Christine Keating MD Physical medicine and Rehabilitation Back and Spine center Low back pain Second most common cause for physician visits Most common cause of activity limitation in people less than 45 70-85% of people will have back pain at some point in their life LBP is a common problem but many different causes, and many times a definite source can not be found 1
Low back pain The number # 1 reason for missed days at work Ranked the sixth most costly medical condition Over $100 billion dollars spent annually in the US on back pain At any one time, 80 million Americans are experiencing back pain The number one predictor for returning back pain is previous back pain Bed rest is no longer considered the best treatment option Lifetime recurrence rate 85% Treatments 2
Non traditional treatments for Back pain Acupuncture Dry needling Cupping Massage Cranio-sacral massage Rolfing Feldenkrais Exercise Tai Chi Yoga Mindfulness based stress reduction Psychological therapies Multidisciplinary Traditional Chinese Medicine Traditional Chinese medicine is based on the theory that the human body has natural energy flowing through it The meridians are channels that allow the energy chi to flow freely. As long as chi moves freely we feel healthy. Illness and injury create obstructions which effect the way we feel 3
Acupuncture Acupuncture Ancient practice of Chinese medicine developed 8,000 years ago with foundations in Dadaist theisms Thin needles are placed in specific points of obstruction in the body to attract blood flow with its nutrients and oxygen to repair the damaged tissue. It is also said to boost lymphatic system to carry away toxins Over 3 million Americans use acupuncture. (It is more popular in other countries) The goal is to release our bodies natural energy by stimulating the 14 energy pathways/meridians It is said to release endorphins which are natural pain relievers 4
Acupuncture Acupuncture Spine in 2013 showed self reported pain improvement, but the studies were limited by poor study quality Acupuncture vsno treatment there was a statistically significant improvement in function Acupuncture vsmeds there was statistical significance in level of pain but no clinical relevance Acupuncture vs tens: no difference Acupuncture vs sham acupuncture there was improvement in pain with acupuncture Acupuncture and usual care vsusual care there was greater improvement in self reported pain with using acupuncture Electroacupuncture vs usual care there was statistically significant self reported pain improvement with electroacupuncture Lam, Megan. Galvin, rose. curry, Philip. Effectiveness of Acupuncture for Nonspecific chronic low back pain. Spine. 2013;38:2124-2138 5
Acupuncture Acupuncture had a clinically meaningful reductions in self reported pain and function post treatment when compared to no treatment, sham treatment, or medications There is improved function and pain when acupuncture is used with traditional non specific chronic low back pain treatment Acupuncture is an effective treatment and should be used with traditional treatment. Studies in the future need longer follow-up, and not just immediately after the intervention Lam, Megan. Galvin, rose. curry, Philip. Effectiveness of Acupuncture for Nonspecific chronic low back pain. Spine. 2013;38:2124-2138 Acupuncture Annals of internal medicine published a review in 2017 They showed that in acute low back pain acupuncture had decreased pain but no improvement in function when compared to sham treatment In chronic low back pain there was improved pain and function immediately after treatment compared to no acupuncture There was no long term difference in pain and function compared to no acupuncture In summary, there are some immediate benefits, but no documented long term benefits, but there were only two trials of acupuncture long term Chou, Roger; Deyo, Richard; Friedly, Janna et al. Nonpharmacologis Therapies for Low Back Pain: A systemic review for an American College of Physicians Clinic Practice Guideline. Annals of internal medicine. 166(7): 493-506 6
Dry needling Thin needles inserted into the muscle to stimulate the trigger point and elicit a local twitch response Trigger point is tight muscle band that triggers pain when touched It is different from acupuncture: acupuncture s goal is to release/unblock the energy flow and create balance. Dry needling stimulates the muscle that is causing the pain and muscle soreness Dry Needling Compared to other treatments dry needling myofascial trigger points decreased intensity of low back pain post treatment Dry needling plus other treatments was more effective than dry needling alone in decreasing pain intensity It is unclear whether dry needling improves functional disability, data remains insufficient Liu, Lin. Huang, Quing-Min, et al Evidence for Dry needling in the managemetnof myofascial trigger points associated with low back pain: a systemis review. Arch Phys med and rehab. 2018;99:144-52 7
