Tuesday, 26 November 2013

Chronic Low back pain – Treatment In conventional medicine perspective

Low back pain is a Musculoskeletal disorders (MSDs, affecting over 80% of the population in US alone some points in their life. Chronic LBP (pain has persisted for longer than 3 months(1) prevalence in older adults was significantly higher than the 21-to-44-year age group (12.3% vs. 6.5%, p < .001). Older adults were more disabled, had longer symptom duration, and were less depressed(2)..Many older adults remain quite functional despite CLBP, and because age-related comorbidities often exist independently of pain (e.g., medical illnesses, sleep disturbance, mobility difficulty), the unique impact of CLBP is unknown. We conducted this research to identify the multidimensional factors that distinguish independent community dwelling older adults with CLBP from those that are pain-free(3).
VI. Treatments
A. In conventional medicine perspective
A.1. Non surgical treatment
1. Exercise therapy
Exercise therapy is the most widely used type of conservative treatment for low back pain. Systematic reviews have shown that exercise therapy is effective for chronic but not for acute low back pain. In a study of Exercise therapy for chronic nonspecific low-back pain, suggested that compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. It is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment(37).
Other showed that Exercise therapy that consists of individually designed programs, including stretching or strengthening, and is delivered with supervision may improve pain and function in chronic nonspecific low back pain(38).
1.1. Hip mobilizations and exercise
In the study to to investigate the short-term outcomes in patients with CLBP managed with impairment-based manual therapy and exercise directed at the hip joints, found that  an impairment-based approach directed at the hip joints may lead to improvements in pain, function, and disability in patients with CLBP(39).
2. Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is a beneficial treatment for chronic nonspecific back pain, leading to improvements in a wide range of relevant cognitive, behavioral and physical variables. This is especially evident when CBT is compared to treatment as usual or wait-list controls, but mixed and inconclusive when compared with various other treatments, according to the study by Uni Health, Uni Research, Bergen, Norway(40).
Other researchers suggested that the self-rated treatment effectiveness and satisfaction appeared to be higher in the three active treatments. Several physical performance tasks improved in Active Physical Treatment (APT) and Combined Treatment of APT and CBT (CT) but not in Cognitive-Behavioral Treatment (CBT). No clinically relevant differences were found between the CT and APT, or between CT and CBT(41).
3.   Medication
The range of regularly prescribed pharmacological agents to treat Chronic Low back pain extends from nonopioids (paracetamol, NSAIDs, and COX-2 inhibitors) to opioids, antidepressants and anticonvulsants(42).

3.1. Non-steroidal anti-inflammatory drugs (NSAIDs)
Transdermal fentanyl significantly improved visual analog scale scores and Oswestry Disability Index scores in 73% of patients, especially those with specific low back pain awaiting surgery; however, it did not decrease pain in 27% of patients, including patients with non-specific low back pain or multiple back operations(43).
Side effects include  nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, drowsiness, etc.
3.2. Opioids 
tapentadol’s μ-opioid agonism makes a greater contribution to analgesia in acute pain, while noradrenaline reuptake inhibition makes a greater contribution in chronic neuropathic pain models. Tapentadol also produces fewer adverse events than oxycodone at equianalgesic doses, and thus may have a ‘μ-sparing effect’, according to the study by Johns Hopkins University School of Medicine(44)
Side effects include Nausea, dizziness, constipation, CNS sedation, etc.
3.3. Antidepressants
Selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) are a class of medication used as antidepressants in the treatment of depression, anxiety disorders, and some other disorders. In a study of a total of 575 patients enrolled, 45 of 89 (50.6%) taking SSRIs/SNRIs and 303 of 486 (62.3%) not taking SSRIs/SNRIs successfully titrated to oxymorphone ER, showed that during the double-blind treatment phase, there was no significant difference in the frequency of serious AEs in patients treated with oxymorphone ER taking (1/29; 3.4%) versus those not taking (3/146; 2.0%) SSRIs/SNRIs. Visual analog scale scores were similar in patients taking versus those not taking SSRIs/SNRIs throughout the study(45).
Side effects include  nausea/vomiting, drowsiness, headache, bruxism, tinnitus, extremely vivid or strange dreams, dizziness, fatigue, etc.
