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Attorney General George Jepsen announced today that Aetna and American Specialty Health Networks, Inc. have agreed to review and reprocess chiropractic benefit claims that may have been denied improperly under Connecticut law.
The company was responding to questions raised by the Attorney General after several complaints were made by chiropractic providers on behalf of themselves and their patients. They were concerned that Aetna’s claims administration agreement with American Specialty Health Network, which took effect July 1, did not appear to include all the chiropractic services covered under Connecticut law.
Connecticut law requires health insurance plans to cover chiropractic care “to the same extent” coverage is provided for services rendered by a physician.
“Aetna’s prompt and fair response to this issue means providers will be paid for covered services and Aetna’s enrollees will continue to receive the care to which they are entitled,” Jepsen said. “Everyone benefits from this cooperation.”
Chiropractors licensed in Connecticut are permitted to provide a wide range of services, such as the use of X-ray and other diagnostic technology, the administration of foods and vitamins and preventative care. If health insurance plans cover those services when provided by physicians, they also must be covered when provided by chiropractors in Connecticut.
Aetna told Jepsen the claim system will be updated to include the procedure codes for qualifying services a chiropractor can provide in Connecticut. In addition, ASHN will review eligible claims submitted since July 1 and reprocess those denied incorrectly. No estimate was available on the number of claims affected.
Since July 1, American Specialty Health Network has provided claims administration and other services for chiropractic benefits available under Aetna’s health insurance plans with the exception of Aetna’s Traditional Choice plans in Connecticut.
Tuesday, August 2, 2011
Friday, May 13, 2011
Chiropractic manipulation results in little or no risk of chest injury
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Dynamic chest compression occurs during spinal manipulation. While dynamic chest compression has been well studied in events such as motor vehicle collisions, chest compression forces have not been studied during chiropractic manipulation. In a study published online today in the Journal of Manipulative and Physiological Therapeutics, researchers quantified and analyzed the magnitude of chest compressions during typical as well as maximum chiropractic manipulation and have found them to be well under the threshold for injury.
"Results from this preliminary study showed that maximum chest compression during chiropractic manipulation of the thoracic spine is unlikely to result in injury," according to lead investigator Brian D. Stemper, PhD, Associate Professor, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI. "We performed this study to get a better understanding of the force limits of chiropractic manipulation. This information may lead to safer manipulation procedures and help to decrease the possibility of adverse patient outcomes."
In the first part of the study Professor Stemper and his co-investigators worked with two practicing doctors of chiropractic, each with a minimum of 4 years of doctoral training and at least 7 years of healthcare experience. Using a crash test dummy they measured the level of chest compression induced during "normal" chiropractic manipulation and during spinal manipulations wherein the doctors of chiropractic exerted maximum effort. They performed simulated chiropractic manipulations on the test dummy at the midback level (T7 to T8 vertebrae).
In the second part of the study, an instrumented mechanical device was used to apply and measure the forces necessary to induce chest compression in the test dummy. These forces were increased until injurious levels of force were reached. The likelihood of injury was assessed and classified using the Abbreviated Injury Scale (AIS), which is a useful classification system that has been correlated to injury thresholds during biomechanical experimentation.
In the present study, manipulations incorporating typical and maximum efforts by the doctors of chiropractic resulted in maximum chest compressions corresponding to minimal risk of AIS 1 level injuries.
As with all types of patient care, Professor Stemper cautions that "individual patient characteristics including age, degeneration, and gender" should be taken into consideration during treatment such as chiropractic manipulation.
###
The article is "An Experimental Study of Chest Compression During Chiropractic Manipulation of the Thoracic Spine Using an Anthropomorphic Test Device" by Brian D. Stemper, PhD, Jason J. Hallman, PhD, and Boyd M. Peterson, DC. It will appear in the Journal of Manipulative and Physiological Therapeutics, Volume 34, Issue 5 (June 2011), DOI 10.1016/j.jmpt.2011.04.001, published by Elsevier.
Dynamic chest compression occurs during spinal manipulation. While dynamic chest compression has been well studied in events such as motor vehicle collisions, chest compression forces have not been studied during chiropractic manipulation. In a study published online today in the Journal of Manipulative and Physiological Therapeutics, researchers quantified and analyzed the magnitude of chest compressions during typical as well as maximum chiropractic manipulation and have found them to be well under the threshold for injury.
"Results from this preliminary study showed that maximum chest compression during chiropractic manipulation of the thoracic spine is unlikely to result in injury," according to lead investigator Brian D. Stemper, PhD, Associate Professor, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI. "We performed this study to get a better understanding of the force limits of chiropractic manipulation. This information may lead to safer manipulation procedures and help to decrease the possibility of adverse patient outcomes."
In the first part of the study Professor Stemper and his co-investigators worked with two practicing doctors of chiropractic, each with a minimum of 4 years of doctoral training and at least 7 years of healthcare experience. Using a crash test dummy they measured the level of chest compression induced during "normal" chiropractic manipulation and during spinal manipulations wherein the doctors of chiropractic exerted maximum effort. They performed simulated chiropractic manipulations on the test dummy at the midback level (T7 to T8 vertebrae).
In the second part of the study, an instrumented mechanical device was used to apply and measure the forces necessary to induce chest compression in the test dummy. These forces were increased until injurious levels of force were reached. The likelihood of injury was assessed and classified using the Abbreviated Injury Scale (AIS), which is a useful classification system that has been correlated to injury thresholds during biomechanical experimentation.
In the present study, manipulations incorporating typical and maximum efforts by the doctors of chiropractic resulted in maximum chest compressions corresponding to minimal risk of AIS 1 level injuries.
As with all types of patient care, Professor Stemper cautions that "individual patient characteristics including age, degeneration, and gender" should be taken into consideration during treatment such as chiropractic manipulation.
###
The article is "An Experimental Study of Chest Compression During Chiropractic Manipulation of the Thoracic Spine Using an Anthropomorphic Test Device" by Brian D. Stemper, PhD, Jason J. Hallman, PhD, and Boyd M. Peterson, DC. It will appear in the Journal of Manipulative and Physiological Therapeutics, Volume 34, Issue 5 (June 2011), DOI 10.1016/j.jmpt.2011.04.001, published by Elsevier.
Wednesday, February 16, 2011
For Back Pain, Spinal Manipulation Holds Its Own
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Source: Health Behavior News Service
If you’re suffering from chronic lower back pain, a new review of existing research finds that spinal manipulation − the kind of hands-on regimen that a chiropractor might perform on you − is as helpful as other common treatments like painkillers.
Spinal manipulation is also safe, researchers found. Ultimately, “the decision to refer for manipulation should be based upon costs, preferences of the patient and providers, and relative safety of all treatment options,” said review lead author Sidney Rubinstein, a chiropractor in private practice and a postdoctoral researcher at the VU University Medical Center in Amsterdam.
Surveys suggest that half of working Americans suffer from back pain each year. An estimated 25 percent of American adults reported that they suffered from back pain for at least a day within the last three months, according to a 2006 Centers for Disease Control and Prevention report, and lower back pain is the fifth most common reason that people go to the doctor.
Patients frequently turn to painkillers, which can cause side effects and be addictive, or to physical therapy, which is time-consuming and expensive. The new review looks at a third option − spinal manipulation.
In North America, Rubinstein said, chiropractors perform most spinal manipulation. Practitioners move their hands around a patient’s spine and joints, often producing an audible crack.
“The effectiveness of this therapy has long been controversial,” Rubinstein said. “Some proponents are slowly starting to view it as effective for chronic low-back pain. The results of this review will support that view.”
The review authors looked for randomized controlled studies, which are researchers consider as the most reliable forms of medical research. They found 26 studies − with 6,070 participants − that met their criteria for inclusion in their review, but deemed only nine studies to be of high quality.
The findings appear in the latest issue of The Cochrane Library. The journal is a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
The researchers found that spinal manipulation worked about as well as the other treatments. It appears to work well in particular for certain kinds of patients, Rubinstein said, including those with restricted movement in the back, those without psychological issues, and those without symptoms below the knee related to the sciatic nerve.
Spinal manipulation “appears to be no better or worse than other existing therapies for patients with chronic low-back pain,” the review says.
There is one small caveat, however. In medical research, scientists often compare a treatment to a placebo, which is difficult when you are talking about something that's difficult to fake − like spinal manipulation.
Three of the studies reviewed the kind of spinal manipulation that produces a crack sound and tried to fool some patients into not realizing they were getting a sham treatment. However, it is unclear if they succeeded, Rubinstein said. One study appeared to show that patients could distinguish whether they were getting the real thing.
So how well do the treatments − spinal manipulation and the other examined in the review − work overall? Rubinstein said studies have shown that they help about two-thirds of patients. Sti other researchers say they have a modest impact at best.
In general, most treatments for lower-back pain “aren’t all that effective, even the ones we think that work, but some people respond better than others,” said Dr. Roger Chou, a physician and researcher with Oregon Health & Science University who has studied back pain.
“Right now the best we can say is that clinicians and patients have a number of moderately effective treatment options to consider, including exercise, manipulation, acupuncture, yoga, massage, cognitive behavioral therapy and some of the analgesic medications, and that it should be a decision between the clinician and patient,” Chou said. “In general, I think exercise is a preferred option since it has a lot of other health benefits.”
Dr. Tim Carey, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, said that many patients try several treatments, of which spinal manipulation is just one approach.
“We do not have a good sense of how manual therapy fits in an exercise regimen in a patient who is also taking medication, just as an example,” said Carey, who studies back pain. “While manual therapy seems to be an option for chronic low back pain, the evidence at present does not support a role as a preferred option.”
TERMS OF USE: This story is protected by copyright. When reproducing any material, including interview excerpts, attribution to the Health Behavior News Service, part of the Center for Advancing Health, is required.
Source: Health Behavior News Service
If you’re suffering from chronic lower back pain, a new review of existing research finds that spinal manipulation − the kind of hands-on regimen that a chiropractor might perform on you − is as helpful as other common treatments like painkillers.
Spinal manipulation is also safe, researchers found. Ultimately, “the decision to refer for manipulation should be based upon costs, preferences of the patient and providers, and relative safety of all treatment options,” said review lead author Sidney Rubinstein, a chiropractor in private practice and a postdoctoral researcher at the VU University Medical Center in Amsterdam.
Surveys suggest that half of working Americans suffer from back pain each year. An estimated 25 percent of American adults reported that they suffered from back pain for at least a day within the last three months, according to a 2006 Centers for Disease Control and Prevention report, and lower back pain is the fifth most common reason that people go to the doctor.
Patients frequently turn to painkillers, which can cause side effects and be addictive, or to physical therapy, which is time-consuming and expensive. The new review looks at a third option − spinal manipulation.
In North America, Rubinstein said, chiropractors perform most spinal manipulation. Practitioners move their hands around a patient’s spine and joints, often producing an audible crack.
“The effectiveness of this therapy has long been controversial,” Rubinstein said. “Some proponents are slowly starting to view it as effective for chronic low-back pain. The results of this review will support that view.”
The review authors looked for randomized controlled studies, which are researchers consider as the most reliable forms of medical research. They found 26 studies − with 6,070 participants − that met their criteria for inclusion in their review, but deemed only nine studies to be of high quality.
The findings appear in the latest issue of The Cochrane Library. The journal is a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
The researchers found that spinal manipulation worked about as well as the other treatments. It appears to work well in particular for certain kinds of patients, Rubinstein said, including those with restricted movement in the back, those without psychological issues, and those without symptoms below the knee related to the sciatic nerve.
Spinal manipulation “appears to be no better or worse than other existing therapies for patients with chronic low-back pain,” the review says.
There is one small caveat, however. In medical research, scientists often compare a treatment to a placebo, which is difficult when you are talking about something that's difficult to fake − like spinal manipulation.
Three of the studies reviewed the kind of spinal manipulation that produces a crack sound and tried to fool some patients into not realizing they were getting a sham treatment. However, it is unclear if they succeeded, Rubinstein said. One study appeared to show that patients could distinguish whether they were getting the real thing.
So how well do the treatments − spinal manipulation and the other examined in the review − work overall? Rubinstein said studies have shown that they help about two-thirds of patients. Sti other researchers say they have a modest impact at best.
In general, most treatments for lower-back pain “aren’t all that effective, even the ones we think that work, but some people respond better than others,” said Dr. Roger Chou, a physician and researcher with Oregon Health & Science University who has studied back pain.
“Right now the best we can say is that clinicians and patients have a number of moderately effective treatment options to consider, including exercise, manipulation, acupuncture, yoga, massage, cognitive behavioral therapy and some of the analgesic medications, and that it should be a decision between the clinician and patient,” Chou said. “In general, I think exercise is a preferred option since it has a lot of other health benefits.”
