prolotherapy is used most often for patients with CLBP from ligament or tendon injury. Trauma or repetitive sprain injuries are the most common cause of these soft tissue injuries. Prolotherapy may help patients with spinal instability from collagen deficiency.

The treatment is usually performed by a medical or osteopathic physician who then performs a spinal manipulation to the injected area. Patients are advised to do exercises flexing and extending the spine for several weeks.

Injections are given on a regular basis over a period of time. This could be weekly, biweekly (twice a month), or once a month. Six to eight treatments are given depending on the patient’s response to the treatment.

Studies of prolotherapy are very limited. Positive responses with decreased pain and disability have been reported. There is some debate about the best injection solution to use. Optimal dose size is also uncertain. It appears that prolotherapy may not be effective if too little solution is used. Using higher doses doesn’t seem to have any negative effect. The frequency and dose vary from physician to physician.

At least one study showed that results were poor with injection alone without manipulation and exercise afterward. Prolotherapy should be considered when patients have not responded well to other treatments. More study is needed to understand how this treatment works and who can benefit the most by it.

Patients with chronic lower back pain (CLBP) are often treated with NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, simple analgesics or opioids. However, for many, these medications do not sufficiently relieve their CLBP.

Since CLBP can usually be divided into two types of pain, nociceptive (pain from tissue injury) or neuropathic (pain from nerve injury), physicians have often tried using off-label medications to manage the neuropathic pain, while avoiding them for nociceptive pain.

The medications used as adjunctive pain medications include those used to treat depression: tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs), as well as anti-epileptic medications.

The theories regarding how these medications work depends on the medication itself. For example, capsaicin cream and anti-inflammatories work on blocking the activity of inflammatory pain enzymes. Medications like gabapentin and pregabalin can block a windup phenomenon with the dorsal horn increasing activity of N-methyl-o-aspartate receptors and voltage-gated calcium channels.

When looking at the use of TCAs and SNRIs, they may enhance the descending inhibition of pain pathways depressed at the spinal cord level by increasing levels of the neurotransmitters serotonin and norepinephrine. Carbamazepine may make nerves less excitable.

There are several types of TCAs, which work on different structural levels. Action of SSRIs appears to be that the medications address the emotional disturbances that may relate to neuropathic pain. SNRIs, however, affect both serotonergic and noradrenergic pathways. Antiepileptics began due to the FDA approval for their use in postherpetic neuropathy (PHN), and diabetic peripheral neuropathy (DPN). The first-generation antiepileptics are thought to act by inhibiting voltage-gated sodium channel and maybe stabilizing the effect on neuronal membranes. Carbamazepine, a first-generation antiepileptic requires close monitoring of blood levels because of its narrow therapeutic window.

Second-generation antiepileptics, such as gabapentin, inhibit excitatory neurotransmitter release. It requires a slow titration to therapeutic levels. Third-generation antiepileptics, such as pregabalin, acts at a voltage-gated calcium channel, much like gabapentin. Topiramate, on the other hand, is thought to block voltage-dependent sodium channels and inhibit excitatory neurotransmission, as well as potentiate GABA transmission. Finally, lamotrigine appears to work through sodium blockade and neural membrane stabilization.

No antiepileptics are FDA-approved nor demonstrated by clinical trial for use for CLBP, however many physicians do use them off-label to manage primarily neuropathic or radicular pain. Carbamazepine is approved for neuropathic states and gabapentin is approved for PHM. Pregabalin is approved for PDN and PHN. Phenytoin has no FDA approval for neuropathic pain, but has been found effective for treatment of trigeminal neuralgia.

Antidepressants do not have many studies to back up their use in pain control in CLBP, however, there have been studies done for neuropathic pain. These conditions include painful polyneuropathy, PHN, central poststroke pain, and postmastectomy pain.

