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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."
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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. |
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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." |
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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." |
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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.
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| 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".
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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 |
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| 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. |
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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. |
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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."
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 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.
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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, |
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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. "
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Bed
rest and Standard traction |
| According
to the AHCPR "Conventional traction does not
appear to be effective for low back pain or
radiculopathy. The |
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| evidence
shows that bed rest with traction is ineffective.
It adds the complications of immobilization to the
deleterious effects of bed rest." |
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::Continued::
in
Assessment Of LBP
section of Physicians Forum
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