Dr. Tim Carey, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, said that many patients try several treatments, of which spinal manipulation is just one approach.
“We do not have a good sense of how manual therapy fits in an exercise regimen in a patient who is also taking medication, just as an example,” said Carey, who studies back pain. “While manual therapy seems to be an option for chronic low back pain, the evidence at present does not support a role as a preferred option.”
TERMS OF USE: This story is protected by copyright. When reproducing any material, including interview excerpts, attribution to the Health Behavior News Service, part of the Center for Advancing Health, is required.
Saturday, July 10, 2010
Chiropractic and Neck Pain: Conservative Care of Cervical Pain, Injury
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Your neck, also called the cervical spine, begins at the base of the skull and contains seven small vertebrae. Incredibly, the cervical spine supports the full weight of your head, which is on average about 12 pounds. While the cervical spine can move your head in nearly every direction, this flexibility makes the neck very susceptible to pain and injury.
The neck’s susceptibility to injury is due in part to biomechanics. Activities and events that affect cervical biomechanics include extended sitting, repetitive movement, accidents, falls and blows to the body or head, normal aging, and everyday wear and tear. Neck pain can be very bothersome, and it can have a variety of causes.
Here are some of the most typical causes of neck pain:
Injury and Accidents: A sudden forced movement of the head or neck in any direction and the resulting “rebound” in the opposite direction is known as whiplash. The sudden “whipping” motion injures the surrounding and supporting tissues of the neck and head. Muscles react by tightening and contracting, creating muscle fatigue, which can result in pain and stiffness. Severe whiplash can also be associated with injury to the intervertebral joints, discs, ligaments, muscles, and nerve roots. Car accidents are the most common cause of whiplash.
Growing Older: Degenerative disorders such as osteoarthritis, spinal stenosis, and degenerative disc disease directly affect the spine.
* Osteoarthritis, a common joint disorder, causes progressive deterioration of cartilage. The body reacts by forming bone spurs that affect joint motion.
* Spinal stenosis causes the small nerve passageways in the vertebrae to narrow, compressing and trapping nerve roots. Stenosis may cause neck, shoulder, and arm pain, as well as numbness, when these nerves are unable to function normally.
* Degenerative disc disease can cause reduction in the elasticity and height of intervertebral discs. Over time, a disc may bulge or herniate, causing tingling, numbness, and pain that runs into the arm.
Daily Life: Poor posture, obesity, and weak abdominal muscles often disrupt spinal balance, causing the neck to bend forward to compensate. Stress and emotional tension can cause muscles to tighten and contract, resulting in pain and stiffness. Postural stress can contribute to chronic neck pain with symptoms extending into the upper back and the arms.
Chiropractic Care of Neck Pain
During your visit, your doctor of chiropractic will perform exams to locate the source of your pain and will ask you questions about your current symptoms and remedies you may have already tried. For example:
* When did the pain start?
* What have you done for your neck pain?
* Does the pain radiate or travel to other parts of your body?
* Does anything reduce the pain or make it worse?
Your doctor of chiropractic will also do physical and neurological exams. In the physical exam, your doctor will observe your posture, range of motion, and physical condition, noting movement that causes pain. Your doctor will feel your spine, note its curvature and alignment, and feel for muscle spasm. A check of your shoulder area is also in order. During the neurological exam, your doctor will test your reflexes, muscle strength, other nerve changes, and pain spread.
In some instances, your chiropractor might order tests to help diagnose your condition. An x-ray can show narrowed disc space, fractures, bone spurs, or arthritis. A computerized axial tomography scan (a CT or CAT scan) or a magnetic resonance imaging test (an MRI) can show bulging discs and herniations. If nerve damage is suspected, your doctor may order a special test called electromyography (an EMG) to measure how quickly your nerves respond.
Chiropractors are conservative care doctors; their scope of practice does not include the use of drugs or surgery. If your chiropractor diagnoses a condition outside of this conservative scope, such as a neck fracture or an indication of an organic disease, he or she will refer you to the appropriate medical physician or specialist. He or she may also ask for permission to inform your family physician of the care you are receiving to ensure that your chiropractic care and medical care are properly coordinated.
Neck Adjustments
A neck adjustment (also known as a cervical manipulation) is a precise procedure applied to the joints of the neck, usually by hand. A neck adjustment works to improve the mobility of the spine and to restore range of motion; it can also increase movement of the adjoining muscles. Patients typically notice an improved ability to turn and tilt the head, and a reduction of pain, soreness, and stiffness.
Of course, your chiropractor will develop a program of care that may combine more than one type of treatment, depending on your personal needs. In addition to manipulation, the treatment plan may include mobilization, massage or rehabilitative exercises, or something else.
Research Supporting Chiropractic Care
One of the most recent reviews of scientific literature found evidence that patients with chronic neck pain enrolled in clinical trials reported significant improvement following chiropractic spinal manipulation.
As part of the literature review, published in the March/April 2007 issue of the Journal of
Manipulative and Physiological Therapeutics, the researchers reviewed nine previously published trials and found “high-quality evidence” that patients with chronic neck pain showed significant pain-level improvements following spinal manipulation. No trial group was reported as having remained unchanged, and all groups showed positive changes up to 12 weeks post-treatment.
Your neck, also called the cervical spine, begins at the base of the skull and contains seven small vertebrae. Incredibly, the cervical spine supports the full weight of your head, which is on average about 12 pounds. While the cervical spine can move your head in nearly every direction, this flexibility makes the neck very susceptible to pain and injury.
The neck’s susceptibility to injury is due in part to biomechanics. Activities and events that affect cervical biomechanics include extended sitting, repetitive movement, accidents, falls and blows to the body or head, normal aging, and everyday wear and tear. Neck pain can be very bothersome, and it can have a variety of causes.
Here are some of the most typical causes of neck pain:
Injury and Accidents: A sudden forced movement of the head or neck in any direction and the resulting “rebound” in the opposite direction is known as whiplash. The sudden “whipping” motion injures the surrounding and supporting tissues of the neck and head. Muscles react by tightening and contracting, creating muscle fatigue, which can result in pain and stiffness. Severe whiplash can also be associated with injury to the intervertebral joints, discs, ligaments, muscles, and nerve roots. Car accidents are the most common cause of whiplash.
Growing Older: Degenerative disorders such as osteoarthritis, spinal stenosis, and degenerative disc disease directly affect the spine.
* Osteoarthritis, a common joint disorder, causes progressive deterioration of cartilage. The body reacts by forming bone spurs that affect joint motion.
* Spinal stenosis causes the small nerve passageways in the vertebrae to narrow, compressing and trapping nerve roots. Stenosis may cause neck, shoulder, and arm pain, as well as numbness, when these nerves are unable to function normally.
* Degenerative disc disease can cause reduction in the elasticity and height of intervertebral discs. Over time, a disc may bulge or herniate, causing tingling, numbness, and pain that runs into the arm.
Daily Life: Poor posture, obesity, and weak abdominal muscles often disrupt spinal balance, causing the neck to bend forward to compensate. Stress and emotional tension can cause muscles to tighten and contract, resulting in pain and stiffness. Postural stress can contribute to chronic neck pain with symptoms extending into the upper back and the arms.
Chiropractic Care of Neck Pain
During your visit, your doctor of chiropractic will perform exams to locate the source of your pain and will ask you questions about your current symptoms and remedies you may have already tried. For example:
* When did the pain start?
* What have you done for your neck pain?
* Does the pain radiate or travel to other parts of your body?
* Does anything reduce the pain or make it worse?
Your doctor of chiropractic will also do physical and neurological exams. In the physical exam, your doctor will observe your posture, range of motion, and physical condition, noting movement that causes pain. Your doctor will feel your spine, note its curvature and alignment, and feel for muscle spasm. A check of your shoulder area is also in order. During the neurological exam, your doctor will test your reflexes, muscle strength, other nerve changes, and pain spread.
In some instances, your chiropractor might order tests to help diagnose your condition. An x-ray can show narrowed disc space, fractures, bone spurs, or arthritis. A computerized axial tomography scan (a CT or CAT scan) or a magnetic resonance imaging test (an MRI) can show bulging discs and herniations. If nerve damage is suspected, your doctor may order a special test called electromyography (an EMG) to measure how quickly your nerves respond.
Chiropractors are conservative care doctors; their scope of practice does not include the use of drugs or surgery. If your chiropractor diagnoses a condition outside of this conservative scope, such as a neck fracture or an indication of an organic disease, he or she will refer you to the appropriate medical physician or specialist. He or she may also ask for permission to inform your family physician of the care you are receiving to ensure that your chiropractic care and medical care are properly coordinated.
Neck Adjustments
A neck adjustment (also known as a cervical manipulation) is a precise procedure applied to the joints of the neck, usually by hand. A neck adjustment works to improve the mobility of the spine and to restore range of motion; it can also increase movement of the adjoining muscles. Patients typically notice an improved ability to turn and tilt the head, and a reduction of pain, soreness, and stiffness.
Of course, your chiropractor will develop a program of care that may combine more than one type of treatment, depending on your personal needs. In addition to manipulation, the treatment plan may include mobilization, massage or rehabilitative exercises, or something else.
Research Supporting Chiropractic Care
One of the most recent reviews of scientific literature found evidence that patients with chronic neck pain enrolled in clinical trials reported significant improvement following chiropractic spinal manipulation.
As part of the literature review, published in the March/April 2007 issue of the Journal of
Manipulative and Physiological Therapeutics, the researchers reviewed nine previously published trials and found “high-quality evidence” that patients with chronic neck pain showed significant pain-level improvements following spinal manipulation. No trial group was reported as having remained unchanged, and all groups showed positive changes up to 12 weeks post-treatment.
Tuesday, February 9, 2010
Usual Care Often Not Consistent With Clinical Guidelines for Low Back Pain
General practitioners often treat patients with low back pain in a manner that does not appear to match the care endorsed by international clinical guidelines, according to a report in the February 8 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Low back pain is estimated to be the seventh most common reason for a general practitioner visit in Australia and the fifth most common in the United States, according to background information in the article. An overwhelming body of literature on the management of low back pain—more than 1,200 published trials and systematic reviews—makes practice guidelines an efficient way for clinicians to base their care on the best evidence. A previous review concluded that guidelines in 11 countries around the world provide similar recommendations for assessment and management of low back pain.
“Given the proliferation of clinical practice guidelines outlining best practice, it is timely to consider how closely usual care aligns with guideline recommendations,” write Christopher M. Williams, M.App.Sc., of The George Institute for International Health, Camperdown, Australia, and colleagues. The authors assessed the care provided for new episodes of low back pain during 3,533 patient visits to general practitioners in Australia between 2001 and 2008. These visits were mapped to key recommendations in treatment guidelines; in addition, data were compared for two three-year periods before and after the release of Australian national guidelines in 2004.
“Our findings show that key aspects of the usual care provided to patients do not align with the care recommended in international evidence-based guidelines,” the authors write. For example, although guidelines discourage the use of imaging, more than one-quarter of patients were referred for radiology, computed tomography or similar tests.
Only 20.5 percent of patients received advice and 17.7 percent received simple pain-relieving medications, both of which are recommended as part of initial care for low back pain. Instead of the safer and equally effective acetaminophen, patients were more often prescribed non-steroidal anti-inflammatory drugs (37.4 percent) and opioids (19.6 percent).
In addition, patterns of care did not change significantly following the release of local guidelines, the authors note.
“Understanding why general practitioners do not follow key treatment recommendations of guidelines is an important prerequisite to improving this situation,” they write. Evidence suggests that the views of both patients and clinicians, and potentially miscommunication between the two, contribute to departures from guideline-based care.
“In the back pain field, there has been extensive activity in the past two decades focusing on the evaluation of new and existing therapies within clinical trials and systematic reviews,” the authors conclude. “Arguably, we need a parallel line of research that focuses on how best to encourage provision of evidence-based treatments. Educational outreach with broader societal focus may enhance guideline dissemination and reduce the burden of low back pain.”
Low back pain is estimated to be the seventh most common reason for a general practitioner visit in Australia and the fifth most common in the United States, according to background information in the article. An overwhelming body of literature on the management of low back pain—more than 1,200 published trials and systematic reviews—makes practice guidelines an efficient way for clinicians to base their care on the best evidence. A previous review concluded that guidelines in 11 countries around the world provide similar recommendations for assessment and management of low back pain.
“Given the proliferation of clinical practice guidelines outlining best practice, it is timely to consider how closely usual care aligns with guideline recommendations,” write Christopher M. Williams, M.App.Sc., of The George Institute for International Health, Camperdown, Australia, and colleagues. The authors assessed the care provided for new episodes of low back pain during 3,533 patient visits to general practitioners in Australia between 2001 and 2008. These visits were mapped to key recommendations in treatment guidelines; in addition, data were compared for two three-year periods before and after the release of Australian national guidelines in 2004.