The authors of this study reviewed various analyses and trials to determine the usefulness of the above-mentioned medications in treating CLBP. This is what they found:

– Neuropathic pain and antidepressants: relieved over several weeks of treatment independent of any antidepressant effect.
– 30 percent of patients given antidepressants experienced more than 50 percent of pain relief
– comparing various TCAs among each other was difficult because of the different dosages in the studies, the titrations, and study end points.
– Venlafaxine appeared to provide a higher success rate in symptom improvement than did imipramine for patients with PPN.
– Venlafaxine was superior to placebo in treatment of neuropathic pain following breast cancer, despite low doses.
– Duloxetine, through several randomized,controlled trials, has shown improvement of major depressive disorders and improvement in overall neck and back pain.
– The FDA has approved duloxetine for DPNP.
– There is limited evidence to evaluate the efficacy of antiepileptics for the relief of radicular or neuropathic CLBP.
– Carbamazepine has not been evaluated for CBBP or radiculary symptoms.
– Gabapentin has not been evaluated formally for treatment of CLBP.
– No studies have been done to specifically evaluate topiramate for CLBP, however in one study, researchers concluded that topiramate (200 mg mean dose) do provide a small but real analgesic effect on CLBP.
– A small study round that lamotrigine did reduce sciatic pain.
– No meaningful clinical evidence exists for the use of valproic acid, felbamate, and zonigran.

As with all medications, the issue of side effects is an important one. When using TCAs for CLBP, doctors must take into account the typical side effects of blurred vision, cognitive changes, dry mouth, constipation and sexual dysfunction. TCAs should be used with caution in patients with glaucoma, urinary retention, or autonomic neuropathy, as well as patients with orthostatic hypotension and cardiovascular problems.

With SNRIs, venlafaxine appears to be the less tolerated of the group, with side effects of nausea, sexual dysfunction, an withdrawal problems. Side effects of duloxetine include nausea, somnolence, hyperhidrosis, anorexia, and constipation.

When patients are given antiepileptics, side effects of carbamazepine can include Steven-Johnson syndrome, agranulocytosis, aplastic anemia, and hepatic toxicity. Gabapetin side effects include dizziness, somnolence, peripheral edema, weight gain, and vertigo.

In conclusion, the article authors state that the evidence that supports the use of adjunctive medications for CLBP is limited but appears reasonable in low doses, if acetaminophen and NSAIDs have not been appropriate treatments.

Acupuncture, a treatment that goes back over 2000 years, is gaining popularity as an alternative treatment in the Western world, particularly for treatment of chronic lower back pain (CLBP). There are different styles of acupuncture available: Japanese Meridian Therapy, French Energetic acupuncture, Korean Constitutional acupuncture, and Lemington Five Elements acupuncture. Other forms have also been created.

Use of acupuncture is based on the belief that the body is a balance of two opposing forces: yin and yang. When a person is sick or disabled, these become unbalanced, blocking the flow of vital energy in the body. Through applying needles to acupuncture points along certain pathways in the body, the balance is restored.

How acupuncture works is not known, however researchers do have several theories. They range from the nervous system reacting to the needles and producing biochemical and endorphins that influence pain sensation to stimulation of vascular and immunomodulatory factors, such as mediators of inflammation.

While acupuncture does not have any specific diagnostic testing to be performed before beginning treatment, there are some groups of patients who should not undergo acupuncture. They include those who have hemophilia, bleeding disorders, septicemia, cellulitis, skin infections, or loss of skin integrity from burns or ulcerations at the site where the needles will be inserted. If the acupuncturist uses electroacupuncture, this should not be performed over the brain or heart, nor in an area of an implanted electrical device. Pregnant women, those taking anticoagulants, and people with metal allergies should proceed with caution.

The authors of this article reviewed several studies that investigated the efficacy of acupuncture compared with other forms of treatment, including sham treatments. The findings are as follows:

