Journal of Back and Musculoskeletal Rehabilitation - Volume 3, issue 4
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Journal of Back and Musculoskeletal Rehabilitation is a journal whose main focus is to present relevant information about the interdisciplinary approach to musculoskeletal rehabilitation for clinicians who treat patients with back and musculoskeletal pain complaints. It will provide readers with both 1) a general fund of knowledge on the assessment and management of specific problems and 2) new information considered to be state-of-the-art in the field. The intended audience is multidisciplinary as well as multi-specialty.
In each issue clinicians can find information which they can use in their patient setting the very next day. Manuscripts are provided from a range of health care providers including those in physical medicine, orthopedic surgery, rheumatology, neurosurgery, physical therapy, radiology, osteopathy, chiropractic and nursing on topics ranging from chronic pain to sports medicine. Diagnostic decision trees and treatment algorithms are encouraged in each manuscript. Controversial topics are discussed in commentaries and rebuttals. Associated areas such as medical-legal, worker's compensation and practice guidelines are included.
The journal publishes original research papers, review articles, programme descriptions and cast studies. Letters to the editors, commentaries, and editorials are also welcomed. Manuscripts are peer reviewed. Constructive critiques are given to each author. Suggestions for thematic issues and proposed manuscripts are welcomed.
Abstract: Why do so many patients opt for a surgical solution to lumbosacral (L-S) radicular pain? A rhetoric as well as specific question. Recently a Big Ten coach underwent the scalpel for the third time in two years. “Pain” not masochism was his response when questioned by the press, “Why the knife?” Most physicians and patients equate the severity of L-S radicular pain with the seriousness of the disc derangement. This is not so! Most physicians are aware that radicular pain is inversely proportional to the weakness associated with L-S disc herniation or extrusion. The natural history…is a general remission of pain with a little exercise, perhaps some medication, and mostly Mother Nature. A sudden cessation of pain suggests a “dead” root and significant weakness. Unfortunate? Not necessarily. Electrodiagnostic studies can demonstrate a L-S radiculopathy within two weeks of onset and after one week can differentiate neurapraxic (reversible) weakness from permanent weakness. In both instances surgery is not the treatment of choice. In the first instance a conduction block at this inflamed nerve root is the problem and in the second scenario the weakness is generally not reversible with surgery (in fact the operation could be blamed). Nonradicular back pain needs a physiatric evaluation and management program. Patients should be reassured in all situations that most people “get over” acute back pain (including radicular) with minimal residuals if they are patient and educable! After all, rehabilitation is essentially teaching and patient learning. All patients with low back pain need thorough grounding in anatomy and physiology of the low back and biomechanics of lifting, in order to fend off advice of well-meaning friends, relatives, or even other “health” professionals. A recent study announced 10 times more lumbar laminectomies are done in the United States than in Europe. To reduce this number, I suggest all second opinions for this major (e.g., Discectomy) lumbar assault be given by a nonsurgeon who understands back problems (i.e., a physiatrist). Isn't this essentially the same as a gastroenterologist presenting a second opinion for management of a gastric ulcer—medical versus surgical? A physiatrist would provide a second opinion instead of a seconding opinion.
Abstract: Back pain is a pervasive problem which ranks only behind cold symptoms as a reason for all physician visits. Among persons with back pain lasting at least two weeks, 85% will seek the care of a health professional. These patients obtain care from primary care physicians (Family Medicine, Internal Medicine, and Osteopathic physicians), but also see a variety of specialists, including physiatrists, rheumatologists, orthopedic surgeons, and neurosurgeons. Since any of these specialties may evaluate patients early in their course, it is important to adopt a systematic and rational early approach to back pain. This discussion emphasizes recent data suggesting that…such an approach would include a parsimonious diagnostic evaluation, careful attention to patients' concerns, and careful choice of proven effective treatments. Specifically, we propose five strategies that may help to reduce costs of care while maintaining quality: 1. Avoid premature or unnecessary diagnostic tests. 2. Avoid patient deactivation. 3. Avoid ineffective or unproven remedies. 4. Prescribe effective therapy in a cost-conscious manner, and 5. Emphasize lifestyle changes and patient self-efficacy.
