Special thanks to star physical therapist Brace Hayden, DPT, CSCS of Alpine Physical Therapy for providing this write up on a recent article from Spine.

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Low back pain with radiating leg pain or sciatica is a common problem in the United States and often highly expensive to manage. Conservative treatment by general medical practitioners, or the non-surgical approach of patient education, pain medicine and rehabilitation cost upwards of $55,000 per case, per five years. One in ten cases of low back pain have an irritated nerve root or radiculopathy that radiate pain down the leg past the knee. This type of back pain with sciatic leg complications from a bulging disc defined in this paper as “lumbosacral radicular syndrome”, often takes a large financial toll, as there is lost time from work and expensive medical costs.
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Shortening the painful, acute phase of lumbosacral radicular syndrome using a steroid shot to the level of the bulging disc is a widely-accepted and often effective treatment. Dr. Spijker-Huiges and her team of Dutch researchers assessed the costs of possibly shortening the duration of this injury and the medical costs to provide it. The study used a randomized control design where half of the 73 subjects received “care as usual” treatment from their provider and the other half were given a steroid shot to the back at the injured level and the usual medical care. The Dutch providers used the nationally recommended guideline for back pain treatment that includes pain medication, recommendations to maintain normal daily activities as much as they are able, and referrals for other rehabilitative treatments as necessary.

This study found small, but significant differences in many of the research variables they measured over the course of a year in the subjects in both the control and steroid intervention group. Interesting findings turned up less expensive and more cost-effective treatments in the steroid intervention group.  The addition of a steroid shot cost $259 or 191 Euros, but saved the individual the costs of lost work wages, increased total medication use, and increased time in physical therapy and other alternative therapies. Intervening with a steroid shot during the acute phase also had a small, but clinically measurable effect on reducing the individual’s initial pain and disability scores.

The authors noted that careful selection of patients during the acute phase (less than six weeks in duration) of this low back injury is important, as longer durations of radiating back pain do not respond as well. They concluded that implementing steroid injections is a win-win medical treatment for this disabling back injury with few negative side effects and many cost-saving benefits to society over the typical medical care. The patient’s pain and return to work time are also improved; thus, their productivity and income are increased.

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Spijker-Huiges A., MD, et al. Costs and Cost-effectiveness of Epidural Steroids for Acute Lumbosacral Radicular Syndrome in General Practice. An Economic Evaluation Alongside a Pragmatic Randomized Control Trial. In SPINE. Nov. 2014. Vol. 39, Pp. 2007 – 2012.

For more information on this topic, view our clinical module on steroid injections for back and sciatic pain by clicking here.

Special thanks to star physical therapist Brace Hayden, DPT, CSCS  of Alpine Physical Therapy for providing this write up on a recent article from Spine.
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The incidence of “slipping a disc” in your low back or herniating an intervertebral lumbar disc, in the medical vernacular, while attempting to move that heavy filing cabinet is not uncommon. The ensuing low back pain and often accompanying radiating leg or buttock pain from a bulging disc putting pressure on your spinal nerves is also unfortunately, quite common. Dr. Jon Lurie and a collaborative team of researchers based out of Dartmouth’s Department of Medicine, Orthopedics, Health Policy and Clinical Practice set forth to assess the data of 8-years of outcome research from operative versus non-operative treatment for this debilitating back issue.

Decompression surgery to relieve disc-related spine pain is a well-researched and a highly-accepted indication for spine surgery. While in the throws of an episode of raging low back pain, the quick fix of going under the knife seems like a logical decision, but spine surgery comes with plenty of costs and risks. The questions Dr. Lurie’s team set to answer was: why does the rate of surgery vary so greatly geographically in the U.S, if the surgical option is more effective and faster to provide relief? They also aimed to add to the body of knowledge of high-quality, multiple-testing sites, with randomized controlled trials of prospective surgical (or conservatively managed) effects on patients over the long term.