– moderate evidence that acupuncture is more effective for short-term and immediate pain relief, and immediate functional improvement, than no treatment in treating CLBP (1 high-quality study, 2 low-quality studies)
– limited evidence that acupuncture is more effective for short-term functional and global outcomes than no treatment (2 low-quality trials)
– conflicting evidence that acupuncture was more effective than sham therapy for immediate pain relief; more effective according to 1 high-quality trial and no difference for 2 high-quality trials and 3 low-quality trials
– conflicting evidence that acupuncture was more effective than sham acupuncture for short-term pain relief; no difference in 1 high-quality study and more effective in 2 high-quality trials
– strong evidence that there is no difference in intermediate pain relief between acupuncture and sham acupuncture (2 high-quality trials and 2 low-quality trials)
– conflicting evidence that there is no difference in intermediate global improvement between acupuncture and sham acupuncture (positive in 1 high-quality trial and no difference in 1 low-quality trial)
– moderate evidence that acupuncture is more effective than sham treatment for short-term global improvement (1 high-quality trial)
– moderate evidence that acupuncture is no different from sham acupuncture in immediate, short-term, and long-term follow up (2 high-quality trials, 2 low-quality trials)
– moderate evidence that acupuncture showed no difference over sham acupuncture for return to work status at intermediate follow up (1 high quality trial, 1 low-quality trial
– moderate evidence of no difference immediately after treatment between acupuncture and massage, but significant difference in favor of massage at long-term follow up (1 high-quality trial)
– marginally significant difference between acupuncture and massage at long-term follow up for measures of function; massage more effective than acupuncture directly after sessions (1 high-quality trial)
– conflicting evidence on effectiveness of acupuncture compared with transcutaneous electrical nerve stimulation (TENS) immediately after treatment (1 high-quality trial, 1 low-quality trial)
– limited evidence of no difference in pain from acupuncture or TENS at intermediate follow up (1 low-quality trial)
– moderate evidence of no difference between acupuncture and TENS immediately after treatment an limited evidence of no difference at intermediate follow up (1 high-quality trial, 1 low-quality trial)
– moderate evidence that acupuncture provided no difference immediately after treatment and at long-term follow up compared with self-education (1 high-quality trial)
– moderate evidence that spinal manipulation is more effective for pain an functional outcome in the short-term than is acupuncture (1 high-quality study)

As with all treatments, some complications or side effects do occur, as reported in 12 trials. These side effects included local bleeding or hematoma, worsening of CLBP, tiredness, drowsiness, light-headedness, and dizziness. Serious complications, such as hepatitis, septicemia, and pneumothorax were rare.

The authors conclude that there “appears to be some evidence for the use of acupuncture for the treatment of CLBP.” They do caution, however, that more studies are needed to determine positive benefits of acupuncture beyond that of comparisons with placebo.

Many risk factors appear to contribute to the development of chronic lower back pain (CLBP), including lifestyle factors, such as smoking, weight, and exercise. These modifiable risk factors are considered to be an integral component for the prevention and treatment of CLBP.

The authors of this article write that the information available regarding exercise and CLBP suggests that both too little and too much exercise plays a role in CLBP. For example, some physical activity can be too demanding on the lower back in twisting and lifting. However, according to the Centers for Disease Control and Prevention, “regular, moderate-intensity activity is sufficient to produce health benefits in those who are sedentary.” Recommendations are that healthy adults participate in 30 minutes of moderate-intensity five days per week or 20 minutes of vigorous-intensity activity three days per week.

Smoking cessation is a healthy choice for the entire body, not just CLBP, however smoking does also play a role in CLBP. Some hypothesis include repeated microtrauma from chronic cough leading to disc herniation, reduced blood flow to the discs and vertebral bodies that lead to early degeneration, or decreased bone mineral density.

The American Cancer Society has put forth four steps required for a patient to move ahead with smoking cessation: making the decision to quit, setting a quit date and quitting plan, dealing with the withdrawal, and remaining smoke-free. To encourage patients to quit smoking, they must learn the health benefits and they must believe that they are able to do this.

Weight loss is also encouraged for many health issues, although a systemic review of epidemiologic studies only found a 32 percent positive association between obesity and lower back pain. However, weight loss is still of benefit to patients who have CLBP.

The Weight-control Information Network mentions two main categories of weight-loss programs: nonclinical and clinical. The clinical programs are supervised by licensed healthcare professionals while nonclinical are the “do it yourself” weight loss programs.

Upon reviewing studies that investigated the results of smoking cessation, increased physical activity, and weight loss, the authors of this article found that systemic reviews suggest that exercise does have a positive effect on CLBP, while randomized control trials had varying results, ranging from better results in the treatment groups to no difference between treatment and control groups.

One study of 20,332 employees of a large manufacturing company found that total medical charges, including for CLBP, were significantly lower among the former smokers, compared with current smokers.

