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10 Articles in Volume 9, Issue #6
Cytokine Testing in Clinical Pain Practice
Effective Monitoring of Opiates in Chronic Pain Patients
Ethics, Pain Care, and Obama’s Policy Intentions
Interventions for Radiating Upper Extremity and Cervical Facet Pain
Long-Acting Opioids for Refractory Chronic Migraine
Need for More Accurate ER Diagnoses of ACL Injuries
Neural Therapy and Its Role in the Effective Treatment of Chronic Pain
Screening Blood Panel to Evaluate New Chronic Pain Patients
Spinal Pain and Neuromuscular Deficiency
Thermal Imaging Guided Laser Therapy: Part 1

Spinal Pain and Neuromuscular Deficiency

When inhibited deep core muscles of the spine are the cause of back pain, a neuromuscular reactivation approach can help normalize muscle firing patterns between the local and global musculature and thus alleviate back pain.

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

Motor Control Research

The message that is coming from motor control research labs such as Queensland University in Australia is that neuromuscular integrity is important as a determinant of back pain. Furthermore, poor segmental control can predispose one to more spinal injury. Apart from the typical injury and age-related changes we see in the average spine, the more important aspect of spine health may be whether or not the individual is capable of proper neuromuscular spinal stabilization—quite apart from whether there are visual abnormalities in spine architecture. There is research suggesting that trauma, injury, or detrimental age-related changes that can cause pain will reflexively inhibit the deep local lumbo-pelvic core muscles such as the multifidus.7 There is also evidence that once the pain has diminished or disappeared, these deep muscles do not revert back to proper function—much like a light switch that has been turned off and stays off. Pain causes reflex inhibition leading to delayed or disrupted deep muscle activity which leads to poor segmental stabilization and ultimately leads to compensatory strategies wherein the body attempts to find other ways to achieve stability. The use of surface EMG has helped to confirm these compensatory strategies as being primarily that of the more superficial or global musculature showing more EMG activity in trying to substitute for the lesser functioning deep muscles. This becomes problematic and leads to further episodes of pain and injury.

ATM2® Concept

The ATM2, depicted in Figure 1, illustrates a number of typical pelvic, hip, neck and shoulder positioning and exercise motion formats that practitioners are using to restore proper deep core muscle activation. This technology uses a unique pelvic repositioning system made up of two belts tethered to a four-way ratchet system that is able to control the pelvic axis in a three-dimensional manner. This is important because the first step in using this therapy is to find the patients unique pain-free position. Pain is the cause of inhibition so this initial step is vital to the success of the treatment.

Figure 1. Positioning and exercise of isolated muscle groups using ATM2® equipment. Illustration reprinted with permission of the BackProject Corporation.

It is hypothesized that being upright and in a pain-free position using proper pelvic mechanics (neutral spine) enables the central nervous system to instantly transition from a pathological firing pattern (low deep and high superficial muscle activity) to a more normal firing pattern. What the practitioner is thus doing with the ATM2 is using the particular capabilities of this device to position a patient comfortably so as to begin exercising using resistance in a now pain-free manner. The ATM2 concept is not a strengthening system but rather a neuromuscular re-activation system. This device is proving to be a cost-effective intervention in the treatment of back pain since the deep core muscle reactivation phenomenon had not been recognized until very recently. It is interesting to note that every randomized clinical trial we reviewed as part of the referenced meta-analysis that investigated exercise as a treatment intervention all used a different type of exercise training. Further, many did not sufficiently describe exercise type and dosimetry so as to lend itself to replication.

The study of an exercise application should follow the same rules of study as those applied to the study of a new medication. A dose response curve could be established for specific exercise types and categories since they each have unique characteristics and impart unique benefits. The question of whether exercise is an important and useful intervention in the treatment of back pain is the same as asking whether drug therapy is an effective intervention in back pain. If neither exercise nor drug therapy is further defined as to specific sub-types and categories, the question is simply too general and renders any answer confusing. The ATM2 is a very specific form of exercise that utilizes a neuromuscular approach to disinhibiting the deep core muscles of the spine to alleviate back pain. Unlike traditional strength training exercises that rely on progressive overload and specificity (SAID principle), the ATM2 requires neither and achieves the target objective much faster—that objective being deep core muscle reactivation leading to normalized muscle firing patterns between the local and global musculature. The end results have been impressive in preliminary research conducted by various groups across the country. For chronic pain due to longstanding core muscle inhibition, sonography has demonstrated multifidus atrophy. Once core reactivation has occurred and regular core strengthening begins, multifidus hypertrophy has been measureable. Other studies have shown that as core reactivation has begun and pain diminishes, more normal training effects can be seen in target muscles such as the multifidus muscle.8

Conclusion

Low back pain has such enormous direct and indirect costs associated with its presence that the lack of understanding regarding the etiology of low back pain makes it a challenging entity to treat. Therapeutic exercise has been used by musculoskeletal practitioners as a tool in a rather large arsenal of treatment options for the treatment of back pain. Unfortunately, the myriad of treatments and therapies—both invasive and conservative— have collectively done little to reduce the enormity of the problem. Research studies have their own challenges including methodological flaws and shortcomings but at least help to guide our thought processes in the right direction. There have been many products and technologies that have been promoted as a panacea for back pain but most have failed to deliver since we clearly still have a worsening problem in the population. The concept of neuromuscular deep core muscle reactivation comes at a good time when health care dollars are shrinking and measureable and sustainable functional progress is the mantra for all insurance companies. This approach should continue to be studied by those so inclined and noted by all clinicians who are charged with the treatment of back pain.

Last updated on: December 28, 2011
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