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.”
Tuesday, February 9, 2010
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.
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