In conclusion, the authors write that there was “moderate evidence that physical activity with general aerobic an strengthening exercises or aquafitness was more effective than nonactive controls for long-term reductions in disability.” There was limited evidence with home aerobics, and moderate evidence with other types of physical activity. The efficacy of smoking cessation and/or weight loss was not determined. However, the authors caution that further research is needed in this area because of the known benefits of the three lifestyle factors.

Amid the many treatments available for the management of chronic lower back pain (CLBP), watchful waiting remains an approach for patients who do not have acute back pain nor injuries or disabilities that would deteriorate and cause more harm if left untreated.

Watchful waiting must be explained to the patients it is not the same thing as doing nothing. The author of this article defines watchful waiting as “minimal care through rest, activity modification, education, or avoidance of inciting or aggravating factors. Watchful waiting is a passive intervention and does not include any active interventions.”

The patient, unknowingly, may be undertaking watchful waiting on his or her own by not seeking medical attention. Of course, watchful waiting depends on the cause of back pain. In the early 1990s. the US Department of Health and Human Services developed and published clinical practice guidelines on the management of acute lower back pain, divided into these three categories:

1- potentially serious spinal conditions, such as fractures, infections, tumors and cauda equina syndrome
2- sciatica
3- non-specific back symptoms

Many people live with and are able to cope with low-level nagging back pain by ignoring it or adapting their lifestyle to accommodate the pain. Some will self-treat with some success. Often, these patients will seek medical help if the pain becomes more insistent, frequent, or intense.

The author of this study described the steps to watchful waiting. In the Watchfulness stage, the healthcare professional must perform a thorough medical exam to rule out any condition that may require urgent or aggressive treatment. The Waiting stage involves seeing if the pain will resolve with time. The Reassurance part of watchful waiting involves reassuring the patients to reduce anxiety levels and to assure them that they are being monitored and not ignored. The article author writes, “Reassurance usually consists of educating the patient about the basic facts, that this is a common problem, an that 90 percent of patients recover spontaneously in four to six weeks.”

Another part of this approach includes activity modification, whereby the patient may have to rest, although no more than two days of bedrest are recommended, and gradual reintroduction of previous activities. Education, another important aspect in watchful waiting, teaches patients who to be responsible for their back, the steps they must take for good back care, promotion of physical activity, weight loss, and smoking cessation, if these are appropriate.

Red flags for watchful waiting, whereby watchful waiting is not recommended include: age over 70 years, duration of pain of more than six weeks, neurological or progressing neurological deficit, history of cancer, immunosuppression, intravenous drug use, prolonged use of steroids, osteoporosis, recent significant or milder trauma if over the age of 50 years, unexplained fever, and unexplained weight loss.

The only harms noted by the author is that CLBP may worsen and intrude on quality of life and ability to work.

So many people are affected by back pain that it has become the focus of intense study and research. In the last 10 years, a new appreciation has formed for the role of psychosocial issues in chronic low back pain (LBP).

But the pendulum may have swung too far in this direction. Evidence does not support that treating the psychosocial factors resolves LBP any better than physical treatment.

At the same time, researchers are finding better ways to classify and subclassify patients with LBP. The goal is to find specific treatments that work best for each subgroup of patients. This approach is replacing the one-size-fits-all approach used in the past.

One of the more specific treatment methods for LBP is the McKenzie approach. This treatment technique was developed by a physical therapist from New Zealand. It has gained wide support and is in use by many doctors and physical therapists.

The basic idea behind this approach is that if LBP can be centralized, the prognosis is good that the McKenzie method will work. Centralization means that with repeated movements or sustained postures back pain that goes down the leg moves to the middle (central) portion of the low back region. The pain may even go away completely.

The McKenzie assessment enables the therapist to identify how patients should be treated using the concept of directional preference. The examiner tests the patient to find specific lumbrosacral movements that cause the symptoms to centralize, decrease, or disappear. These particular movements become the starting point for treatment.

Self-management is the focus of the McKenzie approach. Once the examiner identifies the movement strategies that are needed, the patient is instructed in what exercises and postures to do.

