The 25th anniversary meeting of the American Back Society (ABS) took place in Las Vegas, June 18-21, 2008. The ABS has a long history of striving to remain contemporary, abreast of cutting edge developments in spine medicine. At the same time, it always fosters a "back to basics" approach to spine care, emphasizing traditional principles of careful patient evaluation, treatment and case management. As usual, chiropractors were well-represented among the attendees and the presenters.
Donelson on Rapidly Reversible Back Pain
Ronald Donelson's Rapidly Reversible Low Back Pain examines the McKenzie approach to assessing and treating back pain. His frequent ABS presentations have been featured many times in these Dynamic Chiropractic reviews of the conferences. To be perfectly frank, this year's presentation was not about a study in progress or recently published, but more an overview of the McKenzie approach that must have seemed very familiar to many of the listeners, as well as readers who have seen my previous columns reviewing Donelson's presentations.
It might be said the theme of this year's presentation was that it's really not fair to see the McKenzie method as a narrowly defined treatment method, defined by the (mostly) extension exercises the patient usually is prescribed. Although the McKenzie intervention component has been featured in several guidelines for low back pain care, the patient-assessment component has been overlooked. It has been stated, "The McKenzie method is first and most importantly a system of assessment and classification from which patient-specific treatments emerge."
The Quebec Task Force concluded, "The inability to find diagnostic subgroups is the fundamental source of error in LBP management," and the Cochrane Back Pain Review Group published that identifying subgroups likely to respond to particular treatments is "the holy grail" in treating low back pain. Continuing to perform RCTs on patients classified as having "nonspecific back pain of mechanical origin" will continue to confound the literature. In addition to the pioneering efforts of the McKenzie people at subtyping back pain, other groups of investigators also are looking into the same problem, including the Palmer Center for Chiropractic Research (Choate et al. "Predicting Patients Response to Spinal Manipulation," as described at ClinicalTrials.gov).
Evidence Informed Management of Low Back Pain, Usually Without Surgery (Haldeman, Dagenais and Mayer)
In a Wednesday special event, Dr. Haldeman et al. conducted a session on a variety of interventions for chronic low back pain including exercise, physical therapy, manual and manipulative therapy, and some surgical and injection procedures. The presenters were instrumental in producing the January/February 2008 issue of The Spine Journal. The entire contents are divided up into some two dozen articles on various approaches to chronic low back pain, each written according to a common format. These articles, unlike typical systematic reviews, do not limit themselves to retrieving RCTs; and may also consider systematic reviews, meta-analyses, observational studies and cohort studies (but not usually case reports). More than anything else, these reviews amount to narrative reviews about systematic reviews, enlarging upon the breadth of material reviewed without overly diluting the methodological rigor on which we all depend.
Haldeman et al. have been taking their message to multiple audiences, including hosting a session at the recent ACC/RAC meeting in March 2008. They use the analogy of the supermarket, in which there are 10 aisles for types of treatment (pharmacology, manual therapy, exercise, physical therapy, education/psychological, complementary and alternative medicine, injections, minimally invasive treatments, surgery and lifestyle therapies). Each aisle has lots of brands. There are some 60 products, for example, in the drug aisle and about 100 brand-name products in the manual-therapy aisle, which includes spinal manipulation.
The main message to be taken home by the consumer in the chronic low back pain supermarket is that "one therapy is not better than another, so if one treatment does not work, then try another." One doctor in the audience referred to the presenters' work as a "consumers' report" for low back pain, a point which adequately summarizes the challenge a patient faces when trying to decide what to do when they experience a case of low back pain.
The presenters first discussed the side effects/harms of each therapy. The longest harms section was for nutritional supplements. These are not likely the worst harms, but this emphasis suggests some bias in the manner the medical community views CAM therapies. They also discussed the desensitization to the side effects of medication, due to our constant exposure to television advertisements. Dr. Haldeman pointed out there are only two diagnostic tests which lead to a specific treatment: the McKenzie method leading to directional preference-based exercises, and nerve blocks leading to destruction of the related nerve(s).
No other tests indicate a specific treatment. A third party assessing this situation may falsely conclude the evidence says "do nothing," and perhaps deny reimbursement. This clearly is not the case, but given the lack of convincing evidence linking diagnostic tests and treatment, and the superiority of treatments over others, how do clinicians forge ahead with their patients? The solution lies in something of a treat from the vaunted evidence-based practice to a more realistic evidence-informed practice.
Dr. Haldeman also made the point that we are mere technicians if we stay purely within our own modality or techniques. We must understand all of the therapies and options for our patients. Failing that, we make the same mistake as the carpenter for whom the entire world is a nail. Doctors must understand the evidence says patient preferences are an important predictor of clinical outcomes, so knowing what options are available for the patient becomes a critical element of case management. Although this might be seen as creating new and unwanted obligations for the spine doctor, Dr. Haldeman proposes someone needs to become the authority on all the different therapies, thus the de facto case manager, so as to route the patient to the optimal practice setting. No one profession has taken on this role as of the present time.
