The most recent symposium of the American Back Society (ABS), December 10-13, 1997, seemed at times to be a tug of war between the old conventional wisdoms and today's new understandings (i.e., tomorrow's conventional wisdoms).
Skirmishing continued between those who continue to see 80% of back and neck pain as idiopathic, albeit mechanical in nature, and those who are quite sure they can identify the pain generators most of the time. It is not obvious why some who emphasize the idiopathic nature of most back and neck pain continue to stress the importance of history and structural diagnosis, instead of concentrating (as some have urged) on treatment in a generic sense: a "black box" approach.
One speaker, defending the old conventional wisdom about the importance of history, attributed the point to a certain ancient Greek physician -- Hypocrisies. Freudian slips don't get any better.
Overview of Osteopathic Manipulation
In his opening remarks, session moderator Philip Greenman, DO, repeated what has come to be an ABS mantra in recent years: "If anybody says they have the answer, they're wrong." Although many of the presenters to follow would identify some "often overlooked" cause of low back pain, their favorite pain generator, Philip Greenman began his talk and the symposium with the more standard recitation: the one which has 80% of all low back pain being idiopathic.
After paying homage to Farfan ("I believe that the etiological factor in backache is mechanical in nature"), Dr. Greenman emphasized the importance of attaining a structural diagnosis of the musculoskeletal system. The osteopathic entity is somatic dysfunction, sometimes called the manipulative lesion: "impaired or altered function of related components of the somatic (bony framework) system, skeletal, arthrodial, and myofascial structures; and related vascular, lymphatic and neuro elements." The acronym identifying the diagnostic triad of somatic dysfunction is ART: asymmetry of form and function; range of motion alteration; and tissue texture abnormality. Dr. Greenman stated quite correctly that all professions that perform manipulation have evolved some version of ART. Chiropractic's Bergmann, Peterson, and Lawrence describe a PARTS protocol, itself modified from Bourdillon and Day (Bergmann T, Peterson DH, Lawrence DJ. Chiropractic Technique. New York, NY: Churchill Livingstone Inc., 1994).
Dr. Greenman defined manipulation as "the therapeutic use of the hands and patient instructions to restore maximal pain free movement of the musculoskeletal system and postural balance," and described the manipulation armamentarium as including these techniques: soft tissue; mobilization without impulse (articulatory); mobilization with impulse (high velocity thrust); myofascial release; muscle energy; and functional (indirect) release by positioning. Proprioceptive balance training is at the centerpiece of his preferred exercise program, in which stretching to symmetry is the key. Muscle weakness due to inhibition by the antagonist cannot be treated without having stretched that antagonist, hence the rationale for stretching as a prerequisite for muscle strengthening.
Dr. Greenman concluded by bringing out a point he shares with chiropractors. The nervous system is part of a neuromusculoskeletal interface: "Nerve roots, plexuses, and peripheral nerves all need the capacity to move within their specific connective tissues as much as possible ... Mobilization of the nervous system ... can assist in the relief of many extremity symptoms recalcitrant to other interventions."
Predicting the Outcome of Mechanical Therapy
It has been said of Robin McKenzie that he "has advanced the field of physical therapy to a greater extent, actually revolutionizing the whole process, than anybody else in this century." Let us see why this may be true. Suppose practitioners of manipulation could have one of their favorite dreams come true, so they could reliably come to a valid structural diagnosis. That would still leave them with the nightmare of not knowing which type of manual treatment is most likely to have a favorable outcome for that diagnosis.
Enter Robin McKenzie and his associates. They have established reliable diagnostic criteria through the centralization and peripheralization principles for an indicated treatment approach; had these criteria validated and tissue-based through provocative discography; and been able to predict responders vs. non-responders to various treatment methods, minimizing the expense of useless treatments. "All patients will benefit from the diagnosis, but not all from the treatment," McKenzie said.
The primary evaluative procedure remains the identification of which body positions centralize or peripheralize the leg pain that accompanies low back pain, or move back pain to the body midline. "Peripheralizers" experience increased distal symptoms, whereas centralizers experience decreased distal symptoms. The examination findings immediately dictate the required treatment, which may involve flexion, but more typically extension, lateral flexion, or combinations thereof. The mechanical diagnosis can identify discogenic pathology, contained vs. non-contained lesions, and potential responders vs. non-responders. The exam procedure directly establishes body positions that reduce or increase discal displacement or derangement. According to McKenzie, "You are halfway there when a back-leg patient reports in the prone position that the pain is now only in the back."
