conservative treatment of low back pain in the older adult: a
TRANSCRIPT
Adams, T. Low Back Pain in Older Adults 1
Conservative Treatment of Low Back Pain in the Older
Adult: A Literature Review
By: Tara Adams
Faculty Advisor: Rodger Tepe, PhD
A senior research project submitted in partial requirement
for the degree Doctor of Chiropractic
April 10, 2012
Adams, T. Low Back Pain in Older Adults 2
ABSTRACT
Objective
This review provides an overview and analysis of the most recent literature concerning the
efficacy of the most common conservative and invasive treatments for low back pain. Emphasis
was given to articles that focused specifically on the treatment of low back pain in the older
adult, although studies focused on a younger adult population have also been included.
Emphasis is given to an inter-comparison of the conservative care options as well as a
comparison between conservative care and surgery for similar conditions.
Data Collection
Computer searches using GoogleScholar, PubMed, Index to Chiropractic Literature and
MANTIS/ChiroAccess from 1999-2012, were searched with a combination of the following
keywords: low-back, pain, aged or elderly or older adult along with a combination of the
following terms: alternative treatment, conservative treatment, spinal manipulation, acupuncture,
exercise, counseling, massage, and surgery. Sources were compiled from the searches as well as
from Dr. Enix’s accumulated research articles and references within the articles.
Conclusions
A consensus of selective reviews and controlled studies, support the recommendation of a trial of
conservative care in the treatment of low back pain. Emerging evidence shows that
psychological factors such as anxiety, depression and fear avoidance all play a role in the
propagation and perseverance of pain. There is no one strategy that has proven pain relief across
the board, yet a combination of the following education/counseling, exercise/stretches, massage,
spinal manipulation, and acupuncture elicits the best outcomes. Sometimes, a combination of
drugs with conservative therapy is necessary. For those whose conservative treatments have
failed, there are always more invasive options. More research is needed on the efficacy of
specific interventions used to combat low back pain in the older adult.
Adams, T. Low Back Pain in Older Adults 3
INTRODUCTION
Low back pain is a common musculoskeletal disorder that affects 80% of the population during
some point of their life.1 “More than 17 million people aged 65 years or older in the United
States experience at least one episode of low back pain (LBP) in a calendar year2. Six million of
those individuals suffer from compromised quality of life because of frequent episodes2.
Consequences of chronic pain in those investigations highlight physical disability3,4,5,6
,
depression and anxiety5,7,8
, sleep disturbance9,10
, and increased utilization of health care
resources11
.”12
In the United States, low back pain is one of the most common reasons people miss work and it
is the most common cause of job-related disability.13
Approximately 149 million days of work
are lost per year specifically attributable to lumbar injuries; with approximately two thirds of
these days lost due to occupational injuries.14
The annual productivity losses resulting from lost
work days are estimated to be $28 billion, and “a small percentage of patients with chronic LBP
accounts for a large fraction of the costs”14
Although low back pain can originate from non-musculoskeletal etiologies, these will not be
discussed in this paper. This review will focus on the most common etiologies of low back pain
in the elderly, as well as efficacy of the following common conservative treatments employed for
chronic or acute low back pain: spinal manipulation, massage, acupuncture, exercise therapy,
electrical therapies, counseling and education.
The differences between the allopathic and alternative models of treatment for low back pain as
well as cost effectiveness and patient satisfaction will also be discussed. Although there are
thousands of research articles studying the treatment of low back pain in the general population,
there are but a handful of studies focusing specifically on treatment of low back pain in the older
patient.
Adams, T. Low Back Pain in Older Adults 4
DISCUSSION
Incidence and trends
“According to government reports, the US population of elderly citizens is increasing
dramatically. In the 1900s, people over 65 comprised 4% of the US population. By 1968, this
had increased to 12.4%, and by 2032, it is estimated that this proportion will increase to 22%.
