Introduction:
For
most episodes of
back pain, especially when chronic, no exact
pathological cause can be identified. However, numerous clinic and
scientific studies have shown that patients with low back pain do
exhibit abnormal spinal motion. This abnormal motion can be both a
cause of back pain and a symptom. For example, muscles that are
strained or deconditioned can put excess stresses on the joints of the
spine, producing abnormal motion. Similarly, abonormal moving joints
that can cause abnormal spinal motion can put excess stresses on the
muscles and ligaments surrounding the joints.
Back pain is one of the most common neurological ailments that people suffer
from all over the world. Second to only upper respiratory infections,
it is the one of the most common reasons for absenteesm from activities
such as work and account for millions of dollars spent in health care
costs every year. Most cases of back pain are often self-limiting and
will go away in a couple of days or so. Other cases of back pain take
much longer to resolve or lead to much more serious conditions.
Acute Lower Back Pain:
Acute
back pain generally lasts from a few days to a few weeks. Most acute
back pain is mechanical in nature, and the result of trauma to the lower
back or a disorder such as arthritis. Acute pain in the low back can
be due to a number of things including sports injuries, work around the
house, slips and falls, posture at work (either sitting or lifting), and
other stressors of the spine.
Symptoms:
Symptoms
may range from muscle ache to shooting or stabbing pain (due to muscle
or nerve referral), limited flexibility and/or range of motion, or an
inability to stand straight. Pain felt in one part of the body may
radiate from a problem elsewhere in the body (for example, neck pain can
cause shoulder, elbow and arm pain). Some acute pain syndromes can
become more serious if left untreated. Lower back pain unrelated
to trauma or other known cause is unusual in pre-teen children,
although, heavy backpacks can strain the back.
Chronic Lower Back Pain:
Chronic
back pain is measured by duration, pain that persists for more than 3
months is considered chronic. It is often progressive and the cause can
be difficult to determine. Often, in addition to the musculoskeletal
complications contributing to the pain, many psychological causes can
also be identified. Being in pain for a long period of time does affect
mental attitude. The person may become depressed mental attitude due
to length of having the pain, having tried various treatments that have
not worked, being off work and not making money or feeling useless, not
being able to do the things they enjoy like playing sports, gardening,
walking, etc etc.
A study by Giles and Muller (2003) that appeared in SPINE, compared the effectiveness of 3 different common treatments of chronic low back pain, in terms of their effectiveness.
Medications:
Patients
with chronic spinal pain that seek the care of physicians frequently
report high unmet needs and expectations. The common drugs that are
prescribed for low back pain include NSAIDs (Non-steriodal
anti-inflammatory drugs), which essentially just mask the problem and
fail to get to the root cause of the pain. As well the adverse reactions
to NSAIDs have been well documented, including:
- Gastrointestinal toxicity, which can manifest as stomach bleeding and ulcer formation (extremely common)
- Allergic reactions
- There
is currently insufficient evidence in the literature for the use of
NSAIDs for chronic low back pain, although they may be effective for
short-term symptomatic relief. Over 6,000 people die every year from
the use of over-the-counter anti-inflammatories.
Acupuncture:
Evidence
on
acupuncture for the treatment of chronic spinal pain is growing in
it's favour. Some evidence in a meta-analysis stated that acupuncture
works quite well for low back pain as well as neck pain. The current
levels of evidence of high quality randomized controlled clinical trials
of acupuncture for chronic low back pain is enough to warrant its
practice. The side effects of acupuncture are very low in comparison to
medical treatments.
Spinal Manipulation (SMT):
SMT
has been extensively researched and shown to be effective for acute low
back pain in the short-term, and has been shown to be much more
favourable comparable to medical care for long-term low back pain in
terms of disability. Patients undergoing chiropractic treatments were
found to be more satisfied after one month of treatment. The SMT
performed was a high-velocity low amplitude thrust to the affected joint
(as determined by the examiner) to mobilize the joint.
Study Protocol:
Patients
were taken from an outpatient clinic at a multi-disciplinary hospital
and were assessed by a sports medicine physician to determine whether
they met the criteria for this study. They were included if they were
determined to have uncomplicated (mechanical) low back pain for a
minimum of 13 weeks and less than 17 years. They did not participate in
the study if they had nerve root involvement, spinal anomalies,
previous surgery, spondylolisthesis greater than grade 1, and/or leg
length inequality of greater than 9mm with scoliosis.
The patients
were randomized to medical treatment, acupuncture, or SMT group. In
total 36 patients were allocated to each of the treatment groups.
Appointments were 20 minutes in length 2x per week for up to 3 months.
NSAIDs prescribed were Celebrex, Vioxx, or paracetamol. Improvements
were measued using disability questionaires, visual analog scale, pain
frequency (1- no pain to 6-constant pain), cervical and lumbar spine
range of motion (ROM), and straight leg raise (SLR).
Results:
|
Manipulation
|
Acupuncture
|
Medication
|
| Asymptomatic Patients at 9 weeks |
9
|
3
|
2
|
| Outcome Measures |
Initial
|
Final
|
Initial
|
Final
|
Initial
|
Final
|
| VAS Back |
6
|
3
|
6
|
7
|
5
|
5
|
| VAS Neck |
6
|
5
|
6
|
4
|
5
|
6
|
| Oswestry (back pain questionaire) |
22
|
14
|
30
|
26
|
32
|
32
|
| NDI (neck questionaire) |
28
|
22
|
37
|
30
|
47
|
42
|
| Lumbar Sitting flexion |
50
|
39
|
49
|
47
|
54
|
51
|
| Lumbar Standing flexion |
40
|
30
|
54
|
56
|
56
|
52
|
| Cervical sitting flexion |
40
|
40
|
30
|
40
|
32
|
38
|
| Cervical sitting extension |
40
|
42
|
32
|
40
|
40
|
35
|
| Disability questionaire |
54
|
68
|
47
|
49
|
41
|
49
|
SMT
yielded the best results by far over all of the outcome measures, with
the exception of the NDI in which acupuncture was shown to have better
results over manipulation. Medication had the worst outcome measure of
all 3 treatments. 9 patients with chronic spinal pain became
ASYMPTOMATC. The current study had rigorous protocols and a wide range
of outcome measures, in which the 3 treatment regimes acted as controls
for the others. Any likely placebo effect would like be distributed
across all of the 3 treatments. SMT was, by far, the superior treatment
for cases of chronic spinal pain, with every fourth patient being
ASYPTOMATIC. Acupuncture was found to be a little more effective for
neck pain and disability. The medical treatments caused adverse
reactions in 6.1% of patients, that disappeared once the medication was
stopped. One final important note, is that since these patients all had
CHRONIC spinal pain it is very unlikely that they would have improved
by 'natural history' or 'self-limiting' improvements.
Reference:
Gilles,
S., and Muller, R. 2003. Chronic Spinal Pain: A Randomized Controlled
Trial Comparing Medication, Acupuncture, and Spinal Manipulation.
SPINE, Volume 28(14): 1490-1503