Keywords: Back pain, diagnosis back pain, lifestyle change, strategies for back pain
Abstract: Plain x-rays of the lumbar spine are not helpful in diagnosing most known causes of low back pain but can reveal structural changes such as disc space narrowing, scoliosis, lumbarization or sacralization, spondylolysis, and spondylolisthesis. Spondylolisthesis is defined as the forward displacement of one vertebrae upon another, usually at the L5-S1 level, but also occurring at L4-5. For spondylolisthesis to occur there must be an anatomical change in the structures which normally resist the anterior displacement of one vertebrae upon the other. Forward slippage is resisted by the bony block of the posterior facets, by the intact neural arch and…pedicle, by normal bone plasticity preventing stretch of the pedicle, and by the intervertebral disc bonding the vertebral bodies together.1 The degree of vertebral body anterior displacement is rated from 1–4 depending upon the severity of the slip.2 Five major categories have been proposed for the classification of spondylolisthesis.3 Clinically, the type most often seen is a defect in the pars interarticularis of L5 with resultant slippage of L5 on S1. This is known as isthmic spondylolisthesis. The other commonly seen type of spondylolisthesis is degenerative, arising from the remodeling of the facet joints so that bony opposition to resist anterior displacement of one vertebrae upon another no longer exists. Degenerative spondylolisthesis most commonly occurs at the L4-5 level in women over the age of 40. Surgical intervention for treatment of spondylolisthesis is well documented,4–6 but literature regarding conservative management is scarce. The purpose of this article is to present an evaluation and treatment approach which has been found by the author to be clinically effective for patients presenting with symptomatic grade I or II isthmic or degenerative spondylolisthesis. Documented conservative treatment for spondylolisthesis includes instruction in exercise and body mechanics, the use of back supports including antilordotic orthoses, and job modifications. Magora7 recommends strengthening of the abdominals and paraspinal muscles, especially in the thoracic area, as well as occupational modifications and instruction in body mechanics, deep-heat therapy, avoidance of maximal forward flexion of the lumbar spine, and in severe cases, bed rest. He recommends three to four months as the minimal trial period for conservative treatment. Gramse et al.8 and Sinaki et al.9 compared two types of exercise programs over a three-year period for patients with symptomatic spondylolisthesis. Patients were divided into two groups with one group performing a flexion routine consisting of abdominal curl-ups, posterior pelvic tilts, and seated trunk flexion; a second group was instructed in extensor strengthening exercises performed in prone lying. The authors found that patients treated with the flexion exercise program were less likely to require the use of back supports, require job modification, or limit their activities because of pain. At three-year follow-up only 19% of the flexion group had moderate or severe pain compared to 67% of the patients in the extension group.9 Gramse et al.8 and Sinaki et al.9 did not describe how they determined that the spondylolisthesis was indeed symptomatic. Bell et al.10 reported 100% success with the use of an antilordotic orthosis in 28 children (mean age 11.4 years) with grade I and grade II isthmic spondylolisthesis. Other authors have been less enthusiastic about the use of corsets and braces.7,11
Abstract: Low back pain (LBP) is the number-one cause of disability of individuals under 40 years of age. The cost to society both in medical expense and loss of productivity is billions of dollars annually.1,2 The etiology of both acute and more persistent LBP is multifactorial, but torso weakness is considered a contributing factor. It is well documented that improved strength, as well as general conditioning, improve the odds of successful return to work.2–7 For these reasons, resistance training is often prescribed for the prevention and rehabilitation of disability secondary to LBP. The purpose of this article is…to review current literature regarding resistance training for rehabilitation of LBP. Trunk strengthening will be reviewed in more detail and general principles for extremity resistance training will be reviewed as well.