This study was considered a ‘concurrent prospective randomized and observational cohort study’, as each of the 1,991 eligible participants chose either a route into randomized study (surgery vs nonsurgery) at one of 13 spine clinics participating in this Spine Patient Outcomes Research Trial (SPORT) or the observational group. The observational group got to choose their not-so-random, treatment route of surgery vs nonsurgery. There was plenty of lenience in the eight-year study for either group to opt in or crossover to the other group as their back issue and provider deemed necessary. The nonoperative group was tracked over the course of the study and received the “usual care” recommendations. These treatments were customized to the individual and included at least: physical therapy, back pain education and counseling, and medication management.

All of the enrolled participants received thorough screenings and imaging tests for eligibility (such as >6 weeks of radiating low back pain with a confirmatory MRI), outcome measures and assessments on a regular basis (6 weeks, 3 months, and 6 months, and annually thereafter). Most surgical participants had the standard bulge trimming or ‘open discectomy’ and exam of their pinched nerve root. The study gets highly complicated statistically, as the analyses were multifactorial and convoluted to best capture the longitudinal comparisons of the randomized and observational groups. Lurie et al. provided plentiful and excellent flow diagrams cited in the original paper for those that want to peruse the detailed statistical intricacies behind such analyses as “intent-to-treat” versus “as-treated” groupings.

The results reiterated the hypothesis that usually, effective and selective surgery relieves radiating low back pain. Over the course of this 8-year study, more measurable improvements were “clinically significant” in all of the main outcome measures (ie. bodily pain, physical function, perceived disability) for the surgical group than those who remained nonoperative. However, both groups experienced heavy amounts of statistically challenging “crossover”, as humans tend to change their mind on the question of: Should I Get My Sciatica Relieved Surgically, Or Should I Wait? The common exception for both groups was neither returned to prior work status. Or once you ‘blow a disc’ hoisting that filing cabinet up the stairwell, you’re less likely to return to moving heavy office equipment regardless of choosing surgery or conservative care for your back. The study goes on to throw the conclusive bone to those deliberating this costly surgery, that “even among patients with strong surgical indications, many (34%) remained in the nonoperative group out to 8 years”. Take comfort in conservative rehabilitative care and do your core stabilization exercises and spine stretches if surgery doesn’t sound like your calling, as improvements in “sciatica bothersomeness” happened in both groups.

Jon O. Lurie, MD, MS, et al. Surgical Versus Nonoperative Treatment for Lumbar Disc Herniation – Eight-Year Results for the Spine Patient Outcomes Research Trial. In Spine. 2014, Volume 39, Number 1. Pp. 3-16.
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For more information, visit our patient guide on this topic by clicking here.

Special thanks to star physical therapist Brace Hayden, DPT, CSCS  of Alpine Physical Therapy for providing this write up on a recent article from Spine.

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It is widely accepted that low back pain is one of the most common orthopedic pains we will experience in a given year. It is also a highly scrutinized and researched health condition, as it is a very costly public health problem that affects a third of all adults.

