Spinal Pain and Neuromuscular Deficiency
The plethora of available treatment methods for low back pain (LBP) is a clear testimonial to the lack of efficacy of any one method to significantly reduce low back pain. This problem has been so elusive that we try and give names to it that reflect our inability to understand its root causes: failed back syndrome, mechanical low back pain, idiopathic low back pain, non specific low back pain and the descriptors continue to grow. In a recent interview with a prominent spine journal, the lead researcher of the APS review, Roger Chou, MD, was asked the question whether there had been progress in understanding the etiology of back pain. His answer was “Overall I would say yes. Even if we have to conclude that we do not yet understand the association between some exposures and low back pain, that in itself is an advance in knowledge.” This is a humbling reminder that back pain continues to be ubiquitous and its incidence has been relatively unaffected by current treatment interventions including both surgical, non-surgical invasive, and conservative modes of treatment.1 There appears to be a greater clarity amongst clinicians and researchers that low back pain is probably not related to any one single factor. Rather there are a number of risk factors for any one person and that future research will need to tease out which set of factors is most relevant to that subset of people at most risk for developing back pain.
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The American Pain Society recently sponsored two major reviews and a clinical practice guideline on invasive treatments for persistent low back pain. Two primary physician reviewers, along with a multidisciplinary panel, then followed up with a series of consensus statements based on the evidence. The concern has been that there is a growing trend towards invasive treatments—both surgical and non-surgical—whose evidence base is questionable. Following are some of the findings. The reviews found that most invasive treatments do not have support from high quality clinical trials—especially those aimed at low back pain without leg symptoms or non-radicular problems. This holds true for everything from injections and thermal therapies to intrathecal pumps. There is a greater degree of evidence in favor of invasive treatments such as decompression surgery for low back pain with leg symptoms such as sciatica.
Regarding diagnostic testing, we continue to want to attribute or correlate imaging results with patient symptoms despite evidence supporting the poor correlation between the two. Our quest to find a specific anatomic “pain generator” seems to drive this desire. Dr. Chou, the lead author in the APS review, could not find any convincing evidence to support the use of any commonly-employed invasive test from discography and facet blocks to sacroiliac joint procedures.2 With regard to discography, a recent study (the Stanford Discography Project) has linked the test with exacerbation of the disease process it sets out to identify. In other words, patients who had discography performed were more likely to have subsequent findings of disc degeneration presumably due to prior disc puncture and injection, according to Carragee et al.3 The researchers also found that new disc herniations were disproportionately found on the side of the annular puncture. This is one example of how a routinely-used diagnostic test not only lacks evidence, but can also be harmful. The implications transcend the medical and into the legal realm.
Machado et al conducted a meta analysis of back treatments for acute and chronic low back pain relief and examined only randomized clinical trials having a valid placebo group to minimize bias in the assessment of treatment effects. Treatments with small treatment effects (10 points on a 100 point scale) included thermal intradiscal techniques, radiotherapy, traction, prolotherapy, physiotherapy, exercise, antidepressants, behavioral interventions, spinal manipulations, NSAIDS and many more. Those interventions with a moderate treatment effect (10-20 points) included RFA, analgesics, herbal medicines, facet injections, cold laser, massage, muscle relaxants, anticonvulsants, back school, nerve blocks, heat, TENS, and acupuncture. There were only 5 treatments with large analgesic effects (>20 points) and these included neuroreflexotherapy, vitamin B12, infrared therapy, electroacupuncture and immunoglobulins. Important to note is that this review measured strictly the analgesic effects of these interventions or the pain relieving value of each treatment.4
The most recent systematic review by Bigos et al examined what, if any, intervention or primary prevention method finds support through high quality randomized clinical trials. Bigos writes “we have found strong and consistent evidence that exercise has a significant impact, both in terms of preventing symptoms and reducing back pain-related work loss. We did not find high quality scientific evidence to support any other prevention methods.”5
What we are seeing is that there is not a tremendous amount of precision in terms of scientific agreement when assessing the impact of an intervention on a target disorder such as back pain. However, some general trends are evident including that exercise has anywhere from a small to a very large treatment effect depending on the outcome being measured—e.g., pain reduction, functional improvement, strength/endurance, disability scores, etc. It is within this context that this report will focus on a novel method of combined exercise and manual therapy referred to as an Active Therapeutic Movement or ATM that is performed with an ATM2® device. This method or intervention for spine-related pain was developed recognizing that traditional interventions (drugs/surgery/injections/physical modalities) targeting disease and/or anatomical structures have fallen short in terms of providing consistent pain relief and restoration of function. Many of the common targets for medical interventions have been the more passive anatomical structures such discs, ligaments, facet joints, vertebral bodies and nerves in general. Results have been disappointing and the problem of spine pain not only persists but is increasing.
There is a new recognition that focuses on neuromuscular elements of the human body and a growing amount of evidence that underscores the interplay between muscles and the nervous system—namely that muscle length, strength and activation must be in harmony. When this is not the case, pain and predisposition to further injury are possible. Research is showing that muscle activation—that is, magnitude and timing—are essential features of a properly functioning system. Much of the research is focusing on the deep or local muscles of the spine such as the multifidus muscle that is a key spine stabilizer in providing segmental control.6