“Our findings show that key aspects of the usual care provided to patients do not align with the care recommended in international evidence-based guidelines,” the authors write. For example, although guidelines discourage the use of imaging, more than one-quarter of patients were referred for radiology, computed tomography or similar tests.
Only 20.5 percent of patients received advice and 17.7 percent received simple pain-relieving medications, both of which are recommended as part of initial care for low back pain. Instead of the safer and equally effective acetaminophen, patients were more often prescribed non-steroidal anti-inflammatory drugs (37.4 percent) and opioids (19.6 percent).
In addition, patterns of care did not change significantly following the release of local guidelines, the authors note.
“Understanding why general practitioners do not follow key treatment recommendations of guidelines is an important prerequisite to improving this situation,” they write. Evidence suggests that the views of both patients and clinicians, and potentially miscommunication between the two, contribute to departures from guideline-based care.
“In the back pain field, there has been extensive activity in the past two decades focusing on the evaluation of new and existing therapies within clinical trials and systematic reviews,” the authors conclude. “Arguably, we need a parallel line of research that focuses on how best to encourage provision of evidence-based treatments. Educational outreach with broader societal focus may enhance guideline dissemination and reduce the burden of low back pain.”
Thursday, January 28, 2010
Osteopathic Manipulative Treatment Improves Back Function in Late Pregnancy
For many pregnant women, it’s inevitable. As their pregnancy progresses, tasks that involve the low back often get more difficult. It is harder to bend over, lift, sit or walk for long periods of time, and back pain increases. Treating back pain, and improving daily function relative to tasks that involve the low back is a challenge because pregnant women are limited to treatments that will not create problems for their developing baby.
“Osteopathic manipulative treatment (OMT) is a viable option for improving function related to the low back and reducing back pain in the third trimester of pregnancy because its does not appear to have any negative side effects,” said John C. Licciardone, D.O., M.S., M.B.A., the lead author of a study on OMT in the third trimester of pregnancy that was recently published in the American Journal of Obstetrics and Gynecology. Results from this study showed that osteopathic manipulative treatment slows or halts the deterioration of back-specific function in the third trimester of pregnancy.
Osteopathic manipulative treatment is a system of hands-on diagnosis and treatment that is used to reduce pain, restore range of motion and to restore normal function and balance in the body.
The Phase II randomized clinical trial of 144 subjects showed that women in the usual obstetric care+osteopathic manipulative treatment group reported less deterioration of back-specific function on the Roland-Morris Disability Scale than women in the usual obstetric care+sham ultrasound and the usual obstetric care only groups when these groups were compared using an intention-to-treat analysis. This study is the first randomized, placebo-controlled trial to explore the potential effects of osteopathic manipulative treatment during the third trimester of pregnancy.
In the study, conducted by The Osteopathic Research Center in conjunction with the Department of Obstetrics and Gynecology at the University of North Texas Health Science Center in Fort Worth, Texas, women were enrolled between the 28th and 30th week of pregnancy. After being randomized to one of the three treatment groups, the women in the usual obstetric care+osteopathic manipulative treatment and usual obstetric care+sham ultrasound groups received treatments immediately following each of their third trimester prenatal visits. Women were excluded or dropped from the study if they were determined to be at high risk by their obstetrician. The median age for women included in the study was 24 years.
Dr. Licicardone noted that outcomes were statistically significant relative to improved low back function in the OMT group. “The results also showed a trend toward pain reduction in the group that received OMT, but pain remained the same or increased in the other groups.”
Usual obstetric care was defined in this study as the conventional prenatal care received during pregnancy. Osteopathic manipulative treatment is generally considered a complementary treatment that is not included as part of routine prenatal care.
“This study is exciting because pregnant women frequently experience a negative impact on their ability to function and perform tasks related to daily living as their pregnancy progresses,” said Dr. Licciardone, the principal investigator for the project, and the executive director of The Osteopathic Research Center. “Since pregnant women are limited in the medications they can take for pain, osteopathic manipulative treatment offers a way to improve back function and decrease pain in the third trimester of pregnancy, when a majority of women experience these symptoms.”
“What is also interesting about this study is that osteopathic physicians (D.O.s) who provide obstetrical care can potentially include osteopathic manipulative treatment as part of their prenatal care for patients,” Licciardone said. “For more than 100 years, osteopathic physicians who have treated pregnant women using osteopathic manipulation have claimed that their patients have less pain, better function and improved delivery outcomes. This study may be the first step in confirming the clinical success of osteopathic physicians in this area of medicine.”
Dr. Licciardone added, “If osteopathic obstetricians view this study as the first step in developing a strong evidence base to support the use of OMT to improve back function and pain in the third trimester of pregnancy, this study could have a significant clinical impact on prenatal care, and it could have important economic implications for treating common back-related symptoms and functional disabilities in late pregnancy.”
Full text of the article is available online.
“Osteopathic manipulative treatment (OMT) is a viable option for improving function related to the low back and reducing back pain in the third trimester of pregnancy because its does not appear to have any negative side effects,” said John C. Licciardone, D.O., M.S., M.B.A., the lead author of a study on OMT in the third trimester of pregnancy that was recently published in the American Journal of Obstetrics and Gynecology. Results from this study showed that osteopathic manipulative treatment slows or halts the deterioration of back-specific function in the third trimester of pregnancy.
Osteopathic manipulative treatment is a system of hands-on diagnosis and treatment that is used to reduce pain, restore range of motion and to restore normal function and balance in the body.
The Phase II randomized clinical trial of 144 subjects showed that women in the usual obstetric care+osteopathic manipulative treatment group reported less deterioration of back-specific function on the Roland-Morris Disability Scale than women in the usual obstetric care+sham ultrasound and the usual obstetric care only groups when these groups were compared using an intention-to-treat analysis. This study is the first randomized, placebo-controlled trial to explore the potential effects of osteopathic manipulative treatment during the third trimester of pregnancy.
In the study, conducted by The Osteopathic Research Center in conjunction with the Department of Obstetrics and Gynecology at the University of North Texas Health Science Center in Fort Worth, Texas, women were enrolled between the 28th and 30th week of pregnancy. After being randomized to one of the three treatment groups, the women in the usual obstetric care+osteopathic manipulative treatment and usual obstetric care+sham ultrasound groups received treatments immediately following each of their third trimester prenatal visits. Women were excluded or dropped from the study if they were determined to be at high risk by their obstetrician. The median age for women included in the study was 24 years.
Dr. Licicardone noted that outcomes were statistically significant relative to improved low back function in the OMT group. “The results also showed a trend toward pain reduction in the group that received OMT, but pain remained the same or increased in the other groups.”
Usual obstetric care was defined in this study as the conventional prenatal care received during pregnancy. Osteopathic manipulative treatment is generally considered a complementary treatment that is not included as part of routine prenatal care.
“This study is exciting because pregnant women frequently experience a negative impact on their ability to function and perform tasks related to daily living as their pregnancy progresses,” said Dr. Licciardone, the principal investigator for the project, and the executive director of The Osteopathic Research Center. “Since pregnant women are limited in the medications they can take for pain, osteopathic manipulative treatment offers a way to improve back function and decrease pain in the third trimester of pregnancy, when a majority of women experience these symptoms.”
“What is also interesting about this study is that osteopathic physicians (D.O.s) who provide obstetrical care can potentially include osteopathic manipulative treatment as part of their prenatal care for patients,” Licciardone said. “For more than 100 years, osteopathic physicians who have treated pregnant women using osteopathic manipulation have claimed that their patients have less pain, better function and improved delivery outcomes. This study may be the first step in confirming the clinical success of osteopathic physicians in this area of medicine.”
Dr. Licciardone added, “If osteopathic obstetricians view this study as the first step in developing a strong evidence base to support the use of OMT to improve back function and pain in the third trimester of pregnancy, this study could have a significant clinical impact on prenatal care, and it could have important economic implications for treating common back-related symptoms and functional disabilities in late pregnancy.”
Full text of the article is available online.
Surgeons Less Likely than Family Doctors to Prefer Back Surgery
Surgeons are less likely than family physicians or patients to view surgery as the preferred treatment option for low back pain, according to a study in the January 1 issue of Spine. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals, and institutions in medicine, nursing, allied health, and pharmacy.
For patients with back pain, quality-of-life issues are the main factor affecting treatment preferences—which has important implications for shared decision-making between patients and their doctors, according to the new study led by Dr. S. Samuel Bederman at University of Toronto.
Family Doctors Have Highest Preferences for Surgery
The researchers presented hypothetical back pain scenarios to surgeons (orthopedic surgeons and neurosurgeons), family physicians, and patients with back and/or leg pain. The scenarios reflected key factors related to back pain: walking ability, pain duration, pain severity, neurological symptoms, factors inducing pain, and pain location. Each group rated their preference for surgery in each scenario, and the factors affecting preferences were analyzed.
Perhaps unexpectedly, surgeons had the lowest overall preferences for surgery, while family physicians had the highest preference for surgery. For orthopedic surgeons, the preference for surgery was somewhat lower than for neurosurgeons. Both the family doctors and patients had a higher preference for surgery than either group of surgeons.
The factors affecting preferences for surgery varied as well. For surgeons, the most important factor was the location of pain. In particular, they preferred surgery for patients with pain predominantly in the leg, rather than the back. Surgery provides better results in patients with problems affecting the spinal nerve roots, which tend to cause leg pain.
Revealing Differences in Reasons for Preferences
In contrast, for family physicians, the most important factor affecting preferences for surgery was neurological symptoms, followed closely by walking ability and pain severity. Family doctors may be unaware of which factors affect the chances of good outcomes from back surgery, the researchers suggest.
For patients, the most important factors were pain severity, walking ability, and pain duration. "All of these symptoms are highly related to quality of life and have little direct bearing on outcomes following surgery," Dr. Bederman and co-authors write.
When other treatments have failed, surgery can help patients with moderate to severe lower back pain. Family physicians play an important role in sending back pain patients for surgical evaluation. However, few studies looked at the factors considered by primary care doctors consider in referring patients for possible spinal surgery. The final decision is generally made through a shared process between the patient, family physician, and surgeon.
The new results suggest that, in various scenarios, surgeons have a lower preference for surgery than family physicians. In addition, the factors that surgeons feel are most important—especially the location of pain—don't match those considered most important by family doctors.
The study also highlights the importance of quality-of-life factors—especially pain severity and duration and walking ability—in affecting patients' treatment preferences. Dr. Bederman and colleagues hope their findings will help in "aligning" the opinions of patients and doctors, thus improving the shared decision-making process and promoting more accurate patient expectations of the results of surgery. "This can directly result in a significant improvement in patient satisfaction with the healthcare process and even overall health status following treatment," the researchers write.
About Spine
Recognized internationally as the leading journal in its field, Spine is an international, peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of spine. It is the leading subspecialty journal for the treatment of spinal disorders. Only original papers are considered for publication with the understanding that they are contributed solely to Spine. According to the latest ISI Science Citation Impact Factor, Spine ranks highest among subspecialty orthopedic titles.
For patients with back pain, quality-of-life issues are the main factor affecting treatment preferences—which has important implications for shared decision-making between patients and their doctors, according to the new study led by Dr. S. Samuel Bederman at University of Toronto.
Family Doctors Have Highest Preferences for Surgery
The researchers presented hypothetical back pain scenarios to surgeons (orthopedic surgeons and neurosurgeons), family physicians, and patients with back and/or leg pain. The scenarios reflected key factors related to back pain: walking ability, pain duration, pain severity, neurological symptoms, factors inducing pain, and pain location. Each group rated their preference for surgery in each scenario, and the factors affecting preferences were analyzed.
Perhaps unexpectedly, surgeons had the lowest overall preferences for surgery, while family physicians had the highest preference for surgery. For orthopedic surgeons, the preference for surgery was somewhat lower than for neurosurgeons. Both the family doctors and patients had a higher preference for surgery than either group of surgeons.
The factors affecting preferences for surgery varied as well. For surgeons, the most important factor was the location of pain. In particular, they preferred surgery for patients with pain predominantly in the leg, rather than the back. Surgery provides better results in patients with problems affecting the spinal nerve roots, which tend to cause leg pain.
Revealing Differences in Reasons for Preferences
In contrast, for family physicians, the most important factor affecting preferences for surgery was neurological symptoms, followed closely by walking ability and pain severity. Family doctors may be unaware of which factors affect the chances of good outcomes from back surgery, the researchers suggest.
For patients, the most important factors were pain severity, walking ability, and pain duration. "All of these symptoms are highly related to quality of life and have little direct bearing on outcomes following surgery," Dr. Bederman and co-authors write.