Treatments for low back pain range from medication, to surgery, to therapist-delivered care. Recently, Dipesh Mistry and a team of health scientists from the UK’s Warwick Medical School, performed a systematic review of the research on the quality and effectiveness of low back pain treatments performed by therapists. Acceptable therapies for low back pain included a lot of treatments from psychological interventions to intensive rehabilitation programs, from laser acupuncture in Australia to high velocity thrust manipulation in Sweden.
The targeted types of low back pain were classified as ‘nonspecific’, meaning they do not come from a likely cause such as a fracture, tumor, infection or inflammatory disease. Nonspecific back pain is generally known as the common back ache or strain.
Mistry’s team combed through the research to select only high-quality, randomized controlled trial-based articles on subjects older than 18 with a history of nonspecific low back pain. Their results largely followed the prior literature reviews consensus small, rather than the conventionally-accepted moderate positive effective gains from therapeutic treatments. They were able to use a total of 39 articles from various search engines (ie. Medline and Cochrane Controlled Trial Register) completed between the years of 1948 to 2013.
They divided the articles into two sub-classifications as either a confirmatory finding or an exploratory finding. Confirmatory are more rigorous, follow-up research that strides to confirm or test the hypothesis. Exploratory are more preliminary research that aims to generate future hypotheses or build a base for future research.
Of the accepted, high-quality studies, only 3 studies (8%) tested hypotheses and were classified as confirmatory. Eighteen studies (46%) were classified as exploratory findings. The remaining 18 (46%), fell short of a substantive conclusion and were given the ‘insufficient findings’ status.
The researchers further tweezed each articles’ respective study methods for appropriate statistical testing for each interaction between studied variables. Fortunately, appropriate stats were employed in 27 of the 39 of the articles. The remaining articles had sub-classification reporting deficiencies or other areas deemed too weak to qualify for this paper’s systematic review.
They concluded that the sub-classified (either the confirmatory or exploratory findings) therapies for treating nonspecific low back pain have been ‘severely underpowered’ in their analysis. In other words, over the past 65 years, the 39 acceptable high-quality articles were only able to provide exploratory class research with insufficient evidence to boot. Moreover, they had poor quality data in their reported findings.
Mistry’s team also generalized that if we hope to better identify which form of low back pain treatment will be the most economical and effective, then we need to better classify which subgroup of persons with back pain are appropriate for each treatment.
Future research was suggested here to develop new methods to effectively identify subgroups in back pain research. Furthermore, they recommended that the low back pain research community needs to collectively revise their current approach to subgrouping the back pain studies. Continued perpetuations of exploratory class research won’t help improve the care for our substantial population of persons with back aches looking for effective therapies.
Dipesh Mistry, MSc, et al. Evaluating the Quality of Subgroup Analyses in Randomized Controlled Trials of Therapist-Delivered Interventions for Nonspecific Low Back Pain. A Systematic Review. In Spine. 2014, Volume 39, Number 7, pp 618 – 629.
For more information on the specialties and services provided by Alpine Physical Therapy, please visit our clinic website by clicking here.

Special thanks to star Alpine physical therapist Brace Hayden, DPT,  for providing this write up on a recent article from Spine.

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There is no arguing that low back pain is an illness that burdens a large percentage of Americans. Sadly, centuries of folk cures and decades of research have fallen short predict reduce the prevalence of low back pain. Modern medicine has dramatically improved the health and livelihood in many arenas, but back pain remains an age-old, expensive, debilitating and frustrating… pain.

The average person with back pain and the American health care reform analyst are equally interested in sorting the worthwhile from the worthless treatments for reducing the duration and frequency of back pain episodes. Comparative effectiveness research hopes to shed light on what services should be recommended and reimbursed by insurance carriers.  For example, the Cochrane Collaboration, another meta-analysis think tank, in 2010 looked at fifty studies on chiropractic treatments on low back pain and found muddled results across years of research.

. . . there is . . no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in . . . low back pain Future research is very likely to change the estimate of (the) effect and our confidence in the results.

Double doctor, J. Michael Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, found very little supportive evidence in his meta-analyses on comparative effectiveness of various manual therapies in his review of the existing literature.  “A comparative effectiveness meta-analysis” was performed to compare the relative effectiveness of various spinal manipulation treatments (from the ancient bonesetter to the modern back cracker), medical management (READ: drugs, injections, etc), physical therapy, and exercise for acute (less than a month) and chronic (more than 3 months) nonsurgical management of low back pain.

The good news is most pain originating from the muscles and joint in the human body is ‘self-limiting’, meaning slowing down, protecting your injury, and letting the body heal will often suffice. Research supports the notion that sixty to seventy percent of acute low back pain settles in six weeks without any medical treatment. Chronic low back pain sufferers get better in a year without treatment 40 to 70 percent of the time.  Pain whether short-term or long-term is indubitably unpleasant, so why suffer any longer than you have to if effective treatment is available.