Foster et al2 noted that approximately 30% of people aged 65 or older used at least 1 alternative
medicine modality in the preceding year.15
Chiropractic was the most frequent provider accessed
at 11%. Del Mundo et al3 have reported that alternative medicine use in rural communities is
significant.16
Seventeen percent of all respondents (all ages) indicated that they used chiropractic
services in the past year.”17
A telephone survey performed of 4437 adults in North Carolina
attempted to disseminate the incidence of low back pain and which treatments had been sought
for the condition. Of the 73% “of those who sought care, 91% went to a medical doctor, 29%
saw a PT, and 25% saw a chiropractor. 37% received a computed tomography scan, 25%
received a magnetic resonance imaging scan, and 10.4% underwent surgery.” 18
Approximately 12.5% of the 65 years of age and older population surveyed, reported low back
pain at that time; with approximately 20% stating they had low back pain within the previous
year.19
According to a survey performed of adults aged 70-79, 36% reported low-back pain.20
In
two different British surveys of the general population, 38% of respondents reported a significant
episode of low-back pain within the last year.21
Over the last 20 years, Britain has also noticed an
exponential increase in the amount of disability benefits being paid due to back pain.21
Similar increases in the incidence of low back pain have also been seen in Australia and the
United States. “By the age of 30 years almost half the population will have experienced a
substantive episode of low back pain.”21
One could conclude that low back pain is becoming
increasingly common throughout the world in both the young and old. Unfortunately, increasing
age is a large predilector of having low-back pain.
Adams, T. Low Back Pain in Older Adults 5
Epidemiology of low back pain in older adults
“Care from doctors of chiropractic emphasizes spinal manipulation, which has been shown to be
effective in several randomized trials.22
A study completed in North Carolina, demonstrated that
39 percent of persons seeking care for acute back pain go to a chiropractor first.23
”24
Several
studies concluded that being female was a common predictor of CAM use. 25,26
One study,
however, by Ness et al reported that men were more likely to go to chiropractors specifically, but
less likely to go to a CAM practitioner in general.27
Other studies concluded that the more
educated26,28,29
and those with a higher income27,29,30
were more likely to see a chiropractor.
Greater than average use of alcohol27,30
as well as the ability to drive,30
also increased their
chances of visiting a chiropractor. A study of older patients showed that those who self-reported
that they are more spiritual,25,26,28
as well as those who were Caucasian,25,30
also had increased
visits to CAM practitioners. The most common reasons the elderly seek out CAM providers
were for pain-related symptoms26,30,31,32,33
usually due to arthritis31,32
, or to improve their quality
of life30
, or for health maintenance30,32
. The majority of older patients reported being satisfied
with the care they received28,34
while others believed the care they received was beneficial31
.
Earlier studies done by Hawk et al.35
and Rupert et al.36
had similar findings.
Etiology of low back pain in older adults
Low back pain can be mechanical or non-mechanical. Non-mechanical low back pain can be
from a neurologic syndrome, a systemic disorder, referred pain or a fracture. A 2001 statistic
states that osteoporosis affects approximately 25 million Americans annually.37
Long term use of
corticosteroids has been shown to increase the risk of osteoporosis. Low bone mass caused by
osteoporosis increases the risk of skeletal fractures. Evidence of vertebral deformities were
found in 39% of men and women.38
The following activities have been shown to increase the likelihood of low back pain; manual
lifting, bending, twisting and whole body vibration.39
“Our data give strong support for a role of
Adams, T. Low Back Pain in Older Adults 6
regular heavy lifting in the etiology of low-back pain and add weight to the evidence implicating
occupational driving as a risk factor. At the same time, however, they suggest that such activities
account for only a small proportion of the total burden of low-back pain in the general
population. Our estimates of the fraction of disease attributable to heavy lifting and car driving
are 14 and 4 %, respectively. Even if allowance is made for uncertainties in these figures, a
substantial proportion of cases remain unexplained.”40