When other treatments have failed, surgery can help patients with moderate to severe lower back pain. Family physicians play an important role in sending back pain patients for surgical evaluation. However, few studies looked at the factors considered by primary care doctors consider in referring patients for possible spinal surgery. The final decision is generally made through a shared process between the patient, family physician, and surgeon.
The new results suggest that, in various scenarios, surgeons have a lower preference for surgery than family physicians. In addition, the factors that surgeons feel are most important—especially the location of pain—don't match those considered most important by family doctors.
The study also highlights the importance of quality-of-life factors—especially pain severity and duration and walking ability—in affecting patients' treatment preferences. Dr. Bederman and colleagues hope their findings will help in "aligning" the opinions of patients and doctors, thus improving the shared decision-making process and promoting more accurate patient expectations of the results of surgery. "This can directly result in a significant improvement in patient satisfaction with the healthcare process and even overall health status following treatment," the researchers write.
About Spine
Recognized internationally as the leading journal in its field, Spine is an international, peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of spine. It is the leading subspecialty journal for the treatment of spinal disorders. Only original papers are considered for publication with the understanding that they are contributed solely to Spine. According to the latest ISI Science Citation Impact Factor, Spine ranks highest among subspecialty orthopedic titles.
Friday, January 15, 2010
Long-term Opioid Use for Back Pain
Despite limited evidence of long-term success in using opioid pain medications for chronic low back pain, opioid prescribing has increased in recent years for back pain and other non-cancer pain indications. The implications are controversial as published studies provide little evidence indicating which patients will benefit from long-term opioid treatment.
New research, published in The Journal of Pain, identifies predictors of long-term opioid use among patients with chronic back pain caused by lumbar spine conditions. Participants were recruited from 13 spine specialty centers in 11 states and totaled 2,110. Forty-two percent reported using opioids for pain from their spine condition and a third said they take opioids every day.
From their analysis of the demographic, medical and social characteristics of study participants, the researchers found that nonsurgical treatment and smoking independently predicted continued long-term opioid use and pain severity did not. The authors noted that smoking can be a marker for substance abuse disorders, which was not a characteristic evaluated in the sample due to limitations for measuring alcohol or drug use. Therefore, the researchers were unable to consider substance abuse as a predictor of long-term opioid use. However, the association with smoking could be interpreted as a surrogate predictor for substance abuse, given its strong link with smoking.
Regarding the nonsurgical predictor, the authors noted that risks associated with continued pain management with opioids in some patients may outweigh the risks of surgery. This might be a factor worth considering in surgical decision making for patients with herniated discs or stenosis, especially those with a history of substance abuse.
About the American Pain Society_Based in Glenview, Ill., the American Pain Society (APS) is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering.
APS was founded in 1978 with 510 charter members. From the outset, the group was conceived as a multidisciplinary organization. APS has enjoyed solid growth since its early days and today has approximately 3,200 members. The Board of Directors includes physicians, nurses, psychologists, basic scientists, pharmacists, policy analysts and more.
New research, published in The Journal of Pain, identifies predictors of long-term opioid use among patients with chronic back pain caused by lumbar spine conditions. Participants were recruited from 13 spine specialty centers in 11 states and totaled 2,110. Forty-two percent reported using opioids for pain from their spine condition and a third said they take opioids every day.
From their analysis of the demographic, medical and social characteristics of study participants, the researchers found that nonsurgical treatment and smoking independently predicted continued long-term opioid use and pain severity did not. The authors noted that smoking can be a marker for substance abuse disorders, which was not a characteristic evaluated in the sample due to limitations for measuring alcohol or drug use. Therefore, the researchers were unable to consider substance abuse as a predictor of long-term opioid use. However, the association with smoking could be interpreted as a surrogate predictor for substance abuse, given its strong link with smoking.
Regarding the nonsurgical predictor, the authors noted that risks associated with continued pain management with opioids in some patients may outweigh the risks of surgery. This might be a factor worth considering in surgical decision making for patients with herniated discs or stenosis, especially those with a history of substance abuse.
About the American Pain Society_Based in Glenview, Ill., the American Pain Society (APS) is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering.
APS was founded in 1978 with 510 charter members. From the outset, the group was conceived as a multidisciplinary organization. APS has enjoyed solid growth since its early days and today has approximately 3,200 members. The Board of Directors includes physicians, nurses, psychologists, basic scientists, pharmacists, policy analysts and more.
Saturday, January 2, 2010
TENS Scores Zero
Widely Used Device for Pain Therapy Not Recommended for Chronic Low Back Pain
A new guideline issued by the American Academy of Neurology finds that transcutaneous electric nerve stimulation (TENS), a widely used pain therapy involving a portable device, is not recommended to treat chronic low-back pain - pain that has persisted for three months or longer - because research shows it is not effective.
The guideline is published in the December 30, 2009, online issue of Neurology®, the medical journal of the American Academy of Neurology.
The guideline determined that TENS can be effective in treating diabetic nerve pain, also called diabetic neuropathy, but more and better research is needed to compare TENS to other treatments for this type of pain.
Research on TENS for chronic low-back pain has produced conflicting results. For the guideline, the authors reviewed all of the evidence for low-back pain lasting three months or longer. Acute low-back pain was not studied. The studies to date show that TENS does not help with chronic low-back pain.
All but one of the studies excluded people with known causes of low-back pain, such as a pinched nerve, severe scoliosis (curving of the spine), severe spondylolisthesis (displacement of a backbone or vertebra) or obesity. In the one study that looked at low-back pain associated with known conditions, TENS was not shown to be effective. The only specific neurologic cause of chronic low-back pain where TENS was studied was multiple sclerosis, and TENS was not shown to help.
"The strongest evidence showed that there is no benefit for people using TENS for chronic low-back pain," said guideline author Richard M. Dubinsky, MD, MPH, of Kansas University Medical Center in Kansas City and a Fellow of the American Academy of Neurology. "Doctors should use clinical judgment regarding TENS use for chronic low-back pain. People who are currently using TENS for their low-back pain should discuss these findings with their doctors."
Dubinsky stated further that good evidence showed that TENS can be effective in treating diabetic nerve pain.
With TENS, a portable, pocket-sized unit applies a mild electrical current to the nerves through electrodes. TENS has been used for pain relief in various disorders for years. Researchers do not know how TENS may provide relief for pain. One theory is that nerves can only carry one signal at a time. The TENS stimulation may confuse the brain and block the real pain signal from getting through.
Back pain -- both acute and chronic -- is the second most common neurologic ailment in the United States, according to the National Institute of Neurological Disorders and Stroke, and is the most common cause of job-related disability. About 60 percent of people with diabetes will develop neuropathy.
A new guideline issued by the American Academy of Neurology finds that transcutaneous electric nerve stimulation (TENS), a widely used pain therapy involving a portable device, is not recommended to treat chronic low-back pain - pain that has persisted for three months or longer - because research shows it is not effective.
The guideline is published in the December 30, 2009, online issue of Neurology®, the medical journal of the American Academy of Neurology.
The guideline determined that TENS can be effective in treating diabetic nerve pain, also called diabetic neuropathy, but more and better research is needed to compare TENS to other treatments for this type of pain.
Research on TENS for chronic low-back pain has produced conflicting results. For the guideline, the authors reviewed all of the evidence for low-back pain lasting three months or longer. Acute low-back pain was not studied. The studies to date show that TENS does not help with chronic low-back pain.
All but one of the studies excluded people with known causes of low-back pain, such as a pinched nerve, severe scoliosis (curving of the spine), severe spondylolisthesis (displacement of a backbone or vertebra) or obesity. In the one study that looked at low-back pain associated with known conditions, TENS was not shown to be effective. The only specific neurologic cause of chronic low-back pain where TENS was studied was multiple sclerosis, and TENS was not shown to help.
"The strongest evidence showed that there is no benefit for people using TENS for chronic low-back pain," said guideline author Richard M. Dubinsky, MD, MPH, of Kansas University Medical Center in Kansas City and a Fellow of the American Academy of Neurology. "Doctors should use clinical judgment regarding TENS use for chronic low-back pain. People who are currently using TENS for their low-back pain should discuss these findings with their doctors."
Dubinsky stated further that good evidence showed that TENS can be effective in treating diabetic nerve pain.
With TENS, a portable, pocket-sized unit applies a mild electrical current to the nerves through electrodes. TENS has been used for pain relief in various disorders for years. Researchers do not know how TENS may provide relief for pain. One theory is that nerves can only carry one signal at a time. The TENS stimulation may confuse the brain and block the real pain signal from getting through.
Back pain -- both acute and chronic -- is the second most common neurologic ailment in the United States, according to the National Institute of Neurological Disorders and Stroke, and is the most common cause of job-related disability. About 60 percent of people with diabetes will develop neuropathy.
Friday, September 25, 2009
Manipulation Improves Late Pregnancy Back Function
A study published by the American Journal of Obstetrics and Gynecology, demonstrates that osteopathic manipulative treatment slows or halts the deterioration of back-specific function in the third trimester of pregnancy.
The Phase II randomized clinical trial of 144 subjects showed that women in the usual obstetric care and osteopathic manipulative treatment group reported less deterioration of back-specific function on the Roland-Morris Disability Scale than women in the usual obstetric care and sham ultrasound and the usual obstetric care only groups when these groups were compared using an intention-to-treat analysis. This study is the first randomized, placebo-controlled trial to explore the potential effects of osteopathic manipulative treatment during the third trimester of pregnancy.
In the study, conducted by The Osteopathic Research Center in conjunction with the Department of Obstetrics and Gynecology at the University of North Texas Health Science Center in Fort Worth, Texas, women were enrolled between the 28th and 30th week of pregnancy. After being randomized to one of the three treatment groups, the women in the usual obstetric care and osteopathic manipulative treatment and usual obstetric care and sham ultrasound groups received treatments immediately following each of their third trimester prenatal visits. Women were excluded from or dropped from the study if they were determined to be at high risk by their obstetrician. The median age for women included in the study was 24 years.
Usual obstetric care was defined in this study as the conventional prenatal care received during pregnancy. Osteopathic manipulative treatment is generally considered a complementary treatment that is not included as part of routine prenatal care.
Osteopathic manipulative treatment is a system of hands-on diagnosis and treatment that is used to reduce pain, restore range of motion and to restore normal function and balance in the body.
“This study is exciting because pregnant women frequently experience a negative impact on their ability to function and perform tasks related to daily living as their pregnancy progresses,” said John Licciardone, D.O., M.S., M.B.A., the principal investigator for the project, and the executive director of The Osteopathic Research Center. “Since pregnant women are limited in the medications they can take for pain, osteopathic manipulative treatment offers a way to improve back function and decrease pain in the third trimester of pregnancy, when a majority of women experience these symptoms.”
“What is also interesting about this study is that osteopathic physicians (D.O.s) who provide obstetrical care can potentially include osteopathic manipulative treatment as part of their prenatal care for patients,” Licciardone said. “For more than 100 years, osteopathic physicians who have treated pregnant women using osteopathic manipulation have claimed that their patients have less pain, better function and improved delivery outcomes. This study may be the first step in confirming the clinical success of osteopathic physicians in this area of medicine.”
Full text of the article is available online at http://www.ajog.org/inpress.
The Phase II randomized clinical trial of 144 subjects showed that women in the usual obstetric care and osteopathic manipulative treatment group reported less deterioration of back-specific function on the Roland-Morris Disability Scale than women in the usual obstetric care and sham ultrasound and the usual obstetric care only groups when these groups were compared using an intention-to-treat analysis. This study is the first randomized, placebo-controlled trial to explore the potential effects of osteopathic manipulative treatment during the third trimester of pregnancy.
In the study, conducted by The Osteopathic Research Center in conjunction with the Department of Obstetrics and Gynecology at the University of North Texas Health Science Center in Fort Worth, Texas, women were enrolled between the 28th and 30th week of pregnancy. After being randomized to one of the three treatment groups, the women in the usual obstetric care and osteopathic manipulative treatment and usual obstetric care and sham ultrasound groups received treatments immediately following each of their third trimester prenatal visits. Women were excluded from or dropped from the study if they were determined to be at high risk by their obstetrician. The median age for women included in the study was 24 years.
Usual obstetric care was defined in this study as the conventional prenatal care received during pregnancy. Osteopathic manipulative treatment is generally considered a complementary treatment that is not included as part of routine prenatal care.
Osteopathic manipulative treatment is a system of hands-on diagnosis and treatment that is used to reduce pain, restore range of motion and to restore normal function and balance in the body.