Keywords: Disability, low back pain, resistance training, torso strengthening
Abstract: Low back pain is one of the most common dysfunctions seen by health care professionals. Eighty percent of the population will suffer from low back pain in their adult life.1–4 Accordingly, this societal problem has taken its toll via missed days of work and the adverse economic impact that results.3–9 The good news is that most people with low back pain improve within a short period of time.1,9–11 Acute attacks of back pain and sciatica can last up to two weeks with chronic attacks persisting for more than three months.10 Vukmir reported that 74.2% of…patients with low back pain improved within one month, 87.3% within three months, and 92.6% within six months.1 Additional good news is the fact that surgery is the appropriate solution for only a small percentage of the patients with low back pain.12,13 Saal and Saal report that nonoperative treatment for lumbar disorders, including intervertebral disc dysfunction prove most successful.13 Weber, in a landmark study, reported that patients who received surgery for lumbar disc herniations showed statistically better results at the one-year follow-up examination. However, at the four-year follow-up, there were no statistically significant differences in how patients who received surgery compared to the patients who did not receive surgery.14 On a less positive note, people who suffer an episode of low back pain, have a greater chance of developing future episodes.10,15 Those patients who develop repeated episodes of low back pain and those patients who do not improve spontaneously over a short period of time can fall into the group known as chronic low back pain. This group creates a major drain on our economic resources and leads to a large number of people who are deemed disabled.1,7,8,12 Therefore, if the health care community is unable to cure all types of low back pain, keeping patients with low back pain functional should be of prime importance. Through the performance of functional activities, such as activities of daily living and working, the societal drain caused by low back pain, would hopefully decrease.
Abstract: Pain is a common symptom in cancer patients. Thirty to fifty percent of patients will experience pain while undergoing cancer treatment, and 70 to 90% of patients with advanced disease report pain.1–7 In addition, greater than 50% of patients state their pain is incompletely controlled. In part, this is due to the difficulty physicians have in accurately assessing the patient's level of pain and response to treatment, as well as utilizing a treatment approach that is agreeable to the patient. It is common that patients underreport the severity of the pain that they are experiencing, as well as their…inability to achieve pain control. There are many possible reasons for this, including their wish to appease the physician; the fear of confirming progression of their disease by admitting to having increased pain; and the concern of possible narcotic addiction. To address these problems, the World Health Organization, the American Pain Society, and the American Society of Clinical Oncology's Ad Hoc Committee on Cancer Pain have published guidelines for assessing and treating pain.8–10 Pain is one of the most disabling conditions experienced by cancer patients.7,11–14 This disabling effect is exacerbated by the patient's fear of the loss of control of both the ability to regulate his/her pain and loss of control of his physical mobility due to the pain. Therefore, it affects the patient both physically and emotionally and further compromises the ability of the patient and family to deal with the disease. The perceived intensity of the pain as well as the level of disability experienced by the patient can be influenced by many variables such as family support and cultural background of the patient. These influences in the patient's life can magnify or diminish his/her perception of pain and disability. Therefore, in the same way that patients tolerate pain differently, the treatment approach must to some extent be appropriately individualized, periodically reviewed, and frequently altered to change with the needs of the patient. This is one reason why those involved with cancer rehabilitation use an individualized interdisciplinary approach to the patients' needs, including pain control. In addition to the traditional use of analgesics, chemotherapy, radiation therapy, surgery, and nerve blocks to palliate pain, cancer rehabilitation employs a wide range of other modalities, both physical and cognitive behavioral, in its treatment approach. Physical and occupational therapy utilize positioning, strengthening, transcutaneous electrical nerve stimulation (TENS), and other electrical stimulation modalities, orthotics, and other assistive devices to alleviate pain and maximize function. In addition, psychological support in its various forms, with both patient and family counseling, affords better handling of the disease. In some cases biofeedback and/or hypnosis can be utilized as an adjunct to pain control. Since the pathophysiology of cancer pain and its pharmacologic, surgical, and radiation treatments were dealt with in a previous issue, they will not be addressed further. This article will focus primarily on the more unique aspects of cancer rehabilitation, and the physical, nonpharmacologic, and behavioral approaches to pain management that practitioners commonly use in relation to neurological pain syndromes in cancer.
