Physical Treatments

According to a recent study by Feline and Lund8 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 al9 published the results of a study involving 269 patients. The objective of these investigators was to identify prognostic indicators of the duration of low back pain in general practice, and the occurrence of a relapse. 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."

 

Clinical Guidelines for the Management of Acute Low Back Pain7, produced by the Royal College of General Practitioners in Great Britain, address the appropriateness of physical agents and passive modalities "these modalities do not appear to have any effect on clinical outcomes." The modalities listed in the Guidelines include ice, heat, short wave diathermy, massage, and ultrasound.

 

The AHCPR Guideline for Acute Low Back Problems in Adults10 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."

 

   
Transcutaneous Electrical Nerve Stimulation (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 output11.

 

Ultrasound
Gam and Johannsen 12 reviewed 293 papers published since 1950, to assess the evidence of the effect of ultrasound for musculoskeletal disorders. Serious methodological problems existed in many of the papers. However, in 13 cases data were presented in a way that made pooling possible. The conclusion of this review was: "None of the methods gave evidence that pain relief could be achieved by ultrasound treatment."

Another meta-analysis looked at 400 randomized clinical trials. Meta-analyses were performed for disorders of the back, neck, shoulder and knee. Results indicated that: "The efficacy of physiotherapy was shown to be convincing for only a few indications and treatments" 13

A controlled study was performed comparing osteopathic manipulation and short-wave diathermy in the treatment of non- specific low back pain.14 The placebo group, which received detuned diathermy, did about as well as those receiving real diathermy or osteopathy. The authors stated, "Benefits obtained with osteopathy and short-wave diathermy in this study may have been achieved through a placebo effect."
In a study comparing drug therapy, conservative physiotherapy and manipulative physiotherapy, "Serial assessments of pain and spinal mobility showed similar response rates in all three treatment groups and no significant difference between therapies ".15

Skargren et all16 reported the results of a study involving 323 patients who were assigned to care by a physiotherapist or a chiropractor. A visual analog scale and the Oswestry pain disability questionnaire were used to evaluate the results. 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."

 

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 the strength and flexibility (up to 12 visits for rehabilitative exercise may be implemented in the first four weeks.) despite the fact that the clinical research on the benefits (efficacy) of exercise in the treatment of low-back pain are not consistent.

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" 17. 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.18 which concluded that "patients who performed flexion exercises actually did worse" and "the exercises were not useful for acute low back pain".

 

 

Passive Modalities
These include, but are not limited to, iontophoresis, phonophoresis, electrical stimulation, ultrasound, diathermy, traction, and other physical agents, during the first four weeks
of treatment. These passive modalities are palliative in nature
and are utilized in hopes that the patient’s pain will be reduced. These modalities should not be used as the sole or primary form of treatment.

 

Acupuncture
Acupuncture has been utilized for mitigation of the mild to moderate pain associated with back problems. The frequency of acupuncture treatments within the initial four weeks of treatment may be up to three times per week for four weeks, or up to twelve office visits. 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 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. If successful, a progressive primary active treatment program should be implemented with the goal of avoiding prolonged disability and possible surgical intervention.

In a randomized, double blind trials, patients were given up to three epidural injections of corticosteroids versus saline 19 20. 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 Supports
It is suggested that immobilization with lumbar supports may provide symptomatic relief of pain and movement reduction in cases of severe acute low back problems. The injured worker should be advised of the potential harm from using a lumbar support for a greater period of time than that prescribed.

According to a large new prospective cohort study conducted by researchers at the National Institute of Occupational Safety and Health, back belts do not prevent back pain or back pain disability. 21 In the largest prospective cohort 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. The study had some obvious strengths. In addition to its large size, it included subjects from a wide geographic area. The investigation had concurrent comparison groups and detailed exposure information, and was able to control for a wide variety of potentially confounding factors.

Results based on these multiple analyses of data 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.

In addition, another large study by Hadler et al. 22 supported the view that back belts are merely a fashion statement and not protective devices. "The findings suggest that back belts be viewed as no more than an option in apparel. "
 

 

Bed rest and Standard traction
According to the AHCPR "Conventional traction does not appear to be effective for low back pain or radiculopathy. The
evidence shows that bed rest with traction is ineffective. It adds the complications of immobilization to the deleterious effects of bed rest."

 

 

::Continued::

in Assessment Of LBP section of Physicians Forum

 

 

Spine Medical Center

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