Some of the most commonly diagnosed mechanical pathologies of the low back are lumbar
herniated disc, lumbar spinal stenosis, degenerated discs, facet joint problems and sprains and
strains.41
Mechanical low back pain is thought to occur from several different mechanisms. One
of which is from direct compression of a nerve (which also usually presents with buttocks and or
leg pain) by discal material, muscle, or new bone growth. Discs are particularly sensitive pain
structures. One study revealed that “Pain was elicited by using blunt surgical instruments or an
electrical current of low voltage in 30% of patients who had stimulation of the paracentral
annulus fibrosis and in 15% with stimulation of the central annulus fibrosis. However, it is
unclear why mechanical back pain syndromes commonly become chronic, with pain persisting
beyond the normal healing period for most soft-tissue or joint injuries in the absence of
nonphysical or operant influence.”42
The periphery of the disc has a small amount of blood
supply and heals slowly. Although this is a possible explanation for how chronic pain begins,
there is no “direct concordance between structural degeneration and spinal pain.”42
There is,
however, an increased risk of low-back pain if one has had a previous episode of low back
pain.21 “
Research to date suggests that the cause of symptomatic radiculopathy is more complex
than just neural dysfunction due to structural impingement….Neurotransmitters and biochemical
factors may sensitize neural elements in the motion segment so that the normal biomechanical
stresses induced by previously asymptomatic movements or lifting tasks cause pain.
Furthermore, injury and the subsequent neurochemical cascade may modify or prolong the pain
stimulus and initiate the degenerative and inflammatory changes described above, which mediate
additional biochemical and morphologic changes. Whether the biochemical changes that occur
Adams, T. Low Back Pain in Older Adults 7
with disk degeneration are the consequence or cause of these painful conditions is unclear.
However, chemical and inflammatory factors may create the environmental substratum on which
biochemical forces cause axial or limb pain with various characteristics and to various degrees.”
42 The following research supports the hypothesis of central sensitization of the spinal cord
facilitating the process of chronic pain.
Facet joint dysfunction is another common pain generator in approximately 15-45% of patients
with low back pain.42
The capsule of the facet has many nerve endings, encapsulated,
unencapsulated and free. Substance P (SP), is one of the neuropeptides that regulates
nociception, and SP filled nerve fibers have been found in degenerated lumbar facets. There is a
direct correlation between those facets with more severe arthritis and those with a larger amount
of SP filled nerve fibers.42
The following statement supports the belief that there is an increase in
nociceptive nerve fibers in areas where previous trauma has occurred.
Muscle strains, trigger points (TrPs) and myofascial pain syndromes are increasingly common
diagnosis related to low back pain. “To date, research suggests that myofascial dysfunction with
characteristic TrPs is a spinal segmental reflex disorder. Animal studies have showed that TrPs
can be abolished by transecting efferent motor nerves or infusing lidocaine; however, spinal
transection above the level of segmental innervation of a TrP-containing muscle does not alter
the TrP response. Simons postulates that abnormal, persistently increased, and excessive
acetylcholine release at the neuromuscular junction generates sustained muscle contraction and a
continuous reverberating cycle.”42
The constant cycle of pain, segmental cord stimulation, pain,
segmental cord stimulation, aforementioned, is thought to be the same cycle that chiropractic
adjustments can interrupt. If not addressed, subconscious reflexive muscle contraction as a result
of neuropathic pain can perpetuate the pain, spasm, pain cycle.
Older adults are at an increased risk for mechanical overload and spasmodic tissues due to a
decrease in hydration, muscle mass and elasticity of connective tissues. Seven articles were
found, detailing chiropractic management of the following conditions commonly faced by
elderly that also present with low back pain; lumbar spinal stenosis 43,44
, spondylolysis of a
lumbar vertebrae45
, far lateral disc herniation46
, lumbar spinal synovial cysts47,48
, and “apparent
Adams, T. Low Back Pain in Older Adults 8
mechanical femoral neuropathy”49
. There are many conditions that may present as low back
pain.