One audience member asked the question: how could a chiropractor give this information without overstepping their scope of practice. Dr. Haldeman responded that if you are providing information, rather than making a decision, you are practicing within your scope. For example, a chiropractor can suggest a patient ask their doctor about the complications rate for a given surgery or the risk of gastrointestinal bleeding while taking NSAID therapy.
Fear Avoidance (Lucas)
Roland Lucas, PT, discussed the role of the nervous system in chronic pain. In particular, he discussed how the patient's attitudes and beliefs about their pain result in fear avoidance behavior, which in turn may delay recovery. This topic has become rather widely discussed in the past few years, as we continue to develop and refine the biopsychosocial model for back pain.
Patients with chronic back pain may believe they will never be able to overcome the pain and move in the same ways they did before the pain. These patients change their activities of daily living (ADLs), gaits and postures for so long they no longer know how to live without pain. This style of living was termed "catastrophyzing;" patients fear pain and so look for and expect it. This type of pain behavior seems to ease the descending inhibition of pain and increase ascending pain signals.
Doctors might contribute to fear avoidance behaviors by labeling pathologies using terms frightening to patients, such as informing them they have a "disc herniation." Labeling has actually been considered a type of direct harm that a doctor can perpetrate on a patient, in that it limits the patient's recovery. Imaging is one diagnostic procedure especially amenable to labeling harm, to the point some doctors think typical cases often can be better managed without them. There were many times in this ABS meeting that this same point was made: there is compelling evidence that imaging might not be needed until the patient is a surgical candidate. Whether this is the best approach to take will continue to be debated. Many chiropractors are likely to dispute this position. Certainly all of them that believe radiographs are necessary for biomechanical analysis as compared with the "red flags only" position.
Advances in Rehab of the Spine (McMillin)
Advances in rehabilitation of the spine may have been the most interesting subject of the entire four days, certainly in the context of chronic low back pain. Why does back pain recur? Why is it we cannot stop the cycle of back pain? While there was evidence presented suggesting benefits from aggressive strengthening of the lumbar extensors for treating chronic patients, what is required in operational terms may be more than training muscles to failure two to three times per week. The focus may benefit from emphasis not just on the lumbar extensors, but the "big eight" exercises: lumbar, neck, gluteals, chest, rotators, rhomboids, quads and lats. After all, The Spine Journal reviews mentioned above did not find extensor exercises superior to conventional exercises.
One of us (Michael Lord) got to spend some time with the primary conference presenter on spine rehab, Dr. Austin McMillin. He provided plenty of food for thought. The spine and extremities require a distinctly different rehab and conditioning focus, in that axial structures are neurologically distinct in their control patterns, with more focus on control and endurance rather than strength. In turn, the functional training of axial muscles requires close reproduction of natural forces and circumstances. Strength and endurance training are inherently different. Strength training encourages type 2 muscle anaerobic fatigue, and the application of this training to axial muscles seems to set them up for control and endurance failure. Excessive focus on strength training for the spine may leave it vulnerable to injury.
Dr. McMillin also questions conventional proprioceptive training. How does proprioception actually work? There is some new evidence suggesting proprioception is not merely a reactive system but a proactive system, allowing anticipatory patterns for upcoming activity. He made a compelling case for the use of proprioception to facilitate greater proactive control with normal proprioceptive stimuli applied within recognizable movement sequences. In addition, he emphasizes free-standing exercises more than floor and ball exercises, or anything that requires equipment (bands, balls, machines, etc.) to facilitate greater reliance on the body's own inherent stability mechanisms. His rationale is that there is evidence dating back to the 1980s to the effect that completely different strategies of postural correction are used when in a standing rather than quadruped posture. Our core functions differently when standing, which is where most of our back injuries occur, not on the floor. So why train the core with the patient on the floor, a non-representative environment?
In this hands-on workshop setting, Dr. McMillin was able to demonstrate the effective and innovative use of low-tech core exercises. He feels these manifest a more functional approach for a wide range of cases. One of the primary advantages of this approach is that it utilizes an active care approach to chronic low back pain, given that passive care is more optimized for acute spine care.
- May S, Donelson R. Evidence-informed management of chronic low back pain with the McKenzie method. Spine J, 2008;8(1):134-41.
- Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther, 2007;37(6):290-302.
- Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil, 2005;86(9):1753-62.
- http://clinicaltrials.gov/ct2/show/NCT00285649?spons=%22Palmer+College+of+Chiropractic%22&spons_ex=Y&rank=2. August 13, 2008.
- Cooperstein R, Haneline M. The advent of narrative systematic reviews. Journal of the American Chiropractic Association, 2008;45(6):24-5.
- www.pccrp.org. June 16, 2008.
- Adkins DL, Boychuk J, Remple MS, Kleim JA. Motor training induces experience-specific patterns of plasticity across motor cortex and spinal cord. J Appl Physiol, 2006;101(6):1776-82.
Click here for previous articles by Robert Cooperstein, MA, DC.
Michael Lord is a research assistant at Palmer College of Chiropractic West.