Dr. Ronald Donelson presented some of the research findings in support of the McKenzie protocols. In a double-blinded study, centralizers and peripheralizers tended to have positive discograms, confirming symptomatic IVD syndromes, whereas those patients whose symptoms were unchanged during the McKenzie exam strongly tended to have negative discograms and thus presumptive nondiscogenic low back pain (Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and annular competence. Spine 1997;22(10):1115-22). The directional preference examination usually shows extension centralizes better than lateral flexion, and lateral flexion better than flexion. The centralizers show mostly no dye leakage, indicating contained lesions with an intact hydrostatic mechanism, whereas peripheralizers were more likely to show dye leakage and thus have non-contained disc lesions. In this study, the McKenzie exam protocol was actually "superior to MRI in making the diagnosis and assessing the dynamics of the lesion." Other studies have shown centralizers, mostly acute patients, to have a favorable non-operative prognosis, as compared with peripheralizers.
Lifting with the Hips -- Not the Back, Not the Legs (too much)
H. Duane Saunders, PT, whose talk was billed as "How to teach your patients all they need to know about body mechanics in 10 minutes or less," needed just a couple of minutes to describe an improved lifting procedure. On the other hand, several more minutes did not suffice for one of two volunteers to actually accomplish this somewhat challenging maneuver.
Mr. Saunders wanted to debunk the old conventional wisdom that we should "lift with our legs, not our backs," since this puts the weight too far in front of the spine. He prefers lifting with the hips: one leg forward, weight kept close, a wide base of support, and bending at the hips, not the back. He implored two volunteers, "Keep your heads up, stick your butts out, bend your knees, and feel the curve in your backs while flexing forward." Only one eventually succeeded, whereupon Mr. Sanders theorized that the other subject must have tight hamstrings (or something).
The Scalenes and Thoracic Outlet Syndrome
Struggling valiantly to deliver his talk despite a really bad throat, Dr. Rene Cailliet explained, "Because we are a vertebral column society, certain conditions may be missed," such as thoracic outlet syndrome. Extension of the cervical spinal column following a whiplash injury is coupled with upper dorsal kyphosis. The resultant stretch on the neck flexors (scalenes) results in compression of the brachial plexus, producing a kind of double crush syndrome in which there is discogenic injury to the nerve roots and peripheral entrapment between the scalenes. Dr. Cailliet feels that the discs and facets are routinely addressed, but that sometimes the muscles (e.g., the scalenes) are often neglected.
William Ruch, DC, author of a recently published book on the subluxation (CRC Press), based on his own unique dissections, presented an evening workshop, "The Scalene Muscles as a Source of Neck Pain." Unfortunately, I could not attend, but he showed me his central point in the hotel lobby using my own body for demonstration purposes. The following text is taken from the program abstracts for Dr. Ruch's talk: "The scalenes' muscle spasms which can be initiated by costosternal joint instability are a common source of neck pain ... The relationship of the cervical spine and upper thoracic region will be briefly reviewed with a focus on the neuromuscular reflexes."
The Pain Generators Can Be Identified
Dr. Nikolai Bogduk is not a shy man, nor does he beat around the bush. He said that what he had to share would "not be good news" for those in this continent (he is from Australia) who continue to profess that spinal pain generators have not been or even can't be identified. This would imply that either the patients here are different, or, more likely, that North American investigators have got it all wrong. Quite unimpressed with the fashion to overemphasize somatization and soft diagnoses like fibromyalgia syndrome, Dr. Bogduk also finds that in Australia, unlike North America, chronic pain can be alleviated.
Although it has been traditionally stated that neck pain comes from discs and muscles, "There is not one shred of data" in support. By comparison, pain does indeed come from the zygapophyseal joints, produced in dermatomal patterns by stimulation of the related zygapophyseal joints. Cervical zygapophyseal joint pain can be diagnosed using double-blind, controlled, diagnostic blocks. Anaesthetizing the nerves' intra-articular blocks (injections) may diminish or abolish the pain. No other diagnostic test for neck pain has been so tested, let alone survived such testing.
In a double-blinded study, Dr. Bogduk was able to conclusively demonstrate that following whiplash injuries, the posterior joints are the pain generators 40-59% of the time. (In the lumbar spine, by comparison, the facets only uncommonly produce low back pain.) Another study addressed the source of headaches in patients with chronic whiplash-associated disorder, finding that in patients in whom headache was the dominant symptom, the pain could be traced to the C2-3 zygapophyseal joint in 53%. Therefore, "Not diagnosing the zyg. joint means you are missing the diagnosis more than half the time."
