FUNCTIONAL RATHER THAN STRUCTURAL

 

 

Sheir-Neiss GI, Kruse RW, Rahman T, et al.  The association of backpack use and back pain in adolescents.  Spine, May 1, 2003: 28(9), pp922-30.  74.4% of 1, 122 students between the ages of 12-18, reported back pain in the previous month and associations were noted between back pain and general health.  Females who used backpacks during the day reported twice the odds of having back pain. 

 

Leinonen V, Kankaanpaa M, Luukkonen M, et al.  Lumbar paraspinal muscle function, perception of lumbar position, and postural control in disc herniation-related back pain.  Spine, April 15, 2003:28(8), pp842-8.  Proper movement sensation and muscular control are necessary to avoid injury; therefore, it is important to understand the variables that affect these important sensory and motor activities.  Patients with sciatica demonstrated impaired lumbar proprioception and postural control compared with health controls.  Although lumbar proprioception and paraspinal reflex control appeared to improve “fairly well” following microdiscectormy, patients did not recover postural control during short-term postsurgical follow-up.  Such findings indicate that the impaired motor control exhibited by sciatica patients will not rectify on its own following discecotmy. 

 

Videman T, et al. Associations between Back Pain History and Lumbar MRI Findings. Spine. March 15, 2003; Vol. 28, No. 6, pp. 582-588.  Findings raise new questions about the underlying mechanisms of LBP. The sensitivities of the only significant MRI parameters, disc height narrowing and annular tears, are poor, and these
findings alone are of limited clinical importance.

Miniaci A, Mascia AT, Salonen DC, Becker EJ, Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. American Journal of Sports Medicine, 30: 1, 66-73, Jan-Feb, 2002.  The purpose of this study was to evaluate the magnetic resonance imaging findings in both shoulders of asymptomatic professional baseball pitchers. Fourteen pitchers who were without significant prior injury underwent a blinded clinical assessment and magnetic resonance imaging of both shoulders. All images were interpreted by two experienced musculoskeletal radiologists. The appearance of the rotator cuff tendons was graded, with additional evaluation of the biceps, labrum, and osseous structures. Ten athletes were found to have stable shoulders and painless full range of motion. Clinically, four athletes had at least a 40 degrees loss in internal rotation as compared with the nonthrowing arm. There were no significant differences in magnetic resonance imaging findings of the supraspinatus and infraspinatus tendons between the throwing and nonthrowing shoulders. The labrum was abnormal in 79% of the 28 shoulders. Enthesopathic changes of the posterior glenoid labrum were identified in the four pitchers who had loss of internal rotation. We conclude that unenhanced magnetic resonance imaging of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of "nonclinical" findings. These data can be useful in separating symptomatic pathologic findings from these variants. Enthesopathic changes of the posterior glenoid labrum in the throwing arm may represent an early Bennett-type lesion. The cause may be excessive traction on the posterior capsule during the pitching motion, with subclinical injury to this area.

 

 

Weisel, S M.D.  Are the individuals with back pain at heightened risk of permanent spinal injury? Backletter 2002; 17(1): 1, 8-10.  Many researchers believe that the injury model itself is flawed and outmoded.  Most BP cannot be attributed to any specific injured structure.  BP typically doesn’t have any obvious traumatic precedent.  Back pain sufferers in the U.S. exceeds 100 million people every year. 

 

 

 

Kibler, M.D. Herring, M.D. et al.  Functional Rehabilitation of Sports and Musculoskeletal Injuries.  Aspen Pub, Gaitersburg, M.D.  1998.  The issue is not simply treatment of symptoms, it is restoration of function.  The absence of symptoms does not mean normal function. 

 

 

 

 

Wilson, Cleary.  Journal of the American Medical Association 1995; Jan 4: 59-65.  In clinical practice, possibly up to 80% of patients who see MD’s have conditions for which no physiological or organic cause is found after routine investigation. 

 

Deyo, MD, MPH, Weinstein, DO. Low back pain.  NEJM.  2001; 344(5): 363-369.  85% of patients with LBP cannot be given a precise dx.  The assoc between sym and imaging results is weak.  Risk factors include things such as heavy lifting, poor conditioning, although LBP is common in subjects with out these risk factors.  For patients with nonspecific back pain a precise pathoanatomical dx is often impossible.  Mechanical Back pain: 97% of the time,

 

 

 

Haldeman, D.C., Ph.D., M.D.  Spine 1990; 15(7): 718-7223.  The pathology model cannot explain back pain or disability.  There is a large percent of symptomatic patients with severe complaints in whom testing fails to reveal any structural lesion. 