“This study is exciting because pregnant women frequently experience a negative impact on their ability to function and perform tasks related to daily living as their pregnancy progresses,” said John Licciardone, D.O., M.S., M.B.A., the principal investigator for the project, and the executive director of The Osteopathic Research Center. “Since pregnant women are limited in the medications they can take for pain, osteopathic manipulative treatment offers a way to improve back function and decrease pain in the third trimester of pregnancy, when a majority of women experience these symptoms.”
“What is also interesting about this study is that osteopathic physicians (D.O.s) who provide obstetrical care can potentially include osteopathic manipulative treatment as part of their prenatal care for patients,” Licciardone said. “For more than 100 years, osteopathic physicians who have treated pregnant women using osteopathic manipulation have claimed that their patients have less pain, better function and improved delivery outcomes. This study may be the first step in confirming the clinical success of osteopathic physicians in this area of medicine.”
Full text of the article is available online at http://www.ajog.org/inpress.
Wednesday, May 13, 2009
New Guideline for Low-Back Pain Interventions, Surgery
The American Pain Society (APS) has issued a new clinical practice guideline for low back pain that emphasizes the use of noninvasive treatments over interventional procedures, as well as shared decision making between provider and patient. The findings are published in the current (May 1, 2009) issue of the journal Spine.
The new APS guideline, based on an extensive review of existing research, provides clinicians with eight recommendations to help determine the best way to treat patients with low-back pain. It also expands its current and previously published guideline for initial evaluation and management of this chronic condition.
“These recommendations are based on an even more complete body of evidence than was available just a few years ago. Consequently, we believe these recommendations will give physicians more confidence when treating patients with persistent back pain,” said Roger Chou, M.D., lead author, director of the APS Clinical Practice Guideline Program, and associate professor of medicine (general internal medicine), Oregon Evidence-based Practice Center, Oregon Health & Science University.
“Unfortunately, randomized trials for a number of commonly used interventional procedures are still too limited to generate evidence-based recommendations, and our review also highlights the need for more research,” Chou added.
Low-back pain is the fifth most common reason for doctor’s visits and accounts for more than $26 billion in direct health care costs nationwide each year. While a number of interventional diagnostic tests and therapies, and surgery are available, and their use is increasing, in some cases their usefulness remains uncertain.
“We have advocated strongly in many of our recommendations for physicians to use shared decision making because of the relatively close trade-offs between potential benefits relative to harms, as well as costs and burdens of these various treatment options,” Chou explained. Shared decision making involves a patient’s full participation in medical choices after receiving comprehensive information about the impact of all options on his or her particular life situation.
To develop the guideline, a multidisciplinary APS panel, augmented by experts on interventional therapies, reviewed 3,348 abstracts and analyzed 161 relevant clinical trials. The panel found that the evidence for the use of these interventions was mixed, sparse or not available. Based on the data the panel gathered, the APS now recommends:
1. Against the use of provocative discography (injection of fluid into the disc in order to determine if it is the source of back pain) for patients with chronic nonradicular low-back pain.
2. The consideration of intensive interdisciplinary rehabilitation with a cognitive/behavioral emphasis for patients with nonradicular low-back pain who do not respond to usual, non-interdisciplinary therapies.
3. Against facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injections for patients with persistent nonradicular low-back pain, and insufficient evidence to guide use of other interventional therapies.
4. A discussion of risks and benefits of surgery and the use of shared decision making with reference to rehabilitation as a similarly effective option for patients with nonradicular low-back pain, common degenerative spinal changes, and persistent and disabling symptoms.
5. Insufficient evidence to guide recommendations for vertebral disc replacement.
6. A discussion of the risks and benefits of epidural steroid injections and shared decision making, including specific review of evidence of lack of long-term benefit for patients with persistent radiculopathy due to herniated lumbar disc.
7. A discussion of the risks and benefits of surgery and use of shared decision making that references moderate benefits that decrease over time for patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain.
8. Discussion of risks and benefits of spinal cord stimulation and shared decision making, including reference to the high rate of complications following stimulator placement for patients with persistent and disabling radicular pain following surgery for herniated disc and no evidence of a persistently compressed nerve root.
Chou and his colleagues also reaffirm their previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. “In general, noninvasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery,” said Chou.
Recommendations from the first APS Clinical Practice Guideline on Low-Back Pain are intended for primary care physicians and appeared in the Oct, 2, 2007, issue of the Annals of Internal Medicine. For diagnosis, the first APS low-back pain guideline advises clinicians to minimize routine use of X-rays or other diagnostic tests except for patients known or believed to have underlying neurological or spinal disorders
About the American Pain Society
Based in Glenview, Ill., the American Pain Society (APS) is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering.APS was founded in 1978 with 510 charter members. From the outset, the group was conceived as a multidisciplinary organization. APS has enjoyed solid growth since its early days and today has approximately 3,200 members. The Board of Directors includes physicians, nurses, psychologists, basic scientists, pharmacists, policy analysts and more.
The new APS guideline, based on an extensive review of existing research, provides clinicians with eight recommendations to help determine the best way to treat patients with low-back pain. It also expands its current and previously published guideline for initial evaluation and management of this chronic condition.
“These recommendations are based on an even more complete body of evidence than was available just a few years ago. Consequently, we believe these recommendations will give physicians more confidence when treating patients with persistent back pain,” said Roger Chou, M.D., lead author, director of the APS Clinical Practice Guideline Program, and associate professor of medicine (general internal medicine), Oregon Evidence-based Practice Center, Oregon Health & Science University.
“Unfortunately, randomized trials for a number of commonly used interventional procedures are still too limited to generate evidence-based recommendations, and our review also highlights the need for more research,” Chou added.
Low-back pain is the fifth most common reason for doctor’s visits and accounts for more than $26 billion in direct health care costs nationwide each year. While a number of interventional diagnostic tests and therapies, and surgery are available, and their use is increasing, in some cases their usefulness remains uncertain.
“We have advocated strongly in many of our recommendations for physicians to use shared decision making because of the relatively close trade-offs between potential benefits relative to harms, as well as costs and burdens of these various treatment options,” Chou explained. Shared decision making involves a patient’s full participation in medical choices after receiving comprehensive information about the impact of all options on his or her particular life situation.
To develop the guideline, a multidisciplinary APS panel, augmented by experts on interventional therapies, reviewed 3,348 abstracts and analyzed 161 relevant clinical trials. The panel found that the evidence for the use of these interventions was mixed, sparse or not available. Based on the data the panel gathered, the APS now recommends:
1. Against the use of provocative discography (injection of fluid into the disc in order to determine if it is the source of back pain) for patients with chronic nonradicular low-back pain.
2. The consideration of intensive interdisciplinary rehabilitation with a cognitive/behavioral emphasis for patients with nonradicular low-back pain who do not respond to usual, non-interdisciplinary therapies.
3. Against facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injections for patients with persistent nonradicular low-back pain, and insufficient evidence to guide use of other interventional therapies.
4. A discussion of risks and benefits of surgery and the use of shared decision making with reference to rehabilitation as a similarly effective option for patients with nonradicular low-back pain, common degenerative spinal changes, and persistent and disabling symptoms.
5. Insufficient evidence to guide recommendations for vertebral disc replacement.
6. A discussion of the risks and benefits of epidural steroid injections and shared decision making, including specific review of evidence of lack of long-term benefit for patients with persistent radiculopathy due to herniated lumbar disc.
7. A discussion of the risks and benefits of surgery and use of shared decision making that references moderate benefits that decrease over time for patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain.
8. Discussion of risks and benefits of spinal cord stimulation and shared decision making, including reference to the high rate of complications following stimulator placement for patients with persistent and disabling radicular pain following surgery for herniated disc and no evidence of a persistently compressed nerve root.
Chou and his colleagues also reaffirm their previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. “In general, noninvasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery,” said Chou.
Recommendations from the first APS Clinical Practice Guideline on Low-Back Pain are intended for primary care physicians and appeared in the Oct, 2, 2007, issue of the Annals of Internal Medicine. For diagnosis, the first APS low-back pain guideline advises clinicians to minimize routine use of X-rays or other diagnostic tests except for patients known or believed to have underlying neurological or spinal disorders
About the American Pain Society
Based in Glenview, Ill., the American Pain Society (APS) is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering.APS was founded in 1978 with 510 charter members. From the outset, the group was conceived as a multidisciplinary organization. APS has enjoyed solid growth since its early days and today has approximately 3,200 members. The Board of Directors includes physicians, nurses, psychologists, basic scientists, pharmacists, policy analysts and more.
Saturday, February 7, 2009
Scans for low-back pain do not improve outcomes
OHSU researchers find regular MRI, CT, radiography scans unnecessary unless a significant underlying condition is first identified
Physicians should not immediately order routine scans for low-back pain unless they observe features of a serious underlying condition, researchers in the Oregon Evidence-Based Practice Center at Oregon Health & Science University report. Their findings are published in this week's edition of the The Lancet.
The regular use of radiography, MRI or CT scans in patients with low-back pain but no indication of a significant underlying condition does not improve their outcome, the researchers report.
"Our study shows that performing routine X-rays or MRIs for patients with low-back pain does not lead to improved pain, function or anxiety level, and there were even some trends toward worse outcomes," said Roger Chou, M.D., lead author; scientific director of the Oregon Evidence-Based Practice Center at OHSU; and associate professor of medical informatics and clinical epidemiology, and medicine (general internal medicine and geriatrics) in the OHSU School of Medicine.
"Clinicians may think they are helping patients by doing routine X-rays or MRIs, but these diagnostic tests increase medical costs, can result in unnecessary surgeries or other invasive procedures, and may cause patients to stop being active — probably the best thing for back health — because they are worried about common findings such as degenerated discs or arthritis, not understanding that these are very weakly associated with back pain."
To reach this conclusion, Chou and colleagues conducted a meta-analysis of randomized controlled trials that compared immediate back imaging — using one of the three scanning types above — with usual clinical care that does not involve immediate imaging. Six trials covering more than 1,800 patients were included, reporting a range of outcomes including pain and function, quality of life, mental health, overall patient-reported improvement, and patient satisfaction.
The analysis found no significant differences between immediate imaging and usual clinical care. The authors say that the results are most applicable to acute or sub-acute low-back pain of the type assessed in a primary care setting with the patient's family doctor.
The authors report that lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.
They added: "Rates of utilization of lumbar MRI are increasing, and implementation of diagnostic-imaging guidelines for low-back pain remains a challenge. However, clinicians are more likely to adhere to guideline recommendations about lumbar imaging now that these are supported by consistent evidence from higher-quality randomized controlled trials."
Patient expectations and preferences about imaging should also be addressed, because 80 percent of patients with low-back pain in one trial would undergo radiography if given the choice, despite no benefits with routine imaging, the reporters report. They indicated educational interventions for reducing the proportion of patients with low-back pain who believe that routine imaging should be done.
Other investigators who participated in this study include: Rick Deyo, M.D., M.P.H., Kaiser Permanente Professor of Evidence-Based Family Medicine, OHSU School of Medicine, Oregon Evidence-Based Practice Center; and Rochelle Fu, Ph.D., assistant professor of public health and preventive medicine, OHSU School of Medicine.
In an accompanying comment, Michael M. Kochen, Department of General Practice, University of Göttingen, Germany, and colleagues discuss how certain factors could hamper doctors changing practice to avoid immediate imaging, "such as patients' expectations about diagnostic testing, reimbursement structures providing financial incentives, or the fear of missing relevant pathology." They conclude: "Meanwhile a promising approach seems to be the way of educating patients in and outside general practitioners surgeries."
Physicians should not immediately order routine scans for low-back pain unless they observe features of a serious underlying condition, researchers in the Oregon Evidence-Based Practice Center at Oregon Health & Science University report. Their findings are published in this week's edition of the The Lancet.
The regular use of radiography, MRI or CT scans in patients with low-back pain but no indication of a significant underlying condition does not improve their outcome, the researchers report.
"Our study shows that performing routine X-rays or MRIs for patients with low-back pain does not lead to improved pain, function or anxiety level, and there were even some trends toward worse outcomes," said Roger Chou, M.D., lead author; scientific director of the Oregon Evidence-Based Practice Center at OHSU; and associate professor of medical informatics and clinical epidemiology, and medicine (general internal medicine and geriatrics) in the OHSU School of Medicine.
"Clinicians may think they are helping patients by doing routine X-rays or MRIs, but these diagnostic tests increase medical costs, can result in unnecessary surgeries or other invasive procedures, and may cause patients to stop being active — probably the best thing for back health — because they are worried about common findings such as degenerated discs or arthritis, not understanding that these are very weakly associated with back pain."
To reach this conclusion, Chou and colleagues conducted a meta-analysis of randomized controlled trials that compared immediate back imaging — using one of the three scanning types above — with usual clinical care that does not involve immediate imaging. Six trials covering more than 1,800 patients were included, reporting a range of outcomes including pain and function, quality of life, mental health, overall patient-reported improvement, and patient satisfaction.