3.4. Anticonvulsants 
Anticonvulsants benzodiazepines, the medication used in the treatment of epileptic seizures and has been used as adjunctive medications for acute low back pain, but have a high incidence of sedation(46).
Side effects are not limited to dependency, rebound anxiety, memory impairment, discontinuation syndrome, muscle weakness, dizziness, mental confusion, depression, etc.
3.5. Antispasmodic drug
Eperisone had an analgesic and muscle relaxant effect in patients with LBP. It should be noted that while it is common practice in rheumatology to combine a pain killer with a muscle relaxant in order to achieve a satisfactory result on both symptoms, the present results with eperisone were achieved with a single drug. With an improved tolerability profile compared with nonsteroidal anti-inflammatory drugs, and a lack of significant adverse effects on the CNS, eperisone hydrochloride represents a valuable alternative to traditional analgesics and muscle relaxants for the treatment of LBP, according to the study by Service of Rehabilitation and Functional Reeducation, S. Orsola-Malpighi Hospital, Bologna(47).
Side effects are not limited to redness, itching, urticaria, edema, rash, pruritus, sleepiness, insomnia, headache, nausea and vomiting, anorexia, abdominal pain, etc.
4. Injection
In the comparison of the clinical effectiveness of FJ injections (FJI) and FJ radiofrequency (FJRF) denervation in patients with chronic low back pain, found that the first choice should be the FJI and if pain reoccurs after a period of time or injection is not effective, RF procedure should be used for the treatment of chronic lumbar pain(47a).
5. Others
In the study to evaluate the use and direct medical costs of pharmacologic and alternative treatments for patients with osteoarthritis (OA) and chronic low back pain (CLBP), researchers at the Avalon Health Solutions, Inc., Philadelphia, Pennsylvania, indicated that Opioids were the most frequently prescribed medication (>70%) in both groups, followed by nonselective nonsteroidal anti-inflammatory drugs (>50%). Over 30% received antidepressants, >20% received benzodiazepines, and 15% in each group received sedative hypnotics. Use of alternative treatments was as follows: chiropractor, OA 11%, CLBP 34%; physical therapy, 20% in both groups; transcutaneous electrical nerve stimulations (TENS), OA 14%, CLBP 22%; acupuncture, hydrotherapy, massage therapy, and biofeedback, <3% in both groups. Mean (SD) total healthcare costs among these patients were, OA: $15,638 ($22,595); CLBP: $11,829 ($20,035). Pharmacologic therapies accounted for approximately 20% of these costs, whereas alternative treatments accounted for only 3% to 4% of the total costs(48).
According to the study of group-based multidisciplinary rehabilitation program and oral drug treatment versus oral drug treatment alone, the group-based multidisciplinary program could improve most domains of quality of life in chronic low back pain patients in the 6-month period. However, there were no significant differences between two groups in sub scales such as general health, social function and role emotional(49).
Also in  a clinical trial comparing group-based multidisciplinary biopsychosocial rehabilitation and intensive individual therapist-assisted back muscle strengthening exercises, showed that both groups showed long-term improvements in pain and disability scores, with only minor statistically significant differences between the 2 groups. The minor outcome difference in favor of the group-based multidisciplinary rehabilitation program is hardly of clinical interest for individual patients(50).
A.2.  Surgical treatments
Most patients with back pain will not benefit from surgery and is performed when conservative treatment is not effective in reducing pain or  if anatomic abnormalities consistent with the distribution of pain are identified. The most common types of low back surgery include
1. Microdiscectomy
In retrospective cohort study of patients who underwent LMD in 2004-2005 were invited to participate and were re-evaluated clinically and radiologically after a three to five year follow-up, found that although many patients may be symptomatic following LMD, significant disability and dissatisfaction are uncommon. Female sex, young age, lack of exercise, and chronic preoperative LBP may predict a worse outcome. Disc collapse is a universal finding, particularly at L4-L5. Neither DSC nor Modic changes seem to affect patient outcome(51).