Arthritis of the spine, such as osteoarthritis and rheumatoid arthritis, are commonly found in the
elderly patient. Since most elderly are retired or do not perform jobs requiring manual labor, the
causes of low back pain in the elderly can often be attributed to biomechanical adaptions due to
degenerative changes in the spine and atrophy of soft tissues. Degenerative changes can lead to
improper biomechanics and postural adaptions, such as anterior head carriage. Similarly,
improper biomechanics can lead to musculoskeletal adaptions and degenerative changes.
Whether the degenerative changes come first or last is debatable on a case by case basis; but
what is known is that improper biomechanics can lead to low back pain. Only a qualified
practitioner can perform the necessary history, physical and examination necessary to determine
the etiology of pain.
Low Back Pain and Falls
Low back pain is a co-morbid factor directly related to the incidence of falls in the elderly. Low
back pain in older adults doubles their risk for falls compared with people without low back
pain.50
Falls are the leading cause of injury and accidental death in adults over the age of 65
years . 51
The elderly represent more than one third of all hospital injury admissions, and more
than 80% of these injuries are caused by unintentional falls.51
These falls are the leading cause of
non-fatal injuries requiring medical attention in the United States.50
“Balance problems and falls
are common among the elderly and are a leading cause of institutionalization in this group that
result in over five million patient outpatient visits per year. It is estimated that between 28% and
35% of individuals over age 65 fall each year, with a fifth of those requiring medical attention.1
The number of fallers increases to over 40% for those 75 and older.51
A history of falling is also
a robust predictor of morbidity among the elderly.52,53
Low back pain (LBP) is the most
frequently reported musculoskeletal condition in the elderly, with a prevalence ranging from
19.7% in people over the age of 65, to as high as 40 % for individuals over 75.51,52,54
LBP is a
leading comorbid factor directly linked to the incidence of falls in the elderly and is sharply on
Adams, T. Low Back Pain in Older Adults 9
the rise; LBP prevalence has increased in the last fourteen years from 3.9% to 10.2%.54,55
LBP in
the elderly can involve a wide range of possible diagnoses and co-morbidities, including a high
incidence of malignant or visceral causes and therefore necessitate a close review of systems in
addition to the usual musculoskeletal examination.55,56
”50
One study attempted to understand the
effect of chiropractic care on balance, chronic pain and dizziness in older adults. They found
that 9 out of the 34 patients studied reported dizziness, all of those who were in the groups that
received chiropractic care showed clinically significant improvement in Dizziness Handicap
Index scores. Those in the non-treatment group had no significant improvement in Dizziness
Handicap Index scores.34
A single-group, pretest/posttest design intervention study of patients
65 years and older revealed that the of 6 patients with significant dizziness at baseline, 3 had
scores of 0 (no dizziness) on the DHI at visit 16.57
Effectiveness and clinical course of healing and prognostic features
It has been demonstrated in several systematic review, that the rapid improvements in low back
pain usually occur within the first three months after initial onset.58,59
After the first three months
there is only a gradual decrease in pain. For example, 6 months after onset, anywhere from 3-
40% of patients are still off -work, and at 12 months post-onset, anywhere from 42-75% of
people still report pain. Recurrences occur often within a year, with approximately 60% with
recurring pain and 33% with recurring absence of work.58
The large population based study completed by Kroft, et al. revealed the following outcomes for
episodes of low back pain seen in general practice. It should be taken into account that patients
self-reported pain and disability and their consultations with providers. Although most people
seeking care from their general practitioner for low back pain did not continue to consult their
Dr. about their symptoms after 3 months, most still had a substantial amount of pain and related
disability. In fact, only 25% of the patients had fully recovered 12 months later.21
It is a falsely
held belief that “90% of episodes of low back pain seen in general practice resolve within one
month.”21
It has been shown that effective early treatment of low back pain can reduce the
Adams, T. Low Back Pain in Older Adults 10
incidence and severity of symptoms as well as reducing the social, economic, and medical
impact.21
Annual cumulative consultation rate among adults in the practices was 6.4%. Of the 463 patients
who consulted with a new episode of low back pain, 275 (59%) had only a single consultation,
and 150 (32%) had repeat consultations confined to the 3 months after initial consultation.