The analysis found no significant differences between immediate imaging and usual clinical care. The authors say that the results are most applicable to acute or sub-acute low-back pain of the type assessed in a primary care setting with the patient's family doctor.
The authors report that lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.
They added: "Rates of utilization of lumbar MRI are increasing, and implementation of diagnostic-imaging guidelines for low-back pain remains a challenge. However, clinicians are more likely to adhere to guideline recommendations about lumbar imaging now that these are supported by consistent evidence from higher-quality randomized controlled trials."
Patient expectations and preferences about imaging should also be addressed, because 80 percent of patients with low-back pain in one trial would undergo radiography if given the choice, despite no benefits with routine imaging, the reporters report. They indicated educational interventions for reducing the proportion of patients with low-back pain who believe that routine imaging should be done.
Other investigators who participated in this study include: Rick Deyo, M.D., M.P.H., Kaiser Permanente Professor of Evidence-Based Family Medicine, OHSU School of Medicine, Oregon Evidence-Based Practice Center; and Rochelle Fu, Ph.D., assistant professor of public health and preventive medicine, OHSU School of Medicine.
In an accompanying comment, Michael M. Kochen, Department of General Practice, University of Göttingen, Germany, and colleagues discuss how certain factors could hamper doctors changing practice to avoid immediate imaging, "such as patients' expectations about diagnostic testing, reimbursement structures providing financial incentives, or the fear of missing relevant pathology." They conclude: "Meanwhile a promising approach seems to be the way of educating patients in and outside general practitioners surgeries."
Tuesday, December 16, 2008
Back pain: Are we treating it right?
A new study by researchers at The George Institute for International Health has found that back pain is a reoccurring problem for five million Australians.
According to lead author, Professor Chris Maher, Director of Musculoskeletal Research at The George Institute, "After an episode of back pain resolves, one in four people will experience a recurrence within one year. This explains why around 25% of the Australian population suffers from back pain at any one time."
Low back pain is the most prevalent and costly musculoskeletal condition in Australia(1), estimated to cost up to $1billion per annum with indirect costs exceeding $8billion(2). It is also the most common health condition causing older Australians to be absent from the labour force.(3)
According to Professor Maher, patients and clinicians need to shift their focus to prevention. "We tend to treat the pain when it's there, but when you recover, patients rarely take steps to prevent the problem from returning. People understand the message about lifting correctly but heavy lifting is only one of the risk factors for developing back pain. What many people do not understand is that some of the risk factors for back pain are also the risk factors for other chronic diseases like heart disease. My advice is that people should take a similar approach to back health, as they do for heart health – eating right, exercise and a healthy lifestyle is definitely good for your heart, and also your spine," he added.
"Good, previous research has shown participation in an exercise program after the original episode of low back pain is highly effective in preventing recurrence. Those in the exercise group had half the rate of recurrence of the control group. Other studies have indicated that strengthening muscles and developing fitness show some benefit in avoiding recurring back pain. Mental stress also increases the risk of back pain so including stress management in a health promotion approach would be a sensible way to reduce your chances of back pain. Just paying attention to lifting correctly is probably not enough, a holistic approach is really best."
According to lead author, Professor Chris Maher, Director of Musculoskeletal Research at The George Institute, "After an episode of back pain resolves, one in four people will experience a recurrence within one year. This explains why around 25% of the Australian population suffers from back pain at any one time."
Low back pain is the most prevalent and costly musculoskeletal condition in Australia(1), estimated to cost up to $1billion per annum with indirect costs exceeding $8billion(2). It is also the most common health condition causing older Australians to be absent from the labour force.(3)
According to Professor Maher, patients and clinicians need to shift their focus to prevention. "We tend to treat the pain when it's there, but when you recover, patients rarely take steps to prevent the problem from returning. People understand the message about lifting correctly but heavy lifting is only one of the risk factors for developing back pain. What many people do not understand is that some of the risk factors for back pain are also the risk factors for other chronic diseases like heart disease. My advice is that people should take a similar approach to back health, as they do for heart health – eating right, exercise and a healthy lifestyle is definitely good for your heart, and also your spine," he added.
"Good, previous research has shown participation in an exercise program after the original episode of low back pain is highly effective in preventing recurrence. Those in the exercise group had half the rate of recurrence of the control group. Other studies have indicated that strengthening muscles and developing fitness show some benefit in avoiding recurring back pain. Mental stress also increases the risk of back pain so including stress management in a health promotion approach would be a sensible way to reduce your chances of back pain. Just paying attention to lifting correctly is probably not enough, a holistic approach is really best."
Thursday, December 11, 2008
Lug Your Luggage Safely
Seasoned travelers have a saying – “Pack your bags, then take out half.” This refers to the fact that most of us bring much more than we need on our trips. Now, even more travelers are echoing that line, especially, since so many airline providers are charging passengers a fee for checking luggage. However, if you are one of those people who cannot decide which half to leave at home, the American Academy of Orthopaedic Surgeons (AAOS) has recommendations to help you carry your baggage safely.
According to the U.S. Consumer Products Safety Commission:_•In 2007, more than 50,000 people were treated in hospital emergency rooms, doctors’ offices, clinics and other medical settings for injuries related to luggage.
Packing light may prevent injuries such as:_• Strains, pulls and tears _o Any of these can occur while carrying a heavy suitcase for an extended period of time. _o Lifting and holding a bag incorrectly or lifting luggage from baggage claim carousels, overhead or under-seat compartments._• The chances of these injuries are even greater when a person has been sitting still for a long period of time (as when on a plane) or when the luggage is over-packed and especially heavy.
“Using proper lifting techniques can ensure that your trip isn’t cut short by an injury,” says William R. Marshall, MD, a spokesperson for the AAOS and orthopaedic surgeon in Fort Walton Beach, Florida. “Even a relatively minor injury, such as a muscle pull, to the back, neck or shoulders can be quite painful in the short term and end up ruining your vacation.”
The Academy offers the following strategies to prevent injuries when lifting and carrying luggage:_• Pack lightly. When possible, pack items in a few smaller bags instead of one large luggage piece. It is better – and may prevent muscle sprains and strains – to carry a lighter bag in each hand rather than one heavy bag in one hand or over one shoulder.
• As with any heavy lifting, you should bend at the knees and lift luggage with your leg muscles—not your back and waist—and avoid twisting and rotating your spine. Stand alongside your suitcase, bend at your knees, then grasp the handle and straighten up. Also, try to carry luggage as close to your body as possible.
• When placing luggage in an overhead compartment, first lift it onto the top of the seat. Then, with the hands situated on the left and right sides of the suitcase, lift it up. If your luggage has wheels, make sure the wheel-side is set in the compartment first. Once wheels are inside, put one hand atop the luggage and push it to the back of the compartment. To remove the luggage, reverse this process.
• If using a backpack, make sure it has two padded and adjustable shoulder straps. Choose one with several compartments to secure various-sized items, packing the heavier things low and towards the center. Always wear a backpack on both shoulders--slinging it over one shoulder does not allow weight to be distributed evenly, which can cause muscle strain.
• If you need to use a duffel or shoulder bag, do not carry it on one shoulder for any length of time. Be sure to switch sides often, as this may prevent soreness and discomfort to the shoulder area.
Other important tips:_• When purchasing new luggage, look for a sturdy, light pieces with wheels and a handle. Avoid purchasing luggage that is too heavy or bulky while empty.
• Do not rush when lifting or carrying a suitcase. If it is too heavy or an awkward shape, ask someone for help.
• Do not carry heavy pieces of luggage for long periods of time. If it is very heavy, and you must carry it, stop and take a break. If at all possible, check your luggage when traveling rather than carrying it on a plane, train or bus.
• Make sure to carry all rolling luggage up flights of stairs.
According to the U.S. Consumer Products Safety Commission:_•In 2007, more than 50,000 people were treated in hospital emergency rooms, doctors’ offices, clinics and other medical settings for injuries related to luggage.
Packing light may prevent injuries such as:_• Strains, pulls and tears _o Any of these can occur while carrying a heavy suitcase for an extended period of time. _o Lifting and holding a bag incorrectly or lifting luggage from baggage claim carousels, overhead or under-seat compartments._• The chances of these injuries are even greater when a person has been sitting still for a long period of time (as when on a plane) or when the luggage is over-packed and especially heavy.
“Using proper lifting techniques can ensure that your trip isn’t cut short by an injury,” says William R. Marshall, MD, a spokesperson for the AAOS and orthopaedic surgeon in Fort Walton Beach, Florida. “Even a relatively minor injury, such as a muscle pull, to the back, neck or shoulders can be quite painful in the short term and end up ruining your vacation.”
The Academy offers the following strategies to prevent injuries when lifting and carrying luggage:_• Pack lightly. When possible, pack items in a few smaller bags instead of one large luggage piece. It is better – and may prevent muscle sprains and strains – to carry a lighter bag in each hand rather than one heavy bag in one hand or over one shoulder.
• As with any heavy lifting, you should bend at the knees and lift luggage with your leg muscles—not your back and waist—and avoid twisting and rotating your spine. Stand alongside your suitcase, bend at your knees, then grasp the handle and straighten up. Also, try to carry luggage as close to your body as possible.
• When placing luggage in an overhead compartment, first lift it onto the top of the seat. Then, with the hands situated on the left and right sides of the suitcase, lift it up. If your luggage has wheels, make sure the wheel-side is set in the compartment first. Once wheels are inside, put one hand atop the luggage and push it to the back of the compartment. To remove the luggage, reverse this process.
• If using a backpack, make sure it has two padded and adjustable shoulder straps. Choose one with several compartments to secure various-sized items, packing the heavier things low and towards the center. Always wear a backpack on both shoulders--slinging it over one shoulder does not allow weight to be distributed evenly, which can cause muscle strain.
• If you need to use a duffel or shoulder bag, do not carry it on one shoulder for any length of time. Be sure to switch sides often, as this may prevent soreness and discomfort to the shoulder area.
Other important tips:_• When purchasing new luggage, look for a sturdy, light pieces with wheels and a handle. Avoid purchasing luggage that is too heavy or bulky while empty.
• Do not rush when lifting or carrying a suitcase. If it is too heavy or an awkward shape, ask someone for help.
• Do not carry heavy pieces of luggage for long periods of time. If it is very heavy, and you must carry it, stop and take a break. If at all possible, check your luggage when traveling rather than carrying it on a plane, train or bus.
• Make sure to carry all rolling luggage up flights of stairs.
Preventing Back Pain
One of the best things you can do to prevent and/or eliminate back pain is to exercise. Both an inactive lifestyle and being overweight contribute to back pain. Exercise benefits you in so many ways, such as lowering blood pressure, helping you maintain a healthy weight, lowering your risk for diabetes, and the list goes on!
Orthotics can help you maintain a healthy spine through the use of spinal pelvic stabilizers. Devices that you wear in your shoes, stabilizers align all three arches of your foot to provide a balanced foundation for your spine and body.
It is estimated that 80 percent of people will experience back pain at some time in their life. Since your back is a complicated structure of bones, joints, muscles, and ligaments, there are many different factors that can play a part in your back pain. It is possible to irritate joints, sprain ligaments, or strain muscles in your back -- which can all cause pain. Poor posture, obesity, and psychological stress can also lead to or worsen back pain. One thing you may not know is that along with chiropractic care, exercise can help prevent back pain.
Doctors of chiropractic (DCs) can help reduce, eliminate, and prevent back pain. Using their hands, they manually adjust the joints and tissue in your back to restore joint mobility, relieving pain and muscle tightness. Maintaining a healthy spine will help keep you healthier overall by keeping your spine free of misalignments that could interfere with your nervous system, the center for all your mental activity. DCs can also provide you with dietary, nutritional, and lifestyle counseling.
Orthotics can help you maintain a healthy spine through the use of spinal pelvic stabilizers. Devices that you wear in your shoes, stabilizers align all three arches of your foot to provide a balanced foundation for your spine and body.
It is estimated that 80 percent of people will experience back pain at some time in their life. Since your back is a complicated structure of bones, joints, muscles, and ligaments, there are many different factors that can play a part in your back pain. It is possible to irritate joints, sprain ligaments, or strain muscles in your back -- which can all cause pain. Poor posture, obesity, and psychological stress can also lead to or worsen back pain. One thing you may not know is that along with chiropractic care, exercise can help prevent back pain.
Doctors of chiropractic (DCs) can help reduce, eliminate, and prevent back pain. Using their hands, they manually adjust the joints and tissue in your back to restore joint mobility, relieving pain and muscle tightness. Maintaining a healthy spine will help keep you healthier overall by keeping your spine free of misalignments that could interfere with your nervous system, the center for all your mental activity. DCs can also provide you with dietary, nutritional, and lifestyle counseling.
