ABS Annual Meeting: San Francisco, Nov. 16-19, 2005 (Part 1 of 2)

To tell the truth, the American Back Society is a very tightly knit group with great stability from year to year. Unlike back meetings where peer reviewers select blind submissions to be presented, speakers at the ABS meetings are invited presenters and usually are selected from organic members of that stable and tightly knit group.

Several advantages accrue to this year-to-year stability. The speakers become very familiar to us; very much like family members Prospective attendees have a pretty good idea, having attended a previous meeting, what tone and level is likely to be struck by the presenters. Speakers and attendees share research in progress, frequently well before publications appear in print. These advantages notwithstanding, there is one less desirable outcome of this stability: Some of the speakers give very similar talks year after year. That is not a problem, of course, for someone who does not attend every meeting, but I do. I cover them for Dynamic Chiropractic.

When I write my symposium reviews, I have to consider that many if not most, DC readers will not have read or distinctly remember my comments from a year or two earlier, so there is no harm covering a similar talk in a similar way. The problem is, as someone who enjoys writing, this author has a hard time writing essentially the same article twice. To avoid that prospect, this year's coverage occasionally refers readers to previous columns available online at www.chiroweb.com, but then proceeds to explore, in my own way, interesting and important points the presenters raised. For example, take Dr. Kuchera...

Kuchera: Somatic Predictors of Chronic Low Back Pain

M. Kuchera, DO, as he usually does, made sure we understood that pain is not just a matter of intensity, as is recorded on pain scales. Likewise, it is not enough to know merely the location or referral zone for pain. Myotomal, dermatomal and sclerotomal pain each has its unique character, and a set of typical terms commonly used by patients to describe them. Understanding that is part of the differential diagnosis, and thus leads to different types of treatment. The table below summarizes some of the information:

According to Kuchera, sclerotomal pain is more neglected than myotomal and dermatomal pain. He noted the pioneering works of George S. Hackett¹ on sclerotomal pain and Janet Travell^2,3 on myotomal pain. Differential diagnosis requires knowing not only the distribution of pain, but also its quality. For example, the pain patterns of the quadratus lumborum and the iliolumbar ligament are the same, but muscle pain is crampy, while ligamentous pain is deep and dull. As he did at the ABS meeting in 2004, Kuchera discussed the TART acronym for somatic dysfunction and Greenman's "dirty half dozen."⁴

Foster: Referred or Radicular Pain

Dr. Foster presented two talks, the first of which covered the same ground as his 2004 presentation on the basics of the bulging disc.⁴ His second talk, new for this symposium, also had a back-to-basics orientation, this time on the differential diagnosis of referred vs. radicular pain. He advocated careful elicitation and interpretation of the pain diagram as central to the diagnosis. The pain diagram not only shows the location of the pain, but also the quality of the pain, as Kuchera had emphasized.

I was somewhat puzzled by Foster's description of "non-discogenic sciatica," which he stated occurs in piriformis and sacroiliac syndrome. He seemed to use the word "sciatica" very loosely as any kind of back syndrome, including leg pain. In a previous ABS symposium,⁵ Dr. Kuslich had made the point that sciatica by definition was neurological in character, whereas non-neurogenic leg pain should not properly be termed sciatic pain. Thus, conditions such as piriformis syndrome and sacroiliac joint dysfunction would mimic sciatica, which results from compression of either the L5 or S1 nerve roots, or mechanical compression of the sciatic nerve, due to spondylolisthesis, spinal stenosis or lumbar DJD.

Donelson, Continued (as Always)

Of all the speakers I hear at ABS meetings, Dr. Ronald Donelson may be the most careful to emphasize the continuity in his work. He almost always presents a work in progress, which will be more complete the next year and published by the following year. As a case in point, at this meeting, Donelson reviewed the published results⁶ of a study he had discussed at the previous two ABS meetings.^7,8 For several years, Donelson has been driving home the point, with great passion and perseverance, that the patient's "directional preference" should inform the clinician's treatment vectors.

For as long as I have been a chiropractor, I have had to endure people, no doubt thinking themselves quite clever in their feigned iconoclastic stance, expostulating that it makes no difference where, how or in what direction manipulation is applied. They say if the joints are moved, the patient will get well. According to these cynics, listings (mechanical diagnoses from which preferred lines of drive are derived) do not really matter just use the popn' pray technique. All the rest is wishful thinking at best and mysticism at worst.

I guess Donelson had to deal with similar comments in his own milieu of orthopedic medicine and physical therapy. He and his colleagues had shown clearly that patients performing McKenzie exercises, designed and prescribed according to their directional preferences, experienced a good clinical outcome. However, as he himself stated, it was not clearly established that these good clinical outcomes were attributable to the specific directions chosen for the exercises, rather than some other variable (placebo, etc.). To address that question, Long, et al., came up with a nice experimental design whereby patients were randomly assigned to exercises matched to their McKenzie examination findings, mismatched relative to the exam findings, or simply unrelated to them. As I described in previous columns, the group doing the matched exercises got the best outcomes, and unlike the other two groups, none was made worse. The conclusion: Listings, as we chiropractors would put it, do in fact matter.