Patients whose symptoms change with postures and activities are good candidates for this treatment approach. Studies are limited but so far, the results show excellent outcomes for patients who can centralize their symptoms. The McKenzie method has been recommended by four clinical guidelines for LBP.

Natural health products (NHPs) are often used by patients with chronic low back pain (LBP). NHPs include herbal remedies, homeopathic medicines, vitamins and minerals. Probiotics, amino acids, and essential fatty acids are other NHPs used by many people.

Evidence for the therapeutic benefits of NHPs is limited. In this report, Dr. J. J. Gagnier, a naturopathic physician from the University of Toronto reviews and summarizes the results of NHPs in the treatment of chronic LBP.

He presents the history behind each category of NHPs. The mechanism of action (theory for how each one works), and the results of high-level studies are also discussed. Four systematic reviews provide the basis for the conclusions presented.

Herbal treatment contains active plant ingredients or plant materials. They come in many forms such as pills; topical creams, oils, or gels; or injection. Pain relief and improved function have been reported with Devil’s claw, willow bark, and capsicum. Side effects (when they occur) are mild and include GI upset, headache, and sweating and flushing.

Vitamins and minerals come in many forms and are usually taken orally (pill by mouth). Vitamin B12 injections have been studied in the treatment of LBP. Pain and disability both improved with this particular treatment.

Homeopathy is based on the idea that giving low doses of remedies can cure these symptoms. Remedies are substances that are able to cause symptoms similar to those already present. Homeopathic remedies come in different forms such as liquids, gels, tablets, sprays, and creams. Research to support this treatment for LBP is lacking.

Studies of NHPs in the treatment of LBP are limited. But early reports look promising. If scientists are able to find one NHP or a combination of natural products that could successfully treat LBP, the cost of health care for this problem could be cut dramatically.

Future studies are still needed to verify findings about vitamin B12 injections. The safety of herbal, nutritional, and homeopathic supplements must be compared with standard treatment such as anti-inflammatory drugs used for most people with LBP. In general, more study is needed before NHPs can be routinely recommended for the treatment of LBP.

Outcomes involving one hundred eighty-three out of one hundred ninety-seven consecutive subjects in the military who underwent single level lumbar microdiscectomy for either contained disc herniation, disc extrusion, or sequestered discs by the same surgeon were studied over a three year period. The mean age of the subjects was 27.0 years. They were followed for a mean of 26 months. All subjects had failed a period of non-operative care including physical therapy and/or transforaminal epidural steroid injections.

Outcomes that were studied included pain using the Visual Analog Scale, disability using the Oswestry disability index, patient satisfaction, return to military duty, and need for additional surgery.

The authors wanted to investigate these clinical outcomes with type and level of disc herniation in a young, active population.

All subjects were allowed to do activities as tolerated with restrictions only on bending, twisting, lifting greater than 20 pounds from the floor, and high impact activity. They were educated on lumbar stretching and core muscle strengthening. Duty restrictions were lifted and subjects were encouraged to gradually resume running, weightlifting, and other high impact activities.

Eighty-four percent of subjects returned to unrestricted military duty, 16 percent had been medically discharged. 85 percent of subjects were satisfied with the outcome of their surgery. This was a young, motivated group of subjects with preinjury physical condition superior to that of the general public. The subjects were made to feel that this was an injury that could be overcome like most musculoskeletal injuries. The subjects with more elite military jobs had better outcomes than their counterparts in other branches of service.

The authors found that surgical outcomes among those subjects with sequestered discs at all levels demonstrated better VAS and Oswestry scores than extruded or contained disc herniations. Disc herniations at L5-S1 also had greater improvements in the VAS and Oswestry compared to the L4-L5 level. Subjects who had more leg pain than back pain also had better VAS outcomes than those with largely back pain. Preexisting restricted duty status at time of first surgical consultation was associated with poorer outcomes. Smokers had a significantly lower return to full active military duty than non-smokers.

In conclusion, the authors feel that microdiscectomy for symptomatic lumbar disc herniations, especially in those with mostly leg pain and have failed nonoperative treatment has a high success rate among a younger population. Patients with contained disc herniations, mostly back versus leg pain, on restricted duty and who smoke have the potential for less satisfaction and poorer outcomes after microdiscectomy.