Abstract: The purpose of this study was to assess the amount of thoracic segmental flexion associated with cervical forward bending. Twenty-four healthy men and women between the ages of 21–29, with no past or present cervical or thoracic dysfunction, participated. Spinal segmental mobility in the thoracic region was measured in the neutral sitting position and sitting with the cervical spine in the forward bent position. Mobility was measured by the Faro Metrecom Skeletal Analysis System. The Faro Metrecom is an external measuring device that records each individual spinal segment's position within the body. Descriptive statistics were used to describe the position…of the thoracic segments when the cervical region was in the neutral and in the forward bent positions. Additionally, intrarater reliability, .83 and .76, and interrater, .72, were analyzed for the thoracic segments in the neutral position. The results show that with cervical flexion there was thoracic segmental flexion. Segments T1–4 demonstrated forward bending ranging from 2.88–4.42°. The greatest amount of flexion occurred at T2, 4.42 degrees, and T3, 4.19 degrees. Below T4 no pattern was noted. The results indicate that upper-thoracic segmental flexion occurs during cervical forward bending. During evaluation and treatment of patients with cervical dysfunction physical therapists routinely evaluate spinal segmental mobility. It is clear to clinicians that cervical segmental mobility is important to cervical range of motion. What it not clear is the role of thoracic segmental mobility in cervical range of motion. Physical therapists frequently evaluate and treat the thoracic region when patients have cervical dysfunction. Therefore, the purpose of this study was to assess the amount of thoracic segmental flexion associated with cervical forward bending. Since the early 1970s when the concept of joint mobilization was brought to American physical therapists, interest in spinal segmental motion has increased. Though interest in this area exists, there is a scarcity ofresearch documenting normal and abnormal spinal segmental mobility. Additionally, most of the studies on spinal segmental mobility have been conducted on cadavers or through radiographic methods. Lysell studied intersegmental movements of the cervical spine using autopsy specimens. Steel balls were placed in fixed points on each vertebrae and then a three-dimensional radiographic examination was used to measure movements of these points during cervical range of motion.1 Ball and Meijers studied cervical mobility using fresh cadaveric cervical spinal specimens. In this study steel pins were inserted into the cervical bodies and serial x-rays were taken.2 Panjabi, Dvorak, and Duranceau studied upper-cervical spine mobility using fresh cadaveric whole cervical spine specimens and steel balls. Their specimens were set into a quick-setting epoxy material to help align the centers of C2 and C7, thereby providing fixation.3 Yamamoto et al. studied three-dimensional movements of the lumbar spine and lumbosacral joint. They used fresh cadaveric whole lumbar spine specimens analyzing from L1 to the sacrum.4 Robert studied intervertebral motion of the whole spine. This was performed with cadavers as the segmental excursions were determined from a point at the inferior surface of the vertebrae to the tip of the spinous process.5 Three separate noncadaveric studies were conducted by Penning,6 Felding7 and Moll and Wright.8 Penning studied normal movements of the cervical spine by superimposing two x-ray films representing the cervical spine in the end positions (i.e., flexion and extension). Fielding studied normal and abnormal motion of the cervical spine from C2 and C7 using cineroentgenography; roentgenograms were taken while the subjects were moving. Moll and Wright studied normal range of spinal mobility using live subjects with markers on the skin. When the subjects moved the separation of the skin markers was recorded. The above studies used procedures that are not convenient for use during clinical sessions. Additionally, the above studies did not evaluate thoracic mobility in relation to cervical motion. In the textbook, Common Vertebral joint Problems,9 Grieve presents a complete discussion of vertebral motion. This section is highly referenced as it pertains to segmental spinal mobility.9 White and Panjabi are the most frequently cited source on spinal segmental mobility.10,11 They reported flexion/extension degrees of motion for the thoracic segments. The ranges of the motion and the “representative angle” (most likely the mean angle) in degrees for each thoracic segment are T1–T5 2–5 (4); T6 2–7 (5); T7–T9 3–8 (6); T10 4–14 (9); and T11–T12 6–20 (12). However, they did not state how their estimated range and “representative angle” in degrees of segmental spinal mobility were measured.10,11 Valencia in the book Physical Therapy of the Cervical and Thoracic Spine states similar motion for the thoracic segments.12 The upper-thoracic spine, T1–T6, has been related to the cervical region anatomically. The upper-thoracic facet joints are orientated like the cervical facet joints and have a similar pattern of movement.11,13 Additionally, the caudal attachment of many cervical muscles is in the thoracic region.13