One of these days, we are going to use the same or similar methodology in chiropractic research. For example, people thought to have posterior rotation of an innominate bone would be randomly assigned to get a PI ilium adjustment or an AS ilium adjustment, and we will see if it makes a difference. I think I know what is going to happen, since I have already found that there is a relationship between pelvic torsion findings and prone blocking preferences.⁹ I describe my findings in more detail in a chapter on blocking procedures I wrote for the third edition of Leon Chaitow's Positional Release, probably due out later this year.

Precision in prescribing optimum exercises can only follow from precision in making the mechanical diagnosis, in careful subtyping of the patient population. If all research subjects are crammed into the black box of "mechanical, nonspecific back pain," then randomized clinical trials are not likely to show enhanced clinical outcomes for one type of treatment versus another. Guideline and best practices panelists will thus conclude that it makes no difference how the patient is treated. (At the 1994 ABS meeting, someone said an unnamed authority had opined that "a warm poultice of camel dung" would be as effective a treatment as anything else for low back pain.)

I hope one day we will know more about what examination findings predict a good outcome for spinal manipulation. Right now, we have approximately two relevant studies. One is by Fritz, et al., who stated: "Two factors; symptom duration of less than 16 days, and no symptoms extending distal to the knee, were associated with a good outcome with spinal manipulation." The other was conducted by her colleague Childs, et al.,¹⁰ who added that certain fear-avoidance beliefs, lumbar flexibility, and better hip range of motion (why?) also were associated with an enhanced response to spinal manipulation.

Dorman on LBP and Ligamentous Pelvic Injuries

In 1994,¹¹ I covered a presentation by Dr. Thomas Dorman. In my article, I wrote: "Apart from Dr. Dorman's excellent discussion of pelvic ligamentous disorders and the prolotherapy for which he has become a leading expert and proponent, he displayed a peculiar penchant for inventing new words." His talk this year was similar and once again went through "posain" (positional pain) and "nulliness" (see explanation below).

Dorman echoed the theme struck by Kuchera: the important and often overlooked entity of sclerotogeous (ligamentous) pain. An elegant comparison was drawn between Kellegren, who found out how to identify pain related to ligaments, and Hackett, who found out how to produce and treat pain in the same areas. (Kellegren also pioneered our understanding of myotomal pain by describing in 1938 areas of referred pain associated with tender points in muscle, thus anticipating Travell.) Dorman, as others before him, extolled the value of the pain diagram. Tension in ligaments can be a source of pain - indeed, posain - and prolonged tension leads to chronic pain.

I would like to focus some attention on Dorman's concept of "nulliness," a term that appears to be catching on. Individuals with posain often complain of numbness, even though physical examination might not demonstrate anesthesia, nor would nerve conduction or evoked potential studies be able to find an objective basis for their subjective complaints. Asked to identify on a diagram the location of this perceived numbness, it is found to conform to a pattern described by Hackett. Thus, according to Dorman, nulliness is a numb-like sensation without an objective counterpart, the apparent result of strained ligaments. In effect, nulliness is to ligamentous pain what myofascial referred pain is to muscles.

Application of local anesthesia at the site of strain may suppress nulliness. The patient finds that stroking the affected area is either pleasant or neutral, and definitely not unpleasant. By comparison, stroking the skin in the distribution of a partially or totally severed nerve (neurotmesis) produces a feeling of pins and needles, experienced as most unpleasant.

References

1. Hackett GS. Ligament and Tendon Relaxation Treated by Prolotherapy, 1955.
2. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. The Lower Extremities. Baltimore: Williams and Wilkins; 1992.
3. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual: Williams and Wilkins; 1998.
4. Cooperstein R. American Back Society 2004, part I. Dynamic Chiropractic, March 26, 2005. www.chiroweb.com/archives/23/07/05.html.
5. Cooperstein R. Back Society Meeting, part I. Dynamic Chiropractic, Feb. 10, 1997. www.chiroweb.com/archives/15/04/05.html.
6. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine 2004;29(23):2593-602.
7. Cooperstein R. The 2003 meeting of the American Back Society, part II. Dynamic Chiropractic 2004. www.chiroweb.com/archives/22/17/05.html.
8. Cooperstein R. American Back Society 2004, part II. Dynamic Chiropractic, July 16, 2005. www.chiroweb.com/archives/23/15/08.html.
9. Cooperstein R, Crum E, Morschhauser E, Lisi A. Sitting PSIS positions and prone blocking preferences: a preliminary report. Journal of Chiropractic Education 2004;18(1):44-45.
10. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141(12):920-928.
11. Cooperstein R. ABS meets in San Francisco. Dynamic Chiropractic, Feb. 11, 1994. www.chiroweb.com/archives/12/04/21.html.