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clinical practice guideline for non-specific low back pain: A review. Physiother Can
2011;63(3):278-286.
After discovering knowledge gaps in the primary care of patients with LBP, the authors
reviewed published clinical care guidelines to construct a point-of-care algorithm that is
intended to be “clinician friendly.”
pain: A double-blind, randomised controlled trial. Lancet 2014;384(9954):1586-1596.
This important and well-executed study showed that acetaminophen was no more
effective than placebo for acute LBP. The incorporation of the results of this study
changed some guideline recommendations.
back pain. J Pain Res 2012;5:579-590.
The authors offer a narrative review based on multiple systematic reviews on NSAIDs.
They conclude that NSAIDs have a role in acute LBP management but response is not
predictable. There are many potential adverse events associated with long-term use.
for the management of neck pain and associated disorders, whiplash-associated
disorders, or non-specific low back pain? A systematic review of systematic reviews by
the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur
Spine J 2016;25(1):34-61.
This review was commissioned by the Province of Ontario to examine the evidence for
neck and LBP treatment after motor vehicle collisions. Some of the conclusions
regarding the use of medications differ some from other guidelines as they suggest
skeletal muscle relaxants as possible first-line treatment rather than secondary
treatment. The study did not find good evidence for the use of NSAIDs for acute spine
pain.
oxycodone/acetaminophen, or placebo for treating acute low back pain: A randomized
clinical trial. JAMA 2015;314(15):1572-1580.
This prospective study has garnered a good deal of editorial responses that have
emphasized the fact that the addition of skeletal muscle relaxants, low-dose opioid
(oxycodone 5 or 10 mg every 8 hours), or placebo did not improve pain control
compared with placebo at 1 week or 3 months after the onset of acute LBP.
Unfortunately, there was no true placebo group and the dose of oxycodone was low and
too infrequent. At 3 months, 25% of all groups still reported moderate to severe LBP.
for sciatica. Cochrane Database Syst Rev 2016;10:CD012382.
The authors present a systematic review to determine efficacy of NSAIDs in patients
with sciatica. Pain reduction was approximately equal in those receiving treatment or
placebo. An increased risk for side effects was reported, even with short-term use.
skeletal muscle relaxants for the management of acute low back pain. P T
2014;39(6):427-435.
The authors present a detailed review of skeletal muscle relaxants, including evidence
for their use, class overuse, and a detailed discussion of the individual drugs.
muscle relaxants for low back pain: Systematic review and meta-analysis. Eur J Pain
2017;21(2):228-237.
This review evaluated skeletal muscle relaxants in patients with LBP. There was highquality evidence that muscle relaxants provide clinically significant pain relief in the
short term for acute LBP. There was no information on long-term outcomes. For
chronic LBP, the effects of skeletal muscle relaxants are not known. There was no
evidence to support the efficacy of benzodiazepines in LBP.
of intravenous dexamethasone reduce symptoms in emergency department patients with
low back pain and radiculopathy (SEBRA)? A double-blind randomised controlled trial.
Emerg Med J 2015;32(7):525-530.
Intravenous dexamethasone (8 mg) was compared with placebo in patients with LBP
and radicular symptoms in the emergency department. A significant reduction in pain
and emergency department length of stay was found. Although the effect on pain was
statistically significant, the improvement did not appear clinically meaningful. Any
benefit was gone at the 6-week follow-up. Dexamethasone may reduce the length of
stay in the emergency department and pain somewhat, but results appear short-lived.
pain: A randomized controlled trial. J Emerg Med 2014;47(1):65-70.
The authors report on 67 patients available for follow-up after having been seen in a
single emergency department for acute LBP. The patients were randomized to receive
prednisone 50 mg daily versus placebo. There were no significant differences between
groups in level of pain, time to return to normal activity, or return to work.
2015;350:g6380.
The authors review the use of opioids for acute and chronic LBP. There are no adequate
studies for opioid use in acute LBP and benefits are inferred from their value in other
acute painful musculoskeletal conditions. Because there are no controlled long-term
studies, neither the effectiveness nor safety of long-term opioid analgesic therapy is
known. The authors review some strategies for reducing risks to patients and the public
health.
tolerability, and dose-dependent effects of opioid analgesics for low back pain: A
systematic review and meta-analysis. JAMA Intern Med 2016;176(7):958-968.
In this systematic review of only randomized controlled trials, the authors found
moderate-quality evidence that opioid analgesics reduce pain in the short term, but the
effect was only modest for doses recommended by guidelines. Approximately 50% of
patients withdrew because of adverse side effects. Evidence on long-term efficacy is
lacking.
patterns and subsequent long-term use among opioid-naïve patients: A statewide
retrospective cohort study. J Gen Intern Med 2017;32(1):21-27.
The authors examined death certificates of Oregon residents who filled opioid
prescriptions and later died and hospital discharge records of those who filled opioid
prescriptions and did not die. The correlation, if any, between early prescription use of
opioids and long-term use also was examined. Of the 536,767 patients who filled an
opioid prescription, 5% became long-term users. Those with the highest number of
refills and those given higher doses or long-acting opioids were more likely to become
chronic opioid users.
classification of predominant neuropathic, nociceptive, or central sensitization pain.
Pain Physician 2015;18(3):E333-E346.
The authors believe there is sufficient evidence to accept the concept of neuropathic
axial LBP. In this study, a method is tested that allows clinicians to differentiate
nociceptive, neuropathic, and central sensitization forms of chronic LBP. Such
knowledge might prove useful to clinicians.
perceptions and mechanisms. PLoS One 2013;8(7):e68273.
In a cohort of 1,083 patients, neuropathic components were detected in 12% of the
patients. The authors thought the patient’s description of pain and its severity were
useful in discriminating between the two types of pain mechanisms.
inflammatory drugs for chronic low back pain. Cochrane Database Syst Rev
2016;2:CD012087.
This Cochrane review looked at randomized controlled trials that investigated NSAID
use for chronic LBP. Fifty percent of the studies showed NSAIDs to be more effective
than placebo, but the effect size was quite small and the level of evidence was low. No
difference was found for any specific NSAID. Sufficient evidence was not available to
judge whether NSAIDs are safe for long-term use.
chronic low back pain: A 12-week, fixed-dose, randomized, double-blind trial. J Pain
2010;11(12):1282-1290.
This randomized, double-blind, placebo-controlled study assessed efficacy and safety of
duloxetine 60 mg once daily in 401 patients with nonneuropathic chronic LBP.
Duloxetine-treated patients reported a significantly greater reduction in pain and had
improved Roland Morris Disability Questionnaire reports. Fifteen percent of the
duloxetine-treated patients discontinued use versus 7% in the placebo-treated patients.
Some of the study authors were employed by the manufacturer of duloxetine drugs.
present in chronic low back pain and soft tissue syndromes? An evidence-based
structured review. Pain Med 2014;15(1):4-15.
This review examined the evidence to determine whether neuropathic pain is present in
patients with chronic LBP. In their review, neuropathic LBP was present in every study
that looked for it, regardless of the method used for diagnosis. The aggregate presence
was 36%. The authors emphasize that this is an important finding because it can
influence and guide treatment.
to lumbar spinal stenosis: A preliminary prospective study. Pain Res Manag
2016;2016:5079675.
The effects of pregabalin in patients with neuropathic leg pain and intermittent
claudication were evaluated using well-established outcome instruments. Pregabalin
significantly improved pain, sleep, gait, and psychological dysfunction and showed a
trend in improving distance before claudication.
sciatica. N Engl J Med 2017;376(12):1111-1120.
This randomized, prospective, blinded study examined the use of pregabalin for patients
with sciatica. No differences were seen between the group treated with pregabalin and
the placebo group. Level of evidence: I.
chronic low back pain: A randomized, double-blind, placebo-controlled study. Clin J
Pain 2006;22(6):526-531.
nonmalignant origin. J Pain Symptom Manage 1993;8(5):279-288.
In a longitudinal clinical study, 33 patients underwent a trial of long-acting or sustained
release opioid medications. Five patients discontinued use because of side effects.
Twenty-eight patients completed the trial, and significant improvement occurred in 21
patients. These patients were treated and followed for a mean of 32 months. Beneficial
effects continued. No drug diversion, addictive behavior, or organ toxicity were noted.
Dosing remained stable.
release oral morphine in strong-opioid naïve patients with chronic low back pain. Spine
(Phila Pa 1976) 2005;30(22):2484-2490.
compared to placebo or other treatments for chronic low-back pain. Cochrane Database
Syst Rev 2013;8:CD004959.
The authors performed a systematic review and meta-analysis to assess efficacy of
opioids in chronic LBP. They concluded there is evidence of short-term efficacy
(moderate for pain and small for function). The effectiveness and safety of long-term
opioid therapy for treatment of chronic LBP remains unproved because of the lack of
long-term studies, rather than because efficacy has been disproved.
opioid epidemic and chronic pain. PM R 2014;6(1):78-84.
This brief overview discusses some of the criteria that should be considered before
undertaking long-term opioid analgesic therapy. In all medical decisions, clinicians
must rely on the best available published evidence, which is not necessarily a very high
level of evidence. Each patient must be considered individually.
Sciences, 2012.
This short but extremely useful text reviews the value of opioid analgesics for some
patients. It also reviews some of the ways to identify higher risk patients and the
preferred way to follow patients on long-term opioid analgesic therapy.
University Press, 2008.
Chapter 11
Therapeutic Exercise
Annie O’Connor MSPT, OCS, Cert. MDT Thomas J. Lotus, DC, FACO,
Cert. MDT
Abstract
Spine-related impairment is the primary cause of disability worldwide and
has a negative effect on global wellness, productivity, and economics. It is
important for care providers to ascertain the effects of spine pain on the
patient’s life and ability to function. Pathoanatomic diagnosis and imaging
findings are not consistently relevant to the dominant pain mechanism and
source of symptoms, and the degree of injury is not always equal to the
intensity of pain. Healthcare providers should be fluent in the use of
classification systems that are valid and reliable for subgrouping patients
with spine pain based on their clinical presentation and provoking and
relieving activities and motions. A better defined common language among
spine care providers will advance the field and allow precise diagnoses and
specific individualized treatments.
Keywords: conservative spine care; low back pain subgroups;
pain mechanism classification system; patient education;
therapeutic exercise
Neither of the following authors nor any immediate family member has received
anything of value from or has stock or stock options held in a commercial company
or institution related directly or indirectly to the subject of this chapter: Ms.
O’Connor and Dr. Lotus.
Introduction
Disability caused by spine-related pain is currently a major health problem,
with approximately $600 billion spent annually in the United States for spine
care.1 A growing body of scientific literature has concluded that
pathoanatomic diagnosis and MRI findings are not consistently relevant to
the dominant pain mechanism and source of symptoms,
2,3
and the degree of
injury may not equal the intensity of pain.4 The literature also supports the
concept of using alternative classification systems
5,6
rather than relying
solely on the pathoanatomic diagnosis. The use of classification systems to
assist in making a diagnosis in patients with low back pain (LBP) is
associated with better outcomes.7 Treatment interventions performed without
reference to a patient’s specific presentation and without an attempt at
classification into a subgroup can lead to suboptimal care, poorer outcomes,
and decreased patient satisfaction.8 A prolonged cycle of nonspecific
treatment undertaken with the hope that one therapy will be effective can lead
to frustration for both the patient and the healthcare provider.
8
The choice of the specific classification or diagnostic system used should
be made carefully by weighing the evidence and pros and cons regarding the
clinician’s practice and broader healthcare implications. An additional tool or
system should be used to assess the psychosocial components of a patient’s
spine pain and potential barriers to recovery. The reliability of two systems,
the classification of mechanical nociceptive spinal pain mechanisms using the
McKenzie Method of Mechanical Diagnosis and Therapy (MDT; McKenzie
Institute International)9 and a treatment-based classification system (TBC),
are supported by evidence in the literature.
10,11
The Pain Mechanism
Classification System (PMCS) was developed in the late 1990s to address
both nociceptive movement-dominated pain mechanisms and centrally
mediated pain mechanisms related to the emotional, social, and sensorimotor
dimensions of pain. More recently, the PMCS has been found to be a reliable
classification system with good interrater and intrarater reliability and high
specificity.
7,12-14
The PMCS also has a high likelihood ratio for identifying the
dominant pain mechanism, with 95% of clinical characteristics covered and
applicability across many pain locations, patient ages, and levels of
neurologic and musculoskeletal disability.
7,15
Classification systems are
important for directing specific interventions. The PMCS has been shown to
effectively and efficiently guide and direct patient education and active care,
especially on the patient’s first clinical visit.
7,13,15
Regardless of whether spine
pain is acute or chronic, the PMCS, MDT, and TBC promote independence in
self-care without the need for passive treatments performed in a rehabilitation
setting.
Foundation Principles of Spine Classification Systems
Not all nociceptive spine-related symptoms are caused by structural,
pathologic, mechanical, or chemical mechanisms. In 35% of patients with
chronic pain, there is an underlying central nervous system (CNS)–mediated
mechanism.7 The PMCS, MDT, and TBC systems for spine-related
conditions direct specific therapeutic exercise for LBP dominated by
nociceptive pain mechanisms. The PMCS is unique in that it takes into
account mechanical nociceptive and centrally mediated sources of pain that
represent the cognitive, emotional, social, psychological, and sensorimotor
dimensions of a patient’s pain experience.
7,16
These three classification
systems have evidence to support their effects on positive outcomes,
decreased cost to the healthcare system, and help in selecting active
therapeutic exercises.
Therapeutic exercise is a conservative intervention offered by many
providers with various training backgrounds. Therapeutic exercise should
include a strong patient education component for self-management of spinerelated problems. Conservative care is an overarching term that includes the
concepts of active treatment directed for immediate cure of a disease or
management of an injury, causal treatment to prevent a disease, nonsurgical
care to avoid radical medical therapeutic measures or surgical procedures,
and empiric treatment that has proved to be beneficial.
17
When a surgeon refers a patient to a provider of conservative care, the
surgeon should ensure that the provider prioritizes patient education and
active care before ordering procedures such as passive electrical modalities,
tests, manual medicine interventions, and injections. Patient education and
active exercise should be directed toward reducing or eliminating the
mechanism of spine-related pain preventing the recurrence of pain. The care
provider should use both patient- and clinician-rated validated outcome
measures. The surgeon should assess the effects of conservative care
interventions by reviewing results of the outcome measures and take
responsibility for ensuring that all aspects of evidence-based medicine have
been performed relative to the selected education and exercise intervention.
This approach also provides the surgeon with an understanding of the
services offered by therapeutic exercise providers and their contribution to
disease management.
Patient Education
Appropriate Language
Education is an important aspect of patient recovery and self-maintenance.
The healthcare provider must be cautious in the selection of words or
statements used to educate a patient because some types of communication
can be hurtful or harmful. In contrast, other words and statements can be
helpful and may provide a patient with hope and a change in mind-set about a
condition, diagnosis, or symptom.
Examples of words and statements that can be misleading or may conflict
with appropriate conservative care include instructing a patient with pain to
stop moving because it may be harmful, listing activities that the patient
should never do, and indicating that the care provider is unsure of the best
treatment and the patient must get accustomed to his or her pain. In contrast,
other words and statements will promote a patient’s engagement in his or her
care. For example, a patient should be reassured that the pain is real, but that
not all pain is bad. Understanding the behavior of pain during movements
will determine the safety of the pain. A patient can be informed about the
mechanism causing the pain (eg, a tight, trapped, or sensitive nerve) and the
potential for recovery with the appropriate exercise therapy.
14,16
Reassurance
that the patient is “not crazy” and referral to a medical professional who can
help the patient cope with life stressors also is an example of positive
communication.
Methods and Outcomes
Studies have shown the benefits of providing education to patients with
LBP.
18-21
Advice to patients with LBP to exercise when back pain is at its
worst has resulted in increased satisfaction and improved functional
outcomes.18 For example, patients can be given booklets with detailed
exercise instructions after a medical consultation. Cognitive changes have
been documented in patients who are given reassurance that exercise is not
Figure 1
harmful.19 Words can heal and have an immediate effect by physically
altering the patient’s perception of the meaning of pain; this may decrease the
need for further interventions.22 Activity guidelines have shown that the
concept of movement-safe pain is critical to a successful outcome. Patients
who read an educational book on self-treatment of back pain demonstrated
long-term improvements and had fewer recurring pain episodes than those
who did not read the book.20 A reduction in fear-avoidance behaviors was
found in patients with chronic back pain who were provided with information
about the neurophysiology of pain mechanisms. This strategy decreased pain
and improved outcomes.
21
Illustration depicting the referencing of spine pain on a
continuum, which involves the nervous system and certain
pain mechanisms that can be mechanically or neurologically
influenced. (Reproduced with permission from O’Connor A, Kolski MC:
Psychology in pain management, in O’Connor A, Kolski MC: A World
of Hurt: A Guide to Classifying Pain. St. Louis, MO, Thomas Land,
2015, pp 194-195.)
Advice given to a patient may translate into behavioral changes.23 The
clinician should be careful to use terms and phrases familiar to the patient and
should remember that patient-friendly language is important.
24,25
Using a
classification system such as the PMCS can efficiently and effectively guide
patient education and provide activity guidelines and exercise prescriptions.
The PMCS provides a common language and image that the patient and
provider can use to enhance communication regarding the dominating pain
mechanism.16 Also, group education can be as effective as individual patient
education. Consideration should be given to the development of short (<8
weeks) group interventions.
26
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