Cupping Cupping Is an ancient Chinese practice developed 3000 years ago Cupping creates suction above the damaged tissue stimulating blood flow to the area to stimulate healing and get rid of waste It can be done by PT, massage therapist, acupuncturist, chiropractors 8
Cupping There are multiple types of cupping. Wet cupping and dry cupping being the most common Wet cupping involves controlled bleeding Literature limited. In a review one RCT, and 6 non- RCT and 20 case reports found The RCT showed decreased pain with wet cupping vs no intervention Research limited, there is large variation in type of cupping, sites and dosage. Cupping is promising for pain control and improved function Huang, Cia-yu, Choong, Mun-Yau. Effectiveness of cupping therapy for low back pain: A systemic review. acupunct Med 2013 31: 336-7 Massage Improves blood circulation which can help relieve soreness Relaxes muscles to help with improved movement and ROM Increases endorphin levels There is some short term benefits when compared to other noninvasive treatments with decreased pain and improved function. Results were varied in 13 included trials Chou, Roger; Deyo, Richard; Friedly, Janna et al. Nonpharmacologis Therapies for Low Back Pain: A systemic review for an American College of Physicians Clinic Practice Guideline. Annals of internal medicine. 166(7): 493-506 9
CranioSacral Therapy (CST) Developed by an osteopathic physician John Upledger Gentle hands on method of enhancing the craniosacral system which includes CSF and membranes Using light touch to the spine and pelvic bones you release restrictions in the craniosacral system to improve function of central nervous system by regulating flow of CSF Rolfing Developed by Ida Rolf she saw the body as constantly in a struggle with gravity, creating imbalance inefficiency in movement and pain Rolfing bodywork affects the body s posture and structure by manipulating the myofascial system Rolfing is a system of soft tissue manipulation and movement education that organizes the whole body in 10 sessions to align the human body energy field with gravitational field Rolfing focuses on entire body to create overall ease and balance. Massage focuses on specific areas with tension It is not known whether Rolfing is safe or cost effective 10
Feldenkrais Method Feldenkrais method It is an exercise therapy It is said to realign the connections between brain and body and improve body movement and psychological state It is movement therapy, helping patients to become more aware of movements and habits, so they can change and develop new patterns The goal is to improve posture, flexibility and coordination to change restrictive patterns. There is no evidence to support its use 11
Tai Chi Tai chi is a slow motion exercise where muscles are kept relax and joints are never at the end ROM Focusing the mind on the movement of the body helps bring about mental calm Two trials showed that Tai Chi improved pain when compared to no Tai chi. One study showed improved function Chou, Roger; Deyo, Richard; Friedly, Janna et al. Nonpharmacologis Therapies for Low Back Pain: A systemic review for an American College of Physicians Clinic Practice Guideline. Annals of internal medicine. 166(7): 493-506 Yoga There are many different types of yoga practices. It is physical exercise with a meditative and spiritual core Fourteen trials evaluated yoga for chronic low back pain. Yoga was associated with better function and pain control but not statistically significant Cochrane review showed no clear difference between yoga and other exercise for back pain Chou, Roger; Deyo, Richard; Friedly, Janna et al. Nonpharmacologis Therapies for Low Back Pain: A systemic review for an American College of Physicians Clinic Practice Guideline. Annals of internal medicine. 166(7): 493-506 12
Exercise For chronic low back pain, exercise was associated with greater pain relief and function There needs to be better adherence to home Exercise program, 50-70% do not continue Exercise that incorporates individual stretching strengthening to meet patient needs and functional requirements Chou, Roger; Deyo, Richard; Friedly, Janna et al. Nonpharmacologis Therapies for Low Back Pain: A systemic review for an American College of Physicians Clinic Practice Guideline. Annals of internal medicine. 166(7): 493-506 Lack of activity destroys the good condition of every human being. While movementand methodical physical exercisesave it and preserve it --Plato 13