2. Discectomy(SD)
Recurrent or persistent low back pain (LBP) after surgical discectomy (SD) for intervertebral disc herniation has been well documented(52)
3. Laminectomy
In the study of Twenty age-matched Sprague-Dawley male rats divided into operative and non-operative (control) groups, operative animals underwent a bilateral L5-L6 laminectomy with right-side L5-6 disc injury, a post-laminectomy pain model previously published by this lab, showed that  the post-laminectomy condition creates quantifiable fibrosis of the spinal nerve to surrounding structures and supports the conclusion that this fibrosis may play a role in the post-laminectomy pain syndrome(53).
4. Spinal fusion
In the study to determine the prognostic accuracy of tests for patient selection that are currently used in clinical practice to identify those patients with chronic LBP who will benefit from spinal fusion, showed that no subset of patients with chronic LBP could be identified for whom spinal fusion is a predictable and effective treatment. Best evidence does not support the use of current tests for patient selection in clinical practice(54).
5. Etc.
In a meta-analysis of randomised controlled trials to investigate the effectiveness of surgical fusion for the treatment of chronic low back pain compared to non-surgical intervention, by searching the Several electronic databases (MEDLINE, EMBASE, CINAHL and Science Citation Index) from 1966 to 2005, found that the pooled mean difference in ODI between the surgical and non-surgical groups was in favour of surgery (mean difference of ODI: 4.13, 95%CI: −0.82 to 9.08, p = 0.10, I2 = 44.4%). Surgical treatment was associated with a 16% pooled rate of early complication (95%CI: 12–20, I2 = 0%). Surgical fusion for chronic low back pain favoured a marginal improvement in the ODI compared to non-surgical intervention. This difference in ODI was not statistically significant and is of minimal clinical importance. Surgery was found to be associated with a significant risk of complications. Therefore, the cumulative evidence at the present time does not support routine surgical fusion for the treatment of chronic low back pain(55). Others suggested that Fusion surgery is more effective than standard rehabilitation for improving pain in people with chronic non-radicular low back pain, but it is no better than intensive rehabilitation with a cognitive behavioural component(56).
Surgery can be considered in persons who have experienced significant functional disabilities and in those with unremitting pain, especially pain lasting longer than 12 months despite multiple nonsurgical treatments. Good evidence supports the use of spinal fusion for treating back pain caused by fractures, infections, progressive deformity, or instability with spondylolisthesis(57).
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Red flags*
Recent significant trauma, Milder trauma if age is greater than 50 years, Unexplained weight loss, Unexplained fever, Immunosuppression, Previous or current cancer, Intravenous drug use, Osteoporosis, Chronic corticosteroid use, Age greater than 70 years, Focal neurological deficit, Duration greater than 6 week(a)
(a) http://en.wikipedia.org/wiki/Low_back_pain 
(1) https://www.mja.com.au/journal/2004/180/2/management-chronic-low-back-pain
(2) http://jah.sagepub.com/content/22/8/1213.refs
(3) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2065872/
(37) http://www.ncbi.nlm.nih.gov/pubmed/20227641
(38) http://www.ncbi.nlm.nih.gov/pubmed/15867410
(39) http://www.ncbi.nlm.nih.gov/pubmed/22547920 
(40) http://www.ncbi.nlm.nih.gov/pubmed/23091394
(41) http://www.ncbi.nlm.nih.gov/pubmed/16426449
(42) http://www.ncbi.nlm.nih.gov/pubmed/21887117
(43) http://www.ncbi.nlm.nih.gov/pubmed/22665347
(44) http://www.ncbi.nlm.nih.gov/pubmed/21887117
(45) http://www.ncbi.nlm.nih.gov/pubmed/22437221
(46) http://www.ncbi.nlm.nih.gov/pubmed/20205483
(47) http://www.ncbi.nlm.nih.gov/pubmed/18836866
(47a) http://www.ncbi.nlm.nih.gov/pubmed/22437295
(48) http://www.ncbi.nlm.nih.gov/pubmed/22304678
(49) http://www.ncbi.nlm.nih.gov/pubmed/21642845 
(50) http://www.ncbi.nlm.nih.gov/pubmed/20147878
(51) http://www.ncbi.nlm.nih.gov/pubmed/21515503
(52) http://www.ncbi.nlm.nih.gov/pubmed/18164474

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