New Health News, You Can Use
This is the common low back pain, lumbago. Sciatica and spinal stenosis is not included.
“Acupuncture in my practice experience continues to improve with some results that are astonishing. I have patients who find acupuncture relieves their sinus obstructions during their allergy seasons when nothing else works.” Bill Chesnut, MD
| May 9, 2016 Cleveland Clinic Wellness Newsletter | |||
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“Low back pain is increasingly seen as a chronic condition that requires multimodal approach. Combining exercise, massage, topical modalities like heat or an electrical stimulator, anti-inflammatories, acetaminophen helps most people. There is a condition of hypersensitivity to pain that is now being documented by testing. This makes the pain worse. Exercises make the pain better if properly done and daily. This is another tool to add, mindfulness training, which helped lower low back pain levels. The first two paragraphs are from Medscape. The second article below is from the Journal of American Medical Association Internal Medicine for the details and more comment” Bill Chesnut, MD
Mindfulness training focused on stress reduction may benefit people with chronic low back pain
Reuters (2/23, Doyle) reports that in a 282-patient study, an eight-week program of mindfulness training focused on reducing stress may benefit people with chronic low back pain. The findings were published online Feb. 22 in JAMA Internal Medicine.
According to Medscape (2/23, Garcia), an accompanying editorial observed, “Attention to underlying mechanisms of behavioral change (i.e., how or why the treatment leads to change) will be key, as will efforts directed at identifying what treatment components and/or specific combinations might be particularly influential in treatment outcomes.”
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The Editorial referenced above by Medscape: Why We Need Nonpharmacologic Approaches to Manage Chronic Low Back Pain in Older Adults
M. Carrington Reid, MD, PhD1; Anthony D. Ong, PhD2; Charles R. Henderson Jr, MS2 JAMA Intern Med. Published online February 22, 2016. doi:10.1001/jamainternmed.2015.8348
Chronic pain is one of the most common conditions encountered by health care professionals, particularly among patients 65 years and older, and is associated with substantial disability and costs.1,2 Management of chronic pain in older adults is complicated by age-related physiologic changes, competing comorbidities that limit treatment choices, and numerous patient (eg, fear of deleterious effects of medications) and physician (eg, lack of training) barriers. One of the most significant barriers to effective management, however, is a limited evidence base to guide treatment decisions. Recent reviews have documented the paucity of high-quality randomized clinical trials in the field.1,2 Shortcomings include study durations of 12 weeks or less, a lack of study population diversity, and enrollment of young-old study populations without major comorbidities. Studies focused on nonpharmacologic interventions are particularly needed, given that many barriers exist regarding the use of pharmacologic treatments in this target population. Studies further document that older adults with chronic pain are receptive to nonpharmacologic therapies3,4; many already use nondrug treatments and cite concerns about adverse drug effects and the use of too many medications as reasons.4 In this issue of JAMA Internal Medicine, Morone and colleagues5 begin to address this important knowledge gap by presenting data from a well-conducted randomized clinical trial that evaluated the effects of a mindfulness meditation intervention among older adults with chronic low back pain.
“This publication from PAIN is an example of increasing findings showing that some people have increased awareness of their musculoskeletal system sensations. This is also described, as here, as “hypersensitivity”, a term I don’t use because it may be prejudicial in tone. There is more data in the fibromyalgia literature that you can access by Internet search. I added emphasis to the last two sentences about conclusions of this research.” Bill Chesnut, MD
Pain Volume 107, Issues 1–2, January 2004, Pages 7–15
Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia
Abstract
Patients with chronic pain after whiplash injury and fibromyalgia patients display exaggerated pain after sensory stimulation. Because evident tissue damage is usually lacking, this exaggerated pain perception could be explained by hyperexcitability of the central nervous system. The nociceptive withdrawal reflex (a spinal reflex) may be used to study the excitability state of spinal cord neurons. We tested the hypothesis that patients with chronic whiplash pain and fibromyalgia display facilitated withdrawal reflex and therefore spinal cord hypersensitivity. Three groups were studied: whiplash (n=27), fibromyalgia (n=22) and healthy controls (n=29). Two types of transcutaneous electrical stimulation of the sural nerve were applied: single stimulus and five repeated stimuli at 2 Hz. Electromyography was recorded from the biceps femoris muscle. The main outcome measurement was the minimum current intensity eliciting a spinal reflex (reflex threshold). Reflex thresholds were significantly lower in the whiplash compared with the control group, after both single (P=0.024) and repeated (P=0.035) stimulation. The same was observed for the fibromyalgia group, after both stimulation modalities (P=0.001 and 0.046, respectively). We provide evidence for spinal cord hyperexcitability in patients with chronic pain after whiplash injury and in fibromyalgia patients. This can cause exaggerated pain following low intensity nociceptive or innocuous peripheral stimulation. Spinal hypersensitivity may explain, at least in part, pain in the absence of detectable tissue damage.
