Chapter 189 Nonoperative Management of Neck and Back Pain
Low back pain (LBP) usually is benign and self-limiting. Health care providers are in a position to improve patient response to back symptoms greatly by providing reassurance, encouraging activity, and emphasizing that more than 90% of LBP complaints resolve without any specific therapies.1
LBP is second only to upper respiratory problems as the reason why patients visit a primary care provider.2 Pain of spinal origin will affect 70% to 85% of the population at some point in their lives and is the most common cause of disability in patients younger than 45 years of age.3 It accounts for a large fraction of the health care budget. LBP treatment costs increased from $4.6 billion in 1977 to $11.4 billion in 1997. In 2005, an estimated $85.9 billion was spent in the United States.4 Annually, $20 to $50 billion is spent on workers’ compensation claims, with 10% of patients with back pain accounting for 85% to 90% of the costs.3,5,6 Although most adults experience low back and neck pain, only a small percentage (~1%) require surgery.
In 2005, 15% of adults in the United States reported back problems, compared with 12% in 1997.4 As more people seek treatment for back pain, the cost per individual is rising. One study4 found that the inflation-adjusted cost per study subject rose from $4695 in 1997 to $6096 in 2005. The natural history of LBP suggests that the passing of time is the best treatment, as 90% of cases resolve spontaneously within 2 weeks to 3 months of onset.3,7 LBP affects men and women equally, and the onset most often occurs between the ages of 30 and 50 years. Eighty percent of the population will experience acute LBP at least once, and 30% of this group will become chronic sufferers. The annual prevalence ranges from 14% to 45%.
Etiology
The etiology of spine pain is multifactorial. The cause of LBP may originate within spinal structures such as ligaments, facet joints, vertebral periosteum, paravertebral musculature and fascia, blood vessels, the anulus fibrosus, and spinal nerve roots. Disease states or processes such as cancer, infection, or musculoligamentous injuries also are causes of spinal pain, as are degenerative processes of the spine such as spinal canal stenosis, foraminal stenosis, and disc disease. No pathoanatomic diagnosis can be given to 85% of patients with isolated spine/LBP because of the poor association between symptoms and imaging results.6 “Strain” and “sprain” are commonly used as catch-all diagnoses for generalized LBP in the absence of major red flags.
Classification of Spinal Pain
Mechanical Pain
Mechanical spinal pain is generally described as deep and agonizing. It is worsened with loading of the spine during activity and relieved or alleviated by unloading of the spine with rest. Mechanical pain has a deep and aching quality. It usually is associated with degenerative conditions seen in older adults or the development of a pseudarthrosis after a failed fusion. It also may be present with tumor.8
Myofascial Pain
Myofascial pain is consistent with “muscle spasm.” Patients with significant trapezius spasm will describe tension-type headaches. Myofascial pain usually is self limiting and responds well to stretching exercise and muscle relaxants. Patients with underlying instability or mechanical pain often describe associated myofascial pain. “Strains” and “sprains” of the neck or low back are catchall terms used for nonspecific spine pain and usually are grouped within this category.8
Risk Factors
Adults are at risk of an episode of back pain regardless of timing, activity, or environment. However, many factors may make one patient’s risk comparatively higher than another. Risk factors for low back and neck pain include advancing age up to 55 years, Caucasian race, living in the western United States, prolonged driving of a motor vehicle, heavy lifting and twisting, overexertion, prolonged sitting or standing, trauma, obesity, poor conditioning, and smoking.9–12 In addition, there is a high prevalence of major depression in patients with chronic pain.13
Special attention should be given to the definite link between psychological variables and pain of spinal origin that has been discussed in the literature. Recognition of psychological variables emphasizes the need to highlight the multidimensional approach needed for caring for individuals with spine pain. Psychological distress can more than double the risk of low back pain.14 Stress, distress, anxiety, mood, emotion, cognitive functioning, personality factors, and abuse have been shown to be linked to the onset of back and neck pain. Psychological variables may play a role not only in chronic pain but also in the etiology of the onset of acute pain.15 Resultant disability caused by LBP may be a psychological stress-related disorder.16 A complex pathway of physical work demands, the patient’s reaction to the psychosocial environment, and the unique attributes of the person may affect physical loading on the spine, increasing the risk of LBP.17
Prevention
Ultimately, the best way to prevent LBP is to reduce risk factors. Patient education focusing on the prevention of episodes of LBP should include participation in an exercise program consisting of aerobic exercise, stretching, and strengthening exercise.18 Exercises showed strong positive results as an effective preventive measure against back and neck pain.19 Stretching and strengthening exercises may be done at home, thereby helping to reduce the monumental financial burden on the health care system. Smokers should be instructed to quit, because smokers have more severe symptoms that are present a greater portion of the day compared with nonsmokers.20 Another preventive intervention includes maintaining weight appropriate to height, because obesity is positively linked to LBP.12 Linton and van Tulder19 reviewed 27 controlled trials regarding interventions for the prevention of back and neck pain. Their review found that back schools were not effective for prevention. Evidence showed that lumbar supports were consistently negative, and there is strong evidence that they are not effective. Neither ergonomic interventions nor risk factor modification could be considered because of a lack of quality controlled trials and subsequent evidence.