Take More Breaks to Avoid Back Injury at Work
Take More Breaks to Avoid Back Injury at Work, Study Says
Workers who lift for a living need to take longer or more frequent breaks than they now do to avoid back injury, according to a new study at Ohio State University.
The study also suggests that people who are new on the job need to take breaks even more often than experienced workers, and that the risk of injury is higher at the end of a work shift.
People who participated in the study lifted boxes onto conveyor belts for eight hours, while researchers measured the amount of oxygen that was reaching the muscles in their lower back.
The oxygen level indicated how hard the muscles were working, and whether they were becoming fatigued, explained William Marras, professor of industrial welding and systems engineering at Ohio State. His research and others' has shown that muscle fatigue is linked to back injury.
The study, which appeared in a recent issue of the journal Clinical Biomechanics, is the first to examine what happens to muscle oxygenation over a full workday.
Despite the fact that the study participants were performing the same job at the same pace all day, their back muscles needed more oxygen as the day went on. Taking a half-hour lunch break helped their muscles recover from the morning's exertion, but once they started working again, their oxygen needs rose steeply and kept climbing throughout the afternoon.
"That was alarming to us, because it means that their muscles were becoming fatigued much faster during the afternoon, and we know that fatigue increases the risk of back injury," Marras said.
Two 15-minute breaks, one mid-morning and the other mid-afternoon, helped muscles recover a little, but not as much as the half-hour lunch.
"This tells us two things," Marras said. "First, rest is good -- a half-hour break does a good job of helping muscles recover. But it also tells us that people are especially at risk for back injury at the end of the day, and the only way to counteract that effect is with more breaks as the day goes on."
Workers who lift for a living need to take longer or more frequent breaks than they now do to avoid back injury, according to a new study at Ohio State University.
The study also suggests that people who are new on the job need to take breaks even more often than experienced workers, and that the risk of injury is higher at the end of a work shift.
People who participated in the study lifted boxes onto conveyor belts for eight hours, while researchers measured the amount of oxygen that was reaching the muscles in their lower back.
The oxygen level indicated how hard the muscles were working, and whether they were becoming fatigued, explained William Marras, professor of industrial welding and systems engineering at Ohio State. His research and others' has shown that muscle fatigue is linked to back injury.
The study, which appeared in a recent issue of the journal Clinical Biomechanics, is the first to examine what happens to muscle oxygenation over a full workday.
Despite the fact that the study participants were performing the same job at the same pace all day, their back muscles needed more oxygen as the day went on. Taking a half-hour lunch break helped their muscles recover from the morning's exertion, but once they started working again, their oxygen needs rose steeply and kept climbing throughout the afternoon.
"That was alarming to us, because it means that their muscles were becoming fatigued much faster during the afternoon, and we know that fatigue increases the risk of back injury," Marras said.
Two 15-minute breaks, one mid-morning and the other mid-afternoon, helped muscles recover a little, but not as much as the half-hour lunch.
"This tells us two things," Marras said. "First, rest is good -- a half-hour break does a good job of helping muscles recover. But it also tells us that people are especially at risk for back injury at the end of the day, and the only way to counteract that effect is with more breaks as the day goes on."
Expanded Musculoskeletal Care During Pregnancy
Women Need Expanded Musculoskeletal Care During Pregnancy, Study Finds
Despite the high prevalence of musculoskeletal pain during pregnancy, few women in underserved populations receive treatment for their low back pain. Moreover, researchers found that pain in a previous pregnancy may predict a high risk for musculoskeletal complaints in future pregnancies. 85 percent of women who experienced pain in a previous pregnancy reported pain during their current pregnancy.
According to Clayton Skaggs, DC, the study’s chief author, 85 percent of women surveyed reported that they had not received treatment for their musculoskeletal pain, and of the small percentage who perceived that their back complaints were addressed, less than 10 percent were satisfied with the symptom relief they obtained.
“Based on the findings of this study, doctors of chiropractic and other health care professionals need to expand the musculoskeletal care available during pregnancy, especially in underserved populations,” Dr. Skaggs said. “As a proactive step, health professionals should consider including back pain screening as part of early obstetrical care to help identify musculoskeletal risk factors and allow for early education and/or treatment.”
The study findings suggest that pregnant women with back pain are predisposed to sleep disturbances. In the survey, close to 80 percent of women reporting sleep disturbances had back pain, whereas only 8 percent of women without pain reported problems sleeping. More alarming was the significant relationship between reports of musculoskeletal pain and the use of pain medication.
Despite the high prevalence of musculoskeletal pain during pregnancy, few women in underserved populations receive treatment for their low back pain. Moreover, researchers found that pain in a previous pregnancy may predict a high risk for musculoskeletal complaints in future pregnancies. 85 percent of women who experienced pain in a previous pregnancy reported pain during their current pregnancy.
According to Clayton Skaggs, DC, the study’s chief author, 85 percent of women surveyed reported that they had not received treatment for their musculoskeletal pain, and of the small percentage who perceived that their back complaints were addressed, less than 10 percent were satisfied with the symptom relief they obtained.
“Based on the findings of this study, doctors of chiropractic and other health care professionals need to expand the musculoskeletal care available during pregnancy, especially in underserved populations,” Dr. Skaggs said. “As a proactive step, health professionals should consider including back pain screening as part of early obstetrical care to help identify musculoskeletal risk factors and allow for early education and/or treatment.”
The study findings suggest that pregnant women with back pain are predisposed to sleep disturbances. In the survey, close to 80 percent of women reporting sleep disturbances had back pain, whereas only 8 percent of women without pain reported problems sleeping. More alarming was the significant relationship between reports of musculoskeletal pain and the use of pain medication.
38% adults: complementary and alternative medicine
Government survey shows 38 percent of adults and 12 percent of children use complementary and alternative medicine
Approximately 38 percent of adults in the United States aged 18 years and over and nearly 12 percent of U.S. children aged 17 years and under use some form of complementary and alternative medicine (CAM), according to a new nationwide government survey.* This survey marks the first time questions were included on children's use of CAM, which is a group of diverse medical and health care systems, practices, and products such as herbal supplements, meditation, chiropractic, and acupuncture that are not generally considered to be part of conventional medicine.
The survey, conducted as part of the 2007 National Health Interview Survey (NHIS), an annual study in which tens of thousands of Americans are interviewed about their health- and illness-related experiences, was developed by the National Center for Complementary and Alternative Medicine (NCCAM), a part of the National Institutes of Health (NIH) and the National Center for Health Statistics (NCHS), a part of the Centers for Disease Control and Prevention (CDC). The survey included questions on 36 types of CAM therapies commonly used in the United States—10 types of provider-based therapies, such as acupuncture and chiropractic, and 26 other therapies that do not require a provider, such as herbal supplements and meditation.
"The 2007 NHIS provides the most current, comprehensive, and reliable source of information on Americans' use of CAM," said Josephine P. Briggs, M.D., director of NCCAM. "These statistics confirm that CAM practices are a frequently used component of Americans' health care regimens, and reinforce the need for rigorous research to study the safety and effectiveness of these therapies. The data also point out the need for patients and health care providers to openly discuss CAM use to ensure safe and coordinated care."
The 2007 survey results, released in a National Health Statistics Report by NCHS, are based on data from more than 23,300 interviews with American adults and more than 9,400 interviews with adults on behalf a child in their household. The 2007 survey is the second conducted by NCCAM and NCHS—the first was done as part of the 2002 NHIS.**
CAM Use Among Adults
Comparison of the data from the 2002 and 2007 surveys suggests that overall use of CAM among adults has remained relatively steady—36 percent in 2002 and 38 percent in 2007. However, there has been substantial variation in the use of some specific CAM therapies, such as deep breathing, meditation, massage therapy, and yoga, which all showed significant increases.
The most commonly used CAM therapies among U.S. adults were
Nonvitamin, nonmineral, natural products (17.7 percent) Most common: fish oil/omega 3/DHA, glucosamine, echinacea, flaxseed oil or pills, and ginseng***
Deep breathing exercises (12.7 percent)
Meditation (9.4 percent)
Chiropractic or osteopathic manipulation (8.6 percent)
Massage (8.3 percent)
Yoga (6.1 percent).
Adults used CAM most often to treat pain including back pain or problems, neck pain or problems, joint pain or stiffness/other joint condition, arthritis, and other musculoskeletal conditions. Adult use of CAM therapies for head or chest colds showed a marked decrease from 2002 to 2007 (9.5 percent in 2002 to 2.0 percent in 2007).
Consistent with results from the 2002 data, in 2007 CAM use among adults was greater among:.
Women (42.8 percent, compared to men 33.5 percent)
Those aged 30-69 (30-39 years: 39.6 percent, 40-49 years: 40.1 percent, 50-59 years: 44.1 percent, 60-69 years: 41.0 percent)
Those with higher levels of education (Masters, doctorate or professional: 55.4 percent)
Those who were not poor (poor: 28.9 percent, near poor: 30.9 percent, not poor: 43.3 percent)
Those living in the West (44.6 percent)
Those who have quit smoking (48.1 percent)
CAM Use Among Children
Overall, CAM use among children is nearly 12 percent, or about 1 in 9 children. Children are five times more likely to use CAM if a parent or other relative uses CAM. Other characteristics of adult and child CAM users are similar—factors such as socioeconomic status, geographic region, the number of health conditions, the number of doctor visits in the last 12 months, and delaying or not receiving conventional care because of cost are all associated with CAM use.
Among children who used CAM in the past 12 months, CAM therapies were used most often for back or neck pain, head or chest colds, anxiety or stress, other musculoskeletal problems, and Attention Deficit/Hyperactivity Disorder (ADD/ADHD).
The most commonly used CAM therapies among children were
Nonvitamin, nonmineral, natural products (3.9 percent) Most common: echinacea, fish oil/omega 3/DHA, combination herb pill, flaxseed oil or pills, and prebiotics or probiotics
Chiropractic or osteopathic manipulation (2.8 percent)
Deep breathing exercises (2.2 percent)
Yoga (2.1 percent).
"The survey results provide information on trends and a rich set of data for investigating who in America is using CAM, the practices they use, and why," said Richard L. Nahin, Ph.D., MPH, acting director of NCCAM's Division of Extramural Research and co-author of the National Health Statistics Report. "Future analyses of these data may help explain some of the observed variation in the use of individual CAM therapies and provide greater insights into CAM use patterns among Americans."
Approximately 38 percent of adults in the United States aged 18 years and over and nearly 12 percent of U.S. children aged 17 years and under use some form of complementary and alternative medicine (CAM), according to a new nationwide government survey.* This survey marks the first time questions were included on children's use of CAM, which is a group of diverse medical and health care systems, practices, and products such as herbal supplements, meditation, chiropractic, and acupuncture that are not generally considered to be part of conventional medicine.
The survey, conducted as part of the 2007 National Health Interview Survey (NHIS), an annual study in which tens of thousands of Americans are interviewed about their health- and illness-related experiences, was developed by the National Center for Complementary and Alternative Medicine (NCCAM), a part of the National Institutes of Health (NIH) and the National Center for Health Statistics (NCHS), a part of the Centers for Disease Control and Prevention (CDC). The survey included questions on 36 types of CAM therapies commonly used in the United States—10 types of provider-based therapies, such as acupuncture and chiropractic, and 26 other therapies that do not require a provider, such as herbal supplements and meditation.
"The 2007 NHIS provides the most current, comprehensive, and reliable source of information on Americans' use of CAM," said Josephine P. Briggs, M.D., director of NCCAM. "These statistics confirm that CAM practices are a frequently used component of Americans' health care regimens, and reinforce the need for rigorous research to study the safety and effectiveness of these therapies. The data also point out the need for patients and health care providers to openly discuss CAM use to ensure safe and coordinated care."
The 2007 survey results, released in a National Health Statistics Report by NCHS, are based on data from more than 23,300 interviews with American adults and more than 9,400 interviews with adults on behalf a child in their household. The 2007 survey is the second conducted by NCCAM and NCHS—the first was done as part of the 2002 NHIS.**
CAM Use Among Adults
Comparison of the data from the 2002 and 2007 surveys suggests that overall use of CAM among adults has remained relatively steady—36 percent in 2002 and 38 percent in 2007. However, there has been substantial variation in the use of some specific CAM therapies, such as deep breathing, meditation, massage therapy, and yoga, which all showed significant increases.
The most commonly used CAM therapies among U.S. adults were
Nonvitamin, nonmineral, natural products (17.7 percent) Most common: fish oil/omega 3/DHA, glucosamine, echinacea, flaxseed oil or pills, and ginseng***
Deep breathing exercises (12.7 percent)
Meditation (9.4 percent)
Chiropractic or osteopathic manipulation (8.6 percent)
Massage (8.3 percent)
Yoga (6.1 percent).