 

 

 

Wiesel M.D.  Spine 1984; 9(6): 49-51.  52 asymptomatic patients had CT scans.  In the 20-39 year age group 19.5% had herniated disc.  Of those 40 and older 50% had abnormal readings: herniations, spinal stenosis, ankylosis, etc. 

 

 

 

Jensen.  Dept. Rehab Med, University of Wa.  New England Journal of Medicine 1994; 331(2)July 14:69-73.  Found a high prevalence of abnormalities in the lumbar spine in 98 people without back pain.  Average age was 42.3 years.  Given the high prevalence of back pain, the discovery of a bulge or protrusion on MRI in people with low back pain may frequently be coincidental.  Abnormalities of lumbars by MRI can be meaningless if considered in isolation.

 

 

 

Stadnik et al.  Radiology 1998; 206: 49-55.  MRI study of lumbar disc abnormalities in 36 asymptomatic volunteers (18 with no history of back pain and 18 with history of back pain).  Annular tears were common in patients with back pain, but also with asymptomatic individuals. 

 

 

 

Bogduk, N, M.D. Ph.D.  American Back Society Newsletter 1998; spring: 6-7: Spondylosis occurs naturally with age and does not correlate significantly with pain. 

 

 

 

Wiesel, M.D. Backletter 1996; 11(8): 89.  Unfortunately, specialized imaging is a two edged sword.  It allows the accurate visualization of clinically important pathology, but also highlights vast numbers of clinically irrelevant asymptomatic abnormalities.

 

 

 

Bogduk, N. M.D., PhD.  What’s in a name? The labeling of back pain.  Medical Journal of Australia.  2000; 173(October 16): 400-401.  The International Association for the Study of Pain wrestled with the Dx of spinal pain.  Recognized that many Dx labels were illegitimate, inappropriate, or fanciful and stipulated strict criteria to be satisfied if a particular Dx label was to be used to ensure consistent and accountable use of terms.  The subcommittee argued that the only intellectually and clinically honest Dx for most cases of LBP as “lumbar spinal pain of unknown or uncertain origin” Labels are cumbersome, “Degenerative disc disease” conveys to patients that they are disintegrating, which they are not. 

 

 

 

Ito T et al.  Spine 2001; 26(6): 648-51 and Postachini F.  Lumbar disc herniation.  Spine 2001; 26(6): 601.  Patient with uncontained lumbar disc herniation can be treated without surgery if they can tolerate their symptoms for the first 2 months.  In this prospective study, all these orthopedic surgeons’ patients with symptoms of disc herniation underwent conservative care for at least 8 weeks-except those with cauda equina syndrome and severe motor weakness.  This protocol reduced disc surgery rate by almost 50%. 

 

Borenstein, M.D. et al.  The value of MRI of the lumbar spine to predict LBP in asymptomatic subjects: a 7 year follow up study.  Journal of Bone and Joint Surgery. 2001; 83-A(9): 1306-11.  In 1989, 67 subjects (average age of 35 yrs) without a history of back pain with MRI of the lumbar spine.  31% had an abnormality of the disc or spinal canal.  Study investigates whether MRI findings predicted development of LBP in asymptomatic subjects.  Findings discovered by MRI can only confirm the clinical suspicions of the clinician.  Treatment should not be based solely upon the MRI. 

 

Yelin EH, Ph.D. et al.  Transitions in employment, morbidity, and disability among persons aged 51-61 with musculoskeletal  and non-musculoskeletal conditions in the U.S., 1992-1994.  Arthritis and Rheumatism 1999; 42(4): 769-79.  A national survey of 8739 people found that painful musculoskeletal (MS) conditions in middle age are normal.  MS conditions affected about 2/3rds of people aged 51-61 and accounted for all but 10% of those with disabilities.  These conditions exact a heavy disability toll.  More than 40% of persons with MS conditions reported disability, which were almost 90% of all persons with disability in this age group.  MS conditions were defined as self-perceived arthritis, rheumatism, or problems of the back or feet.  Questions were designed to detect chronic ailments, not transient ones, but persistent ones, that have lasted or are expected to last.

 

 

 

Chila, D.O.  Patient Care 1990; May 15: 77-92.  The aim is correcting functional impairment rather than treating pathology.  Functional impairments do not readily fit the pathoanatomical medical model of diagnosis.  The emphasis is on altered function, not on a disease state.

 

 

 

Liebenson, D.C., Oslance.  Rehabilitation of the Spine, Williams and Wilkens, Baltimore.  1996: 73.  Overemphasis on treatment of structural pathology results in a failure to identify or focus on functional losses and work demands.  Most orthopedic tests search for structural pathology although they are present in only 20% of cases.  The remaining 80% of patients have no identifiable structural pathology and require treatment based on evaluation of functional deficits. 

 

 

 

Saal, M.D.  Spine 1995; 20(16): 1821-1827.  Structural changes do not necessarily predict levels of pain or disability. 

 

 

 

Mayer, TG, M.D.  Neurologic clinics of North America 1999; 17(1): 11-147.  When healing is biomechanically imperfect, leading to permanent impairment of supporting elements, chronic disability may follow. 

 

 

 

Teasell, M.D. and Harth, M.D.  Spine 1996; 21(7): 844-847.  The focus is no longer on diagnosis or treatment but on maximizing functional abilities for chronic low back pain. 

 

 

 

Waddell G. M.D.  The Back Pain Revolution.  Churchill Livingstone, 1998: 151.  Dysfunction depends on an imbalance between physical stresses and may be triggered by

increased physical stress or increased or unaccustomed use.  Stresses which may increase

vulnerability: Fatigue, lack of fitness, postural abnormalities, and faulty movement patterns.  Dysfunction may become self-perpetuating. 

 

 

 

Waddell G. M.D.  The Back Pain Revolution.  Churchill Livingstone, 1998: 232.  Pain leads to fear avoidance behavior, muscle spasm and guarded movements.  These in turn lead to immobilization and disuse, which contribute to muscle weakness, atrophy, joint stiffness, and loss of coordination and loss of cardiovascular fitness.  All of this contributes to painful musculoskeletal dysfunction. 

 

 

 

Deyo RA, M.D., MPH.  Low Back Pain.  Scientific American 1998; August: 48-53.  Multiple x-ray studies determined that many spine abnormalities were as common in asymptomatic people as in those with pain.

 

 

 

Bigos, M.D.  Acute low back pain in adults.  AHCPR, Dec 1994: 8.  Even after an extensive examination, approximately 15% of patients can be given a definitive diagnosis.

 

 

 

Lawrence RC, MPH et al Arthritis and Rheumatism 1998; 41(5): 778-799. The precise etiology of back pain is unclear, but we presume that most episodes are related to muscle and ligament injuries and bony or disc degenerative changes but definitive diagnosis is usually impossible.  Up to 85% of patients cannot be given a definitive diagnosis because of the weak association among back symptoms, pathologic changes, and imaging results. 

 

 

 

Deyo RA, M.D., MPH.  Scientific American 1998; August: 48-53.  About 98% of back pain patients suffer from injury, usually temporary to the muscles, ligaments, bones or discs.  Up to 85% of patients with LBP are left without a definitive diagnosis. 

 

 

 

Kuritzky, M.D.  Physician and Sports Medicine 1997; 25(1): 56-64.  97% of back pain seen by primary care physicians is mechanical in origin. 

 

 

 

D’Espiro.  Patient Care 1998; April 30: 85-103.  Most back pain is mechanical.  Imaging studies are more likely to confound than aid the diagnostic process.  Up to 90% of all spinal MRI’s can be read as abnormal say experts even in the complete absence of symptoms.  Similarly, many abnormalities seen on CT and X-ray films have no clinical manifestations. 

 

 

 

Gracovetsky SA, Ph.D. et al. Spine 1998; 23(5): 568-575.  Diagnosis has been demonstrated to be nonspecific in 80-90% of low back pain causes. 

 

 

 

Weinstein J, M.D.  Spine Letter 1997; 4(9): 4-6.  Haddox, M.D., and president of the American Academy of Pain Medicine states: The vast majority of people with back and neck pain have muscular pain from scarring and trauma to the muscle and muscular pain doesn’t image. 

 

 

 

Bigos, M.D.; Davis, BS. JOSPT.  The Agency for Health Care Policy and Research defined low back pain not as pain but activity intolerance due to back symptoms.  Don’t let patients confuse recommendations to be more comfortable (pain relief) with conditioning, which is the real treatment for an activity limitation. 

 

 

 

Mikheev, M.D.  The Chiropractic Report 1993; July 1-6.  (orthopedist and chief medical officer for the World Health Organization): Chronic low back pain isn’t an injury but a result of a downward spiral of inactivity and reduced functional capacity. 

 

 

 

Hides JA, Ph.D. et al.  Multifidus muscle recovery is not automatic after resolution of acute, first episode low back pain.  Spine 1996; 21(23): 2763-2769.  39 patients with first episode unilateral acute low back pain and unilateral, segmental inhibition of the multifidus muscle were randomized.  Lack of localized muscle support might be a reason for the high recurrence rate of low back pain following an initial episode. 

 

 

 

Waddell, M.D. In Weinstein, Wiesel (eds).  The Lumbar Spine.  Saunders 1990: 38-56.  In most patients with simple backache, we cannot identify any definite pathologic condition or even the anatomic source of pain.