Current Treatment Therapies
Points for Patient Education
The first step in management of spine pain is educating the patient with regard to the probable cause of his or her pain, including a brief explanation of the anatomic pain generators. By understanding the cause of the pain, patients are more likely to become active participants in their treatment plan. Patients should be encouraged to accept responsibility for managing their recovery rather than expecting the provider to provide an easy fix. The patient recovery process is then directed by activity level rather than level of pain as a limitation.1 The second step is to discuss the process of eliminating or reducing risk factors for future episodes of LB or neck pain and to reinforce the patient’s lifetime commitment to working toward this goal. Third, the patient must be reassured that LBP is a normal and common occurrence, has an excellent prognosis, and, in most cases, abates with the passage of time. Fourth, the patient should be informed that because LBP has a multifactorial etiology, more than one intervention or treatment method probably will be necessary. Finally, whichever treatment methods are chosen, follow-up care is essential, whether the doctor initiates the treatment or refers the patient to another physician or health care provider.
Patients should be encouraged to return to work as soon possible, because this is a predictor for positive outcomes and relief of back pain and helps to reassure patients that they will be able to resume their usual activities/lifestyle.1 Although many invasive and noninvasive therapies are intended to cure or manage LBP, no strong evidence exists to suggest that any single therapy is able to accomplish this as successfully as a therapy that focuses on restoring functional ability without focusing on pain. Patients should be aware that returning to normal activities usually aids functional recovery.1
Medication Therapy
Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective for short-term improvement in patients with LBP.1 No single type of NSAID is more effective than any other.21 Evidence suggests analgesics are not more effective than NSAIDs.22 Evidence has shown that muscle relaxants reduce pain intensity and that the different types are equally effective. Evidence for the use of muscle relaxants for LBP lasting longer than 3 months is lacking. However, the results show symptom relief when compared with a placebo.22 Evidence shows more effective symptom relief when medications are used in conjunction with NSAIDs and are prescribed around the clock rather than on an as-needed basis.6,23
Antidepressant drug therapy may be beneficial, because one third of patients who suffer from chronic LBP also have depression and may benefit. Antidepressants may decrease the patient’s perception of pain by treating underlying depression and improving sleep.1,24 Hypotheses of similarities between the physiology of pain and depression exist; therefore, there may be beneficial effects of antidepressant drug therapy on pain separate from the drug’s antidepressant effects.25 Treating patients who do not have signs and symptoms of clinical depression is controversial. However, tricyclic antidepressants have been shown to be effective in the treatment of nondepressed patients with neuropathic-type pain and significantly increased pain relief over placebo without a significant difference in functioning.26,27
Exercise Therapy
Aerobic Activity
Recently, aerobic exercise has shown the best evidence of efficacy among the exercise regimens, whether for acute, subacute, or chronic LBP.1 Benefits of aerobic exercise include weight loss and psychological effects of improved mood and lessened anxiety. The sense of well-being and accomplishment achieved from a planned aerobic exercise program creates a positive self-image and increases the level of motivation and commitment to the prescribed therapy. Some researchers have suggested that particular types of high-impact exercise should be avoided because of the potential for raising intradiscal pressure.28 This stance, however, has not been backed by objective data. It has been shown that patients participating in an aerobic exercise program received few prescriptions for pain, were given fewer physical therapy referrals, and had improved mood states and lessened depression.29
Stretching Exercises
The literature is inconclusive as to whether or not aggressive stretching exercises help to reduce low back pain.1 Stretching exercises help to improve the extensibility of muscles and other soft tissues, and to reestablish normal joint range of motion. Pain commonly limits mobility. Muscle spasm, or sprain, also may be present. Stretching is thought to maintain mobility and reduce spasm. Kraus et al.,30 in a study of the effects of stretching exercises on back pain, found that nearly 80% of people with chronic back pain who entered the program reported improvement at the end of a 6-week training session.31 More recent investigations have found that unless the exercises are continued, the benefit of stretching exercise may be lost.32 Patient compliance is, again, a large determinant in the outcome.
Isometric Exercises
Isometric exercises and exercise regimens have enjoyed significant popularity. Several studies33,34 suggest that isometric flexion offers the best relief of pain and improved function for LBP and neck pain. With regard to LBP, the rationale in these studies was that flexion (1) widened intervertebral foramina and facet joints, reducing nerve compression; (2) stretched hip flexors and back extensors; (3) strengthened abdominal and gluteus muscles; and (4) reduced dorsal fixation of the lumbosacral junction. Concerns have been raised over the use of flexion exercises, specifically regarding substantial increases in intradiscal pressure that may aggravate bulging or herniation of an intervertebral disc. Randomized controlled trials have shown conflicting results.35–37 However, core strengthening exercises are recommended after the acute pain has diminished.1
McKenzie advocated extension exercises, because they limit the risk of aggravating nerve root compression from extrusion of a disc fragment. This program is complicated and is individualized according to the patient’s symptoms. However, there is a very high noncompliance rate. McKenzie exercises are helpful for pain radiating below the knee.38
Mounting evidence indicates that weak muscles are associated with back and neck pain.31,39,40