Adults used CAM most often to treat pain including back pain or problems, neck pain or problems, joint pain or stiffness/other joint condition, arthritis, and other musculoskeletal conditions. Adult use of CAM therapies for head or chest colds showed a marked decrease from 2002 to 2007 (9.5 percent in 2002 to 2.0 percent in 2007).
Consistent with results from the 2002 data, in 2007 CAM use among adults was greater among:.
Women (42.8 percent, compared to men 33.5 percent)
Those aged 30-69 (30-39 years: 39.6 percent, 40-49 years: 40.1 percent, 50-59 years: 44.1 percent, 60-69 years: 41.0 percent)
Those with higher levels of education (Masters, doctorate or professional: 55.4 percent)
Those who were not poor (poor: 28.9 percent, near poor: 30.9 percent, not poor: 43.3 percent)
Those living in the West (44.6 percent)
Those who have quit smoking (48.1 percent)
CAM Use Among Children
Overall, CAM use among children is nearly 12 percent, or about 1 in 9 children. Children are five times more likely to use CAM if a parent or other relative uses CAM. Other characteristics of adult and child CAM users are similar—factors such as socioeconomic status, geographic region, the number of health conditions, the number of doctor visits in the last 12 months, and delaying or not receiving conventional care because of cost are all associated with CAM use.
Among children who used CAM in the past 12 months, CAM therapies were used most often for back or neck pain, head or chest colds, anxiety or stress, other musculoskeletal problems, and Attention Deficit/Hyperactivity Disorder (ADD/ADHD).
The most commonly used CAM therapies among children were
Nonvitamin, nonmineral, natural products (3.9 percent) Most common: echinacea, fish oil/omega 3/DHA, combination herb pill, flaxseed oil or pills, and prebiotics or probiotics
Chiropractic or osteopathic manipulation (2.8 percent)
Deep breathing exercises (2.2 percent)
Yoga (2.1 percent).
"The survey results provide information on trends and a rich set of data for investigating who in America is using CAM, the practices they use, and why," said Richard L. Nahin, Ph.D., MPH, acting director of NCCAM's Division of Extramural Research and co-author of the National Health Statistics Report. "Future analyses of these data may help explain some of the observed variation in the use of individual CAM therapies and provide greater insights into CAM use patterns among Americans."
Tuesday, July 8, 2008
Low back pain recovery slow
Low back pain recovery slow; and worse for those on compensation
Contrary to current guidelines and common belief, new research published in The British Medical Journal has shown that recovery from low back pain is much slower than previously thought and even slower again for those with a compensable injury.
Australian researchers at The George Institute for International Health proved that prognosis from acute (or recent) lower back pain is not as favourable as claimed in clinical practice guidelines and challenges the common belief that 90% of patients recover within four to six weeks, with our without treatment.
"These are extremely important results because they confirm that low back pain is a significant health problem and that there is substantial room for improvement in its management," said Professor Maher. "We found that recovery from low back pain was typically much slower than previously reported - nearly one third of patients did not recover from the original episode within a year."
Professor Chris Maher, The George Institute, Australia and colleagues studied 973 patients with acute low back pain for one year. Each was managed by their preferred clinician; a doctor, physiotherapist or chiropractor, who followed treatment guidelines established by Australia's National Health and Medical Research Council (NHMRC).
These new findings show that even with treatment, after two months only 50% had fully recovered from the original episode of pain. At one year about 40% reported that their back was still causing them pain.
"These results challenge the accepted view that recovery is rapid following an episode of acute low back pain. For many people back pain becomes a long-term problem that severely impacts their life. This is despite receiving what we think is the best possible care. We clearly need to rethink our approach," Professor Maher added.
The strongest predictor of delayed recovery was if the episode of low back pain was compensable: compensation halved the chances of recovery.
"The results also highlight that we should review our compensation system because people within this system do much worse than those outside of it."
In 2005 the additional health care expenditure due to spine problems was estimated to be US$86 billion or 9% of USA health expenditure .
Contrary to current guidelines and common belief, new research published in The British Medical Journal has shown that recovery from low back pain is much slower than previously thought and even slower again for those with a compensable injury.
Australian researchers at The George Institute for International Health proved that prognosis from acute (or recent) lower back pain is not as favourable as claimed in clinical practice guidelines and challenges the common belief that 90% of patients recover within four to six weeks, with our without treatment.
"These are extremely important results because they confirm that low back pain is a significant health problem and that there is substantial room for improvement in its management," said Professor Maher. "We found that recovery from low back pain was typically much slower than previously reported - nearly one third of patients did not recover from the original episode within a year."
Professor Chris Maher, The George Institute, Australia and colleagues studied 973 patients with acute low back pain for one year. Each was managed by their preferred clinician; a doctor, physiotherapist or chiropractor, who followed treatment guidelines established by Australia's National Health and Medical Research Council (NHMRC).
These new findings show that even with treatment, after two months only 50% had fully recovered from the original episode of pain. At one year about 40% reported that their back was still causing them pain.
"These results challenge the accepted view that recovery is rapid following an episode of acute low back pain. For many people back pain becomes a long-term problem that severely impacts their life. This is despite receiving what we think is the best possible care. We clearly need to rethink our approach," Professor Maher added.
The strongest predictor of delayed recovery was if the episode of low back pain was compensable: compensation halved the chances of recovery.
"The results also highlight that we should review our compensation system because people within this system do much worse than those outside of it."
In 2005 the additional health care expenditure due to spine problems was estimated to be US$86 billion or 9% of USA health expenditure .
Thursday, May 8, 2008
New Low Back Pain Guideline
For low-back pain patients and their doctors, the American Pain Society, www.ampainsoc.org, said today it is expanding its evidence-based, clinical practice guideline on diagnosis and treatment of chronic low back pain to include recommendations on surgery and other interventional treatments. The expanded guideline was previewed today in a symposium at the APS Annual Scientific Meeting.
The second part of the APS guideline is based on a multidisciplinary panel’s review and analysis of volumes of evidence related to diagnosis and treatment of low-back pain with a number of interventional procedures and surgeries, according to Roger Chou, MD, director of the American Pain Society’s Clinical Practice Guideline Program and associate professor of internal medicine, Oregon Health & Science University.
Chou noted that in addition to the multidisciplinary panel that formulated the guideline for evaluation and management of low back pain in primary care settings, additional experts with expertise on interventional therapies and surgeries for low back pain were recruited to review the evidence and formulate the expanded recommendations.
"Prior to finalizing the guideline, APS conducts extensive peer review, and has sent the guideline to more than 20 experts in surgery, interventional pain medicine, primary care, and other disciplines for comments and feedback," Chou said.
Low-back pain is the fifth most common reason for doctor’s office visits and one in four adults report having it last a least a day. Annually, low-back pain is estimated to account for more than $26 billion in direct health care costs in the U.S.
“The evidence is much better than even five or 10 years ago and both the primary care and interventional recommendations will help physicians be more confident when evaluating possible therapies for low back pain,” said Chou. “As always, physicians and patients should discuss possible options proven by the evidence and choose the ones that make sense for their situation," he added.
During the symposium, Chou and two panel co-chairs, Richard Rosenquist, MD, assistant professor of anesthesiology, University of Iowa, and John Loeser, MD, professor, Department of Neurological Surgery, University of Washington, reported that for many interventional procedures the evidence from randomized controlled trials is mixed, sparse, not available or showed no benefits. Accordingly, the expanded, evidence-based APS guideline will report:
* Invasive diagnostics, such as provocative discography, facet joint block and sacroliliac joint block tests, have not been proven to be accurate for diagnosing various spinal conditions, and their ability to effectively guide therapeutic choices and improve ultimate patient outcomes is uncertain.
* Epidural stenois injections are an option for short-term pain relief for persistent radiculopathy (radiating low back pain caused by a herniated disc). Other interventional therapies, such as local injections, prolotherapy, botulinum toxin (botox) injection, facet joint injection, sacroliliac joint injection, radiofrequency denervation and intradiscal electrothermal therapy are not supported by convincing, consistent evidence of benefits from randomized trials.
* Surgery to treat radiculopathy and spinal stenosis is effective, though the benefits diminish over time.
* Effectiveness of surgery for non-radicular low back pain is less certain, with some studies showing no benefits compared to intensive interdisciplinary rehabilitation. In addition, a significant proportion of patients experience suboptimal outcomes including persistent pain or functional deficits following surgery.
The expert panel reaffirms its previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. “In general, non-invasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery,” said Chou.
Recommendations from the first APS Clinical Practice Guideline on Low Back Pain were intended for primary care physicians and appeared in the Oct, 2, 2007 issue of the Annals of Internal Medicine. For diagnosis, the first APS low-back pain guideline advises clinicians to minimize routine use of x-rays or other diagnostic tests except for patients known or believed to have underlying neurological or spinal disorders.
In addressing treatment options, it recommended that medications used should be appropriate for the severity of baseline pain and functional impairment, and clinicians should weigh carefully potential benefits and risks of any drug and explain them. Also for various non-pharmacological treatments supported by the evidence, from spinal manipulation to massage therapy, the first guideline panel recommended they be considered for patients who do not improve with self-care options and prefer not to take pain medications.
About the American Pain Society
Based in Glenview, Ill., the American Pain Society (APS) is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering.
The second part of the APS guideline is based on a multidisciplinary panel’s review and analysis of volumes of evidence related to diagnosis and treatment of low-back pain with a number of interventional procedures and surgeries, according to Roger Chou, MD, director of the American Pain Society’s Clinical Practice Guideline Program and associate professor of internal medicine, Oregon Health & Science University.
Chou noted that in addition to the multidisciplinary panel that formulated the guideline for evaluation and management of low back pain in primary care settings, additional experts with expertise on interventional therapies and surgeries for low back pain were recruited to review the evidence and formulate the expanded recommendations.
"Prior to finalizing the guideline, APS conducts extensive peer review, and has sent the guideline to more than 20 experts in surgery, interventional pain medicine, primary care, and other disciplines for comments and feedback," Chou said.
Low-back pain is the fifth most common reason for doctor’s office visits and one in four adults report having it last a least a day. Annually, low-back pain is estimated to account for more than $26 billion in direct health care costs in the U.S.
“The evidence is much better than even five or 10 years ago and both the primary care and interventional recommendations will help physicians be more confident when evaluating possible therapies for low back pain,” said Chou. “As always, physicians and patients should discuss possible options proven by the evidence and choose the ones that make sense for their situation," he added.
During the symposium, Chou and two panel co-chairs, Richard Rosenquist, MD, assistant professor of anesthesiology, University of Iowa, and John Loeser, MD, professor, Department of Neurological Surgery, University of Washington, reported that for many interventional procedures the evidence from randomized controlled trials is mixed, sparse, not available or showed no benefits. Accordingly, the expanded, evidence-based APS guideline will report:
* Invasive diagnostics, such as provocative discography, facet joint block and sacroliliac joint block tests, have not been proven to be accurate for diagnosing various spinal conditions, and their ability to effectively guide therapeutic choices and improve ultimate patient outcomes is uncertain.
* Epidural stenois injections are an option for short-term pain relief for persistent radiculopathy (radiating low back pain caused by a herniated disc). Other interventional therapies, such as local injections, prolotherapy, botulinum toxin (botox) injection, facet joint injection, sacroliliac joint injection, radiofrequency denervation and intradiscal electrothermal therapy are not supported by convincing, consistent evidence of benefits from randomized trials.
* Surgery to treat radiculopathy and spinal stenosis is effective, though the benefits diminish over time.
* Effectiveness of surgery for non-radicular low back pain is less certain, with some studies showing no benefits compared to intensive interdisciplinary rehabilitation. In addition, a significant proportion of patients experience suboptimal outcomes including persistent pain or functional deficits following surgery.
The expert panel reaffirms its previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. “In general, non-invasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery,” said Chou.
Recommendations from the first APS Clinical Practice Guideline on Low Back Pain were intended for primary care physicians and appeared in the Oct, 2, 2007 issue of the Annals of Internal Medicine. For diagnosis, the first APS low-back pain guideline advises clinicians to minimize routine use of x-rays or other diagnostic tests except for patients known or believed to have underlying neurological or spinal disorders.
In addressing treatment options, it recommended that medications used should be appropriate for the severity of baseline pain and functional impairment, and clinicians should weigh carefully potential benefits and risks of any drug and explain them. Also for various non-pharmacological treatments supported by the evidence, from spinal manipulation to massage therapy, the first guideline panel recommended they be considered for patients who do not improve with self-care options and prefer not to take pain medications.
About the American Pain Society
Based in Glenview, Ill., the American Pain Society (APS) is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering.
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