However, of those interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170
(25%) respectively had completely recovered in terms of pain and disability. The conclusion
drawn from the above statistics demonstrates that that the results are consistent with the
interpretation that 90% of patients with low back pain in primary care will have stopped
consulting their doctor with symptoms within three months. However, most will still be
experiencing low back pain and related disability one year after consultation.21
Although the
strongest predictor of a delay in the return to normal functioning was a high level of functional
impairment at base line,60
increased age also has a negative impact on recovery.61
Allopathic vs Alternative
The allopathic model’s treatment of low back pain consists of prescribing muscle relaxers and
pain relievers. A physical therapy prescription for exercises is the allopath’s second line of
defense. In the event that those interventions fail and the back pain does not resolve, then more
invasive procedures such as cortisone injections or surgeries are recommended.
The alternative, or chiropractic method of treatment for low back pain normally consists of a
sequential flow through the following stages of treatment: acute, subacute, and wellness. The
commonly utilized stages of care documented by chiropractors are: acute, subacute, chronic,
recurrent/flare-up, and wellness. During the acute phase, passive treatments such as spinal
manipulation and physiotherapy (for example, ice, interferential, ultrasound) are used to help
reduce pain. Patients are also educated on how to manage their condition independently.
A chiropractor will generally explain that the patient’s healing is going to require effort of their
part and they must work together with the doctor to achieve their desired goals. In general,
Adams, T. Low Back Pain in Older Adults 11
passive care should lead to active care over the course of 1 to 2 months. During active care
patients are given exercises with the goals of stabilization, and increased function. Upon return
to regular activities it is very important to emphasize to patients that any residual pain they may
feel, does not signify harm to the body.
Following a trial of care with no improvement, all systemic, organic and non-mechanical causes
should always be ruled out before continuing the assumption that pain is of a mechanical nature.
This is especially true in the elderly, for with increased age comes increased risk of co-
morbidities such as cancers, diabetes, genitourinary infections and osteoporosis.
A study completed by Carey et al. compared the outcomes and costs of care for acute low back
pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons.
The status at six months was ascertained for 1555 of the 1633 patients, or 95% of those enrolled
in the study. The times to functional recovery, return to work, and complete recovery from acute
low back pain were similar among patients seen by all six groups of practitioners, but there were
marked differences in the use of health care services. The mean total estimated outpatient
charges were highest for the patients seen by orthopedic surgeons and chiropractors and were
lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest
among the patients who went to the chiropractors.60
Page 914 of the article cited previously
states that the cost data were skewed, but does not mention how the data was skewed.
Spinal manipulation
There is debate over the ultimate goal of spinal manipulation as well as the definition of
“manipulation” across various studies. “Traditional theories, although varied, have tended to
focus on mechanical aspects of manipulation as central to their clinical impact including the
disruption of “adhesions” or release of trapped intra-articular material in spinal joints, and the
realigning of spinal structures.62,63
If reducing restrictions to motion and structural realignment
are the goals of manipulation, the velocity and amplitude of the manipulation may be less
important consideration than the specificity and direction of the technique used because of the
importance of specifically directing the force to the involved spinal segment in the required
Adams, T. Low Back Pain in Older Adults 12
direction.64
More recent explanations, however, suggest that the mechanism of effect for
manipulation may be related to the unique sensory input of a high-velocity, low amplitude thrust
on afferent discharge, and the subsequent effects on motoneuronal activity and central motor
excitability.65,66
Afferent response has been shown to vary based on the velocity and amplitude
of the force applied.67,68
If the mechanisms underlying the clinical effects of manipulation are
related to these neurophysio-logic responses, which are determined by the velocity and
amplitude of the force, distinguishing between thrust and nonthrust techniques is likely to be
critical.”69 “
The evidence supporting superior clinical outcomes with the use of manipulation for
a subