Physical Therapy vs. Surgery for Spinal Stenosis

By Pat Anson, Editor

Physical therapy works just as well as surgery in relieving pain and other symptoms of lumbar spinal stenosis in older patients, according to researchers at the University of Pittsburgh.

Their two year-year study, published in the Annals of Internal Medicine, is believed to be the first that compares outcomes between surgery and physical therapy (PT) for spinal stenosis, a condition caused by narrowing of the spinal canal that causes pain, numbness and weakness in the lower back.  Decompression surgery to relieve pressure on spinal nerves has become a fast-growing intervention in today's older population.

"Probably the biggest point to put across to physicians, patients and practitioners is: Patients don't exhaust all of their non-surgical options before they consent to surgery. And physical therapy is one of their non-surgical options," said principal investigator Anthony Delitto, PhD, chair of the Department of Physical Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences.

Delitto, a physical therapist, was puzzled why some patients responded well to physical therapy  and others to surgery.

In his study, 169 patients aged 50 and older with spinal stenosis agreed to be randomly assigned to two groups: Those who would have decompression surgery and those who would have two standardized physical therapy sessions each week for six weeks.

In his study, 169 patients aged 50 and older with spinal stenosis agreed to be randomly assigned to two groups: Those who would have decompression surgery and those who would have two standardized physical therapy sessions each week for six weeks.

After both groups were re-examined at intervals of six months, one year and two years, the patient outcomes appeared to be about equal. There were no detectable differences between the groups in how their pain abated and the degree to which function was restored in their backs, buttocks and legs.

"The idea we had was to really test the two approaches head to head," said Delitto. "Both groups improved, and they improved to the same degree. Now, embedded in that, there are patients who did well in surgery, and patients who failed in surgery. There are patients who did well in PT, and there are patients who failed with PT. But when we looked across the board at all of those groups, their success and failure rates were about the same."

The research project also revealed issues surrounding physical therapy and the cost of co-pay – which apparently discourage some patients from continuing their treatment.

"One of the big things that we know held patients back from PT were co-payments," Dr. Delitto added. "Patients were on Medicare, and a lot of them were on fixed incomes. Some of those co-payments had to come out of pocket at $25, $30, $35 per visit. That adds up, and some of the patients just couldn't afford it."

Most patients didn't finish the PT regimen allowed under Medicare and one-third of the patients failed to complete even half of the regimen. About one in six didn't show for a single treatment, though they had agreed to consider physical therapy.

Acetaminophen Ineffective for Back Pain

By Pat Anson, Editor

The world’s most widely used over-the-counter pain reliever is ineffective in treating low back pain and provides little benefit to people with osteoarthritis, according to a new study published in the British Medical Journal.

In a systematic review of a dozen research reports (a study of studies), Australian researchers also questioned many of the conventional treatments for back pain and other musculoskeletal conditions.

Acetaminophen -- also known as paracetamol – is the active ingredient in Tylenol, Excedrin, and hundreds of other pain medications. It is often recommended by doctors worldwide for back pain and osteoarthritis.

"Clinicians should carefully weigh benefits and harms when making treatment decisions. Paracetamol is not efficacious and potentially harmful. In this context we cannot justify its continued use for these prevalent diseases,” said Professor David Hunter of the University of Sydney.

The researchers found “high quality” evidence showing that patients taking acetaminophen are at greater risk of liver toxicity and nearly four times more likely to have abnormal results from liver function tests.

"World-wide, paracetamol is the most widely used over-the counter medicine for musculoskeletal conditions so it is important to reconsider treatment recommendations given this new evidence," said lead author, Gustavo Machado of The George Institute and the University of Sydney.

Low back pain is the leading cause of disability worldwide, and osteoarthritis of the hip or knee is the 11th highest contributor to global disability.

"This latest research, the most comprehensive systematic review of its kind, reaffirms this with an even larger, global patient base, and has for the first time also established that the effects of paracetamol for knee and hip osteoarthritis are too small to be of clinical importance." said senior author Manuela Ferreira of the George Institute for Global Health and the University of Sydney.

"We urgently need to take stock of the evidence for common musculoskeletal conditions, a largely under-recognized health priority, and make sure people are receiving appropriate care."

Treatments known to be effective for low back pain include counseling, physical therapy, exercise and psychological therapies such as cognitive behavioral therapy.

Aerobic exercise, strengthening exercise, weight management and anti-inflammatory medicines have been shown to provide benefit for patients with lower limb osteoarthritis.

A recent study published in The Lancet found that acetaminophen had no effect on pain, disability, function, sleep quality, or quality of life for people with low back pain.

Over 50 million people in the U.S. use acetaminophen each week to treat pain and fever. The pain reliever has long been associated with liver injury and allergic reactions such as skin rash. In the U.S. over 50,000 emergency room visits each year are caused by acetaminophen, including 25,000 hospitalizations and 450 deaths.

Depression and Obesity Raise Risk of Low Back Pain

By Pat Anson, Editor

Depression, obesity, smoking, and alcohol use significantly raise the risk of having low back pain, according to a large new study presented at the annual meeting of the American Academy of Orthopaedic Surgeons.

“The results were pretty surprising to us. We kind of expected to find a significant difference but not to that extent,” said lead study author and orthopedic surgeon Scott Shemory, MD.

Shemory and his colleagues at Summa Health and the Crystal Clinic Orthopedic Center in Akron, Ohio reviewed the health records of over 26 million patients from 13 health care systems in the U.S. Of those 26 million patients, 1.2 million were diagnosed with lower back pain.

Researchers then analyzed the records to see if the patients with low back pain had any of the four modifiable risk factors: obesity, depressive disorders, alcohol and tobacco use.

• 19.3% of low back pain patients were depressed
• 16.75% were obese with a body mass index (BMI) over 30
• 16.53% were nicotine dependent.
• 14.66% abused alcohol

The study did not address the “chicken and egg question” of which came first. Do depression and obesity cause low back pain, or does low back pain lead to depression, obesity and other risk factors?

“With our study there was no way to determine the cause and the effect or which came first because there was so much overlap,” Shemory told Pain News Network.

“Especially with alcohol abuse and depressive disorders. Anybody who’s got low back pain for years and years, I don’t think it would be surprising that they would have a higher chance of depression or alcohol abuse.”

Regardless of which came first, Shemory says patients should take steps to improve their health by eliminating risk factors that they can control.

“If a patient has any of these risk factors and has low back pain that doesn’t have a neurogenic cause, like a pinched nerve or something like that, I would be counseling them on trying to control these risk factors, not just for their general health but their back pain and livelihood as well,” he said.

According to the National Instituteof Neurological Disorders and Stroke, about 80 percent of adults experience low back pain at some point in their lives. It is the most common cause of job-related disability and a leading contributor to missed work days. One large survey found that over a quarter of adults reported having low back pain during the past 3 months.

Imaging for Back Pain Often Doesn't Help Older Adults

By Pat Anson, Editor

Spending thousands of dollars on CT scans or MRI’s is often a waste of time and money for older adults with low back pain, according to a large new study published in JAMA.

Researchers at the University of Washington in Seattle say older adults with lower back pain who had spine imaging within six weeks of visiting a primary care doctor had pain and disability over the following year that was no different than other patients who did not have advanced imaging.

“Among older adults with a new primary care visit for back pain, early imaging was not associated with better one-year outcomes. The value of early diagnostic imaging in older adults for back pain without radiculopathy is uncertain,” said Jeffrey G. Jarvik, MD, a professor of radiology in the UW School of Public Health, who studies the cost effectiveness of treatments for patients with low back pain.

Jarvik and his colleagues studied over 5,200 adults aged 65 or older who had a new primary care visit for back pain at three U.S. health care systems. They followed up with the patients 12 months later, comparing pain and disability for those who received early imaging with those who did not. The imaging included radiographs (X-rays), computed tomography (CT scans) and magnetic resonance imaging (MRI) of the lumbar or thoracic spine.

Among the patients studied, 1,174 had early radiographs and 349 had early MRI/CT. At 12 months, neither the early radiograph group nor the early MRI/CT group differed significantly from controls on measures of back or leg pain-related disability.

When to image older adults with back pain remains controversial. Some guidelines recommend that older adults undergo early imaging because they are more likely to have serious underlying medical conditions, such as cancer or infections.

The American College of Radiology recommends early imaging with MRI for patients older than 70 with back pain, as well as patients older than 50 with osteoporosis. European guidelines say patients older than 55 with back pain should have imaging.

However, Jarvik says there is no strong evidence to support those guidelines.

“Despite the lack of evidence supporting routine imaging for older adults with back pain, guidelines commonly recommend that older patients with back pain undergo imaging,” he wrote. "Our study results support an alternative position that regardless of age, early imaging should not be performed routinely.”

Jarvik says adverse consequences from early imaging are more likely in older adults because they can lead to unnecessary treatments, including steroids injections and surgery.

Early imaging for lower back pain is not recommended for people at any age, according to the Choosing Wisely campaign, an initiative of the ABIM Foundation to encourage physicians and patients to make better choices about their healthcare treatment.

“Most people with lower-back pain feel better in about a month whether they get an imaging test or not. In fact, those tests can lead to additional procedures that complicate recovery,” Choosing Wisely states on its website.

“A study that looked at 1,800 people with back pain found that those who had imaging tests soon after reporting the problem fared no better and sometimes did worse than people who took simple steps like applying heat, staying active, and taking an OTC pain reliever. Another study found that back-pain sufferers who had an MRI in the first month were eight times more likely to have surgery, and had a five-fold increase in medical expenses.”

According to HealthCareBlueBook.com, an MRI of the lower back can range from $880 to $1,230, and a CT scan from $1,080 to $1,520.

Mornings Worst for Lower Back Pain

By Pat Anson, Editor

People who suffer from lower back pain are significantly more likely to feel their first aches and pains after waking up in the morning, according to researchers in Australia.

Their study, which was published in the journal Arthritis Care & Research, found a variety of physical and psychosocial triggers that increase the risk of low back pain. People engaged in manual tasks involving awkward positions are eight times more likely to suffer from back pain, while people who are distracted or fatigued during activities were about four times more likely.

"Understanding which risk factors contribute to back pain and controlling exposure to these risks is an important first step in prevention," explains Manuela Ferreira, PhD, an associate professor at Sydney Medical School at The University of Sydney in New South Wales, Australia. "Our study is the first to examine brief exposure to a range of modifiable triggers for an acute episode of low back pain."

Researchers recruited nearly 1,000 participants from 300 primary care clinics in Sydney, Australia, who had acute low back pain. They were asked to self-report on a dozen physical or psychosocial factors in the 96 hours prior to the onset of their back pain.

The risk of a new episode of low back pain varied significantly depending on a range of triggers. Moderate to vigorous physical activity nearly tripled the risk of low back pain, while being distracted during an activity made participants 25 times more likely to have back pain.

Researchers recruited nearly 1,000 participants from 300 primary care clinics in Sydney, Australia, who had acute low back pain. They were asked to self-report on a dozen physical or psychosocial factors in the 96 hours prior to the onset of their back pain.

The risk of a new episode of low back pain varied significantly depending on a range of triggers. Moderate to vigorous physical activity nearly tripled the risk of low back pain, while being distracted during an activity made participants 25 times more likely to have back pain.

One finding not reported previously was that back pain risk was highest between 7:00 a.m. and noon. Ferreira believes that may be because people are not fully alert and discs in the spine may be more susceptible to damage in the morning.

One surprise finding is that growing older appears to moderate the risk of back pain caused by lifting heavy loads. The risk was 13.6 times higher for people at age 20. At age 40 it was 6.0 and at 60 years of age the risk was only 2.7 times higher.

Alcohol and sex appeared to have no association lower back pain.

"Understanding which modifiable risk factors lead to low back pain is an important step toward controlling a condition that affects so many worldwide," said Ferreira. "Our findings enhance knowledge of low back pain triggers and will assist the development of new prevention programs that can reduce suffering from this potentially disabling condition."

Lower back pain is the leading cause of disability worldwide, with nearly 10% of the world's population experiencing back pain at some point in their lives. Low back pain has a greater impact on global health than malaria, diabetes, or lung cancer; yet little progress has been made to identify effective prevention strategies.

Lower back pain is not usually linked to a serious disease. It can be triggered by everyday activities, including bad posture, bending awkwardly, lifting incorrectly or standing for long periods of time.