“This is an example of the media not saying what the study demonstrated. Fortunately, they linked to the original publication in JAMA, October 13, 2015. There you find that PT was not so good, but a little good.” Bill Chesnut, MD
Study examines impact of early physical therapy for lower-back pain
The NPR (10/14, Shallcross) “Shots” blog reports that a study published Oct. 13 in the Journal of the American Medical Association examines “the impact of early physical therapy” for lower-back pain. Researchers “looked at more than 200 patients with lower-back pain to see whether physical therapy sessions would make a difference if they started the sessions soon after they began having pain” instead of waiting a few weeks to see if people could recover on their own.
HealthDay (10/14, Reinberg) points out that “early physical therapy produced a modest improvement in the study participants’ ability to function after three months, compared with no physical therapy” at all. At the one-year mark, however, “no significant difference in function was found between the two groups.”
If you read the entire abstract, http://jama.jamanetwork.com/article.aspx?articleid=2456165&utm_source=BHClistID&utm_medium=BulletinHealthCare&utm_term=101415&utm_content=MorningRounds&utm_campaign=BHCMessageID the conclusions are different than the media reported.
Conclusions and Relevance. Among adults with recent-onset LBP, early physical therapy resulted in statistically significant improvement in disability, but the improvement was modest and did not achieve the minimum clinically important difference compared with usual care.
Trial Registration clinicaltrials.gov Identifier: NCT01726803
“This study and another elsewhere posted are finding that exercise is essential for the common variety of low back pain, lumbago. This summary in the AMA Wire does not point out that this may not be true in patients with actual nerve impingement causing back pain and sciatica pain.” Bill Chesnut, MD
Study suggests exercise prevents lower back pain
The NPR (1/12, Bichell) “Shots” blog reports that a study published in JAMA Internal Medicine analyzed 21 studies of treatment methods for lower back pain, “involving over 30,000 people in total.” The findings show that “back belts and show insoles didn’t seem to offer a benefit,” and that any kind of exercise “reduced the risk of repeated lower-back pain in the year following an episode between 25 and 40 percent.” In a corresponding editorial, Dr. Tim Carey at the University of North Carolina at Chapel Hill writes that healthcare providers don’t prescribe exercise enough, pointing out that “fewer than half of patients participate in an exercise program, even if they have long-term back pain.” Carey discovered that passive treatments, like ultrasound or orthotic insoles, were far more common. The discrepancy may be because of the health industry’s focus on “sellable products, and exercise isn’t one.”
TIME (1/12, Sifferlin) adds that about 80 percent of people will experience lower back pain at some point in their life. While exercise was found to be effective, “the researchers say it’s unclear whether these effects would last beyond a year.” The study authors write, “This finding raises the important issue that, for exercise to remain protective against future [lower back pain], it is likely that ongoing exercise is required.”
“This article is selected by the National Institutes of Health for the National Library of Medicine. Chiropractic and osteopathic spine manipulations do help many.” Bill Chesnut, MD
Spinal Manipulation’s Effects May Go Beyond Those of Placebo or Expectation, Study Finds
A recent clinical trial has added to knowledge about what goes on in the body and brain when people with chronic low-back pain receive spinal manipulation (also known as spinal manipulative therapy). The researchers found that spinal manipulation, compared with placebo and no treatment, significantly reduced pain sensitivity. They also reported there was support for a potential biological target to address central sensitization of pain, a phenomenon of heightened pain sensitivity that is linked with acute pain’s transition to chronic pain, and the persistence of chronic pain. The research, supported in part by NCCAM and the National Center for Medical Rehabilitation Research, part of the National Institute of Child Health and Human Development, appeared in The Journal of Pain.
Researchers randomly assigned 110 adults aged 18 to 60 with chronic low-back pain to one of four treatment groups: actual spinal manipulation; a placebo consisting of a spinal manipulative sham procedure; an “enhanced placebo” that added to the sham procedure “instruction” of telling participants that the hands-on technique they would receive had been shown to significantly reduce low-back pain in some people; or no treatment. For the spinal manipulative and sham treatments, a licensed physical therapist delivered six treatments over 2 weeks.
Among the major findings was that pain sensitivity significantly decreased for the actual spinal manipulation group only and when measured with a protocol for suprathreshold (i.e., above-threshold) heat response. The findings indicate that a decrease in pain sensitivity is greater in response to spinal manipulative therapy than the expectation of receiving the therapy. Also, the enhanced placebo was found as believable a treatment as spinal manipulation and had the highest patient satisfaction of any group.
The researchers noted that areas for further study include whether the observed effects occur in acute low-back pain. They also suggested adding instruction to actual spinal manipulation to state that the therapy has been shown to significantly reduce low-back pain in some people.