This study looked at 56 spinal manipulation studies published between 1974 and 2010 and classified them into six different treatment categories. The categories included: 95 spinal manipulation studies, 31 exercise studies, 51 physical therapy/physiotherapy modalities (for example, ultrasound, electrical stimulation, and hot packs) studies, 40 usual medical care studies, and 40 control group studies of subjects that received no treatment. The results found a 96 percent relative improvement in the first 6 weeks across acute back pain studies was unrelated to treatment. Thus the “carry on with your life” control group and the various treatment groups were nearly equal in settling their acute pain. The chronic pain comparison analyses found that 32 percent of the various treatment studies could claim improved outcomes. The balance of the percentage of claimed improvement in the chronic pain comparison analyses can be attributed to everything else (letting the injury run its course). Looking at the printed boxplots of the 6 treatment categories effect sizes attributable to the passage of time alone, the three largest effect sizes were in the exercise group, then the spinal manipulation group, then the modality group.

This study also examined which spinal manipulation treatment provider did the best job for improving chronic back pain. It was determined in the comparison that getting your spine manipulated in the first 6 weeks has little influence on the outcome of shortening the duration of your acute pain. Five types of spinal manipulation providers (osteopaths, physical therapists, chiropractors, allopathic medical physicians, and bonesetters) were compared.  Spinal manipulation by a physical therapist was found to be most effective, and most variable, in treating both acute and chronic back pain.

In the 36 years and 8,400 patients subjected to comparative spinal manipulation studies research cost from $32 to $80 million. Menke’s comparative analysis makes the bold assertion that ‘equivocal outcomes are unacceptable for this investment’, and funding more research on the topic should be stopped.  It stands to reason, that inadequate analytics and methodology throughout the studies could be part of the problem. The take home message was that all of the compared treatments for acute and chronic low back pain are hard to quantify when looking at their relative effectiveness versus letting the injury run its course.
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J. Michael Menke, DC, PhD.  Do manual therapies help low back Pain? A comparative effectiveness meta-analysis. Spine. April 1, 2014. Volume 39 , Number 7. pp.  e463-e472.

Kegels are often thought of as an exercise purely for pregnant or post partum women, when in fact they can be very beneficial for everyone and particularly those people with low back pain.  Kegel exercises are one of the most commonly known methods of pelvic floor muscle strengthening. Kegels are most commonly described as tightening your pelvic floor muscles as if you are going to the bathroom and have to stop mid-stream.

Although Kegels have earned their merit for their contribution in helping with bladder control issues, Kegels also play another important role in spinal stabilization and management of low back pain. Spinal stabilization refers to the ability of the core muscles to effectively control movement and protect the spine during applied forces.

The three components that make up the core are the deep abdominal muscles (transverse abdominis), deep back muscles (multifidus), and the pelvic floor musculature.  The pelvic floor musculature is often overlooked in its contribution to core stabilization.  It is the interaction between these three muscle groups that provides a strong and stable spine and can significantly affect symptoms of low back pain.

Among individuals with a history of back injury or low back pain, core muscles are often weak and may not be doing their job of stabilizing the low back.  In order for the core to work correctly, it is necessary to have the coordination and cooperation of all three muscle groups together.  By re-training these muscles to work in concert during regular daily activities many people will report less back pain and higher functional abilities.

Although strictly performing Kegel exercises may not cure low back pain, adding Kegel exercises (specifically, contraction of the pelvic floor muscles) to additional exercises aimed at core strengthening may significantly improve the quality of the contraction and improve the overall stability of the low back.
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To improve the health and stability of your back, visit the educational library on our clinic’s website by clicking here. And for additional information on physical therapy approaches to women’s health, clicking here.

The causes of low back pain during pregnancy are individual and can be numerous. Through an individualized evaluation performed by one of Alpine’s Her Health physical therapists we can get to the bottom of your pregnancy-related low back.

Possible solutions that we may provide include core strengthening, postural retraining, instruction in sleep position modification, manual therapy, fitting for a prenatal pelvic support brace, pelvic floor training, and instruction on a safe prenatal exercise program.

Also, water exercise, Pilates, and CoreAlign feel good on a pregnant woman’s body. Thus, we take advantage of our knowledge of these treatment choices to help provide a safe alternative to your pre-pregnancy exercises.
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Tara Mund, DPT, the Director of Her Health at Alpine, describes in the accompanying video what physical therapy can do to help when low back pain occurs during and after pregnancy. Click on the video player below to view.