As for treatment, he has had success with a procedure called cervical percutaneous radio frequency neurotomy. A randomized double-blinded clinical trial proved the procedure effective.
The control subjects received the procedure without the electricity, and success was defined as no postoperative pain at all. Although he sees certain conditions (meniscal entrapment, etc.) where manipulation would be appropriate, Dr. Bogduk finds that the empirical data, including meta-analysis, say manipulation "is of no value over anything else you might do, including talking to the patient," and he does not recommend it.
Lumbar zygapophyseal and sacroiliac joint pain can also be validly diagnosed using controlled intra-articular nerve blocks. Internal disc disruption is diagnosed using controlled disc stimulation coupled with post-discography CT. Worst-case analysis reveals that the prevalence of lumbar zygapophyseal joint pain is 15%; of sacroiliac joint pain is 13%; and internal disc disruption is 39%. Less than 5% of patients received more than one diagnosis, indicating that lumbar zygapophyseal joint pain, sacroiliac joint pain and internal disc disruption are independent conditions, only rarely occurring concurrently. "Collectively, these figures indicate that over 60% of patients with chronic low back pain can be found to have an organic diagnosis, in spite of the traditional wisdom that over 80% of patients cannot be diagnosed."
Alternative (Integrative) Medicine: a Special Symposium
In an ABS first (to my knowledge), alternative medicine was addressed in a special satellite symposium. Chiropractic was conspicuously (and quite intentionally, as it turns out) not represented among the presenters. This suggests that chiropractic care, at least within the ABS, is considered a mainstream, and not an alternative, health care profession.
Ken Farber, MA, spoke on "mindfulness meditation" based stress reduction, in which people receive intensive training in how to cope with chronic pain and sooth themselves. Relaxation therapy "has been shown to he effective in reducing chronic pain in a variety of medical conditions" according to the NIH. Some 2/3 of all chronic patients report "moderate to great improvement" in their conditions.
Robert Elkins, MD, said: "Keep an open mind, but not so open that your brains fall out." Then he said something about "universal and personal energy," followed by a recitation of "the rules for being human." Sorry, but I did not concentrate on these remarks, lest my brains fall out. In conclusion and amidst much applause, Dr. Elkins suggested, "What we need to do here is talk about meta-medicine, the blending of medicine and metaphysics." (Why are these people clapping?).
Alon Marcus, DOM, is trained in Chinese medicine, a comprehensive system including acupuncture, manual medicine, and herbal medicine. He said that although the NIH found that nausea and tooth pain respond well to acupuncture, this does not mean other conditions do not. It is not always equally easy to design blinded, randomized clinical trials for different conditions. Dr. Marcus concluded: "In general, it will take new paradigms of science to evaluate Chinese medicine because treatments vary too frequently for individual patients to design a study of a given modality in the usual way." (I and four other investigators are currently supported by the FCER to conduct a consensus process for procedure-specific, condition-specific guidelines, for the chiropractic treatment of low back conditions. We have not found it necessary to call for new paradigms to evaluate chiropractic treatment methods, despite practice variations and the use of multiple methods.)
Nancy Rakela, OMD, addressing the question why alternative medicine has become so popular in recent years, said, "Our body is a body of energy, alternative medicine works with the energy of the body." She not only does a "regular" exam, but goes beyond that, to work with the patient energetically to promote healing ...
Dana Ullman, MPH, spoke on homeopathy, whose remedies are considered pharmaceutical agents and are thus under the control of the FDA. He pointed out some inconsistencies in the NIH's approach to validating various treatment modalities: "You can't do a double blind study of surgery, and yet the NIH does not call that experimental," as it does in the case of homeopathy, whose treatment modalities are amenable to such trials. Mr. Ullman obviously did not fail to mention the recent publication of a meta-analysis of homeopathy treatments (Lancet, Sept. 20, 1997), showing it more effective than placebo. He stated in conclusion that "either homeopathy works or science doesn't." Really, it could have been worse.
Part II of this article will appear in my next column. It will feature Drs. Haldeman (on spasm); Bogduk (on "nothing works"); Norbash (on upright and dynamic imaging of the spine with MRI); Simon and Scheiman (on NSAID complications); McCarthy (on chiropractic geriatrics); and more.
Robert Cooperstein, DC
San Jose, California
Tel: (510) 536-9929
Fax: (510) 536-1812
Drrcoop-aol.com
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