April 2010 Newsletter from Malik Slosberg, DC, MS

Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Cecchi, F et al. Clinical Rehab 2010; 24(1):26-36.

CT features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain. Kalichman, L, PT, PhD, Kim, DH, MD, et al. The Spine Journal 2010; 10(3):200–208.


Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Cecchi, F et al. Clinical Rehab 2010; 24(1):26-36.

Methods: This randomized controlled trial compared spinal manipulation (SM), back school (BS), & individual physical therapy (PT) in the treatment of 205 CLBP Pts (reported having LBP ‘often’ to ‘always’ for 6 mo) (140 F, 70 M) with 12 months follow-up (F-U) in Italy. Patients (Pts) were randomized to either:

    Outcomes: Roland Morris Disability Questionnaire, Pain Rating Scale at baseline, discharge 3, 6, & 12 months.

    Results: SM Pts had better functional improvement and long-term pain relief than BS or PT, but received more treatments during F-U. Pain recurrences and drug use were reduced more for SM than BS or PT. SM Pts had more functional improvement than either PT or BS at discharge and across all F-Us. Pain relief at F-Us was signif better with SM. LBP recurrences and reduction of pain-related use of drugs were also better for SM. However, Pts in SM grp received more Tx during F-Us. Additional Tx consisted of short cycles of SM. Although SM had significantly better outcomes across all F-Us, the SM group had significantly more visits over the 12 months F-U. SM was less effective than PT in promoting self-management of recurrences, but better with pain control and disability reduction than BS or PT.

    BS PT SM
    Reduction in Disability at Discharge 3.7 4.4 6.7
    Reduction in Pain at Discharge 0.9 1.1 1.0
    Reduction in Disability at 12 mo 4.2 4.0 5.9
    Reduction in Pain at 12 mo 0.7 0.4 1.5
    Recurrences of LBP at 12 mo 24 34 9
    LBP related use of drugs 19 22 8
    Further visits for LBP Tx 14 8 40

    Conclusions: SM provided better short and long-term functional improvement, as well as, more pain relief at F-U than BS or PT. However, the SM group had significantly more visits over the 12 months of follow-up than either BS or PT groups.

    Comments:  The findings of this study are exciting for chiropractors because they indicate that manipulation resulted in better long-term outcomes for patients with CLBP in terms of pain reduction, disability reduction, frequency of recurrences, and LBP - related use of drugs than either back school or individual physical therapy even though both the back school and the individual physical therapy groups care included active exercise training. It is also worth noting that both the BS & PT groups had 15 one hour sessions in 3 weeks, that is 5 one hour sessions a week for 3 weeks versus 4 -6 twenty minutes sessions in the SM group. Both the BS and PT groups had 15 hours of contact time versus only a maximum of 2 hours for the SM group. It is also important to note that there were many more follow-up visits in the SM group which were apparently needed to achieve/maintain these better long-term outcomes. It would be valuable to have another care group included in a subsequent study which includes both SM and the same type of exercise training as was used in either the BS or PT group.
     

    CT features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain. Kalichman, L, PT, PhD, Kim, DH, MD, et al. The Spine Journal 2010; 10(3):200–208.

    Background: This community-based study of 187 subjects (Ss) (150 Ss without LBP in the past 12 months & 37 Ss with LBP in the past 12 months) evaluated the prevalence of lumbar spine degeneration features on CT and the association between lumbar spine degeneration features and LBP.

    Methods: The study calculated the prevalence of spinal degeneration features: disc narrowing, facet joint osteoarthritis (OA), spondylolysis, spondylolisthesis, spinal stenosis and the density of multifidus (MF) & erector spinae (ES) on CT in Ss with and without LBP to evaluate the association of spinal degeneration with age. The prevalence of degeneration features was calculated in four age grps (<40, 40–50, 50–60, & 60+ yrs).
    Results: The average age of Ss was 52.7 years. There is a high prevalence of disc narrowing (63.9%), facet joint OA (64.5%), & spondylolysis (11.5%). Only spinal stenosis showed statistically significant association with self-reported LBP.

    Conclusions: Degenerative features of the lumbar spine were extremely prevalent. The only degenerative feature associated with self-reported LBP was spinal stenosis. Other degenerative features appear to be unassociated with LBP in the past 12 months.

    Paraspinal muscles and LBP: A growing body of studies has demonstrated an association between changes in paraspinal muscles and LBP. Facet joint OA showed significant association with low density of MF & ES, and degenerative spondylolisthesis showed a close to significant association with low density of multifidus. Our results are in accord with a previous study which found that specific training of paraspinal muscles significantly reduces pain and disability in Ss w spondylolysis & spondylolisthesis. It would be interesting to explore if strengthening exercise for paraspinal muscles will prevent the development of facet joint OA and degenerative spondylolisthesis.

    Comments: This new study, like many before it, found that radiographic features of spinal degeneration are extremely prevalent in people greater than 40 years of age whether or not they have a history of significant LBP or not. However, this study is one of the first to evaluate whether there is a correlation between radiographic signs of degeneration and signs of atrophy (in this case low density) of the multifidus (MF) and erector spinae (ES) muscles. The fact that there was a significant association between indicators of MF & ES atrophy and facet joint osteoarthritis and near significant association  with degenerative spondylolisthesis is thought provoking, particularly in light of earlier studies which demonstrated that exercise training of these back muscles resulted in long-term (30 month follow-up) reduction of both pain and disability in people with spondylolysis and spondylolisthesis. This evidence is just one more confirmation of the importance of both evaluating these muscles for atrophy and the likelihood that exercise training focused on enhancing endurance, strength, and motor control of these muscles may contribute to not only improved function, reduced pain, but, perhaps, a reduction facet joint osteoarthritis.