Mindfulness-Based Stress Reduction It uses a combination of mindfulness meditation, yoga, and body awareness to become more mindful Showed improvement in pain and function over usual care at 26 weeks There was no difference in mindfulness and cognitive behavioral therapy for improvements in pain and function Chou, Roger; Deyo, Richard; Friedly, Janna et al. Nonpharmacologis Therapies for Low Back Pain: A systemic review for an American College of Physicians Clinic Practice Guideline. Annals of internal medicine. 166(7): 493-506 Psychological therapies Progressive relaxation, electromyography biofeedback, operant therapy, and cognitive behavioral therapy resulted in lower post-treatment pain when compared to no treatment. Progressive relaxation showed improved pain Only progressive relaxation techniques showed improved function No difference in pain was seen in psychological vs exercise therapy individually Chou, Roger; Deyo, Richard; Friedly, Janna et al. Nonpharmacologis Therapies for Low Back Pain: A systemic review for an American College of Physicians Clinic Practice Guideline. Annals of internal medicine. 166(7): 493-506 14
Multidisciplinary Physical therapy Incorporates physical therapy with behavioral and psychological counseling. Treat the physical with the mental aspects of chronic pain Therapy included exercises, coping skills, education, and relaxation training, along with cognitive behavior therapy, work-related training, and problem solving in stressful situations. There was improved pain and function with chronic pain MattiasBuchner, MD, PhD, et al. The Influence of the Grade of Chronicityon the Outcome of Multidisciplinary Therapy for Chronic Low Back Pain. In Spine. December 15, 2007. Vol. 32. No. 26. Pp. 3060-3066. Rehabilitationis to be a master word in Medicine. --Dr. William Mayo 15
Summary There are few clear differences between the various non-pharmacologic therapies, but limited comparison has been done Exercise and multidisciplinary rehab were associated with increased rates of return to work Exercise therapy, spinal manipulation, massage, and acupuncture were shown to be effective for chronic low back pain but strength of evidence was low to moderate There was little evidence to support passive physical therapies More studies need to be done. There is lots of variation in technique and patients are participating in other therapies Chou, Roger; Deyo, Richard; Friedly, Janna et al. Nonpharmacologis Therapies for Low Back Pain: A systemic review for an American College of Physicians Clinic Practice Guideline. Annals of internal medicine. 166(7): 493-506 Summary There are many non traditional therapies that can be used for chronic low back pain. There is limited literature and limited long term follow up Most of the therapies are safe and can be used in conjunction with traditional treatment Acupuncture has been studied the most, but there needs to be more consistency in technique and increased follow up. 16
Summary Exercise Surgery Chronic Low back pain medication Injections Alternative Helen Keller 17
Resources Cao, Huijuan, Mei Han, Xun Li Clinical research evidence of cupping therapy in China: a systemic Literature review. BMC Complementary and alternative med. 2010 10:70 Chou, Roger; Deyo, Richard; Friedly, Janna et al. Nonpharmacologic Therapies for Low Back Pain: A systemic review for an American College of Physicians Clinic Practice Guideline. Ann Internal med. 2017;166: 493-506. Chou, Roger: Qassem, Amir: Snow, Vincenzeet. al. Diagnosis and treatment of Low back pain: A joint clinical practice Guideline from American college of physicians and the American pain Society. Ann intern. med. 2007;147:478-491. Hayden JA, van TudlerMW, Tomlinson G. Systematic Review: Strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann intern med. 2005;142:776-785. Huang, Cia-yu, Choong, Mun-Yau. Effectiveness of cupping therapy for low back pain: A systemic review. acupunct Med 2013 31: 336-7 Lam, Megan. Galvin, rose. curry, Philip. Effectiveness of Acupuncture for Nonspecific chronic low back pain. Spine. 2013; 38:2124-2138. Liu, Lin. Huang, Quing-Min, et al Evidence for Dry needling in the managemetnof myofascial trigger points associated with low back pain: a systemis review. Arch Phys med and rehab. 2018;99:144-52 Mattias Buchner, MD, PhD, et al. The Influence of the Grade of Chronicity on the Outcome of Multidisciplinary Therapy for Chronic Low Back Pain. In Spine. December 15, 2007. Vol. 32. No. 26. Pp. 3060-3066. Qassem, Amir, Wilt, Timothy, Mclean, Robert. Noninvasive Treatments for Acute, Subacute, and Chronic Low back pain: A Clinical Practice Guideline from the American college of physicians. Ann Intern Med. 2017;166: 514-530. Zhang, Ya-Jing. Cao, Hui-Juan. Li, Xin-Lin. Cupping therapy versus acupuncture for pain related conditions: a systemic review of randomized control trials and trial sequential analysis. Chin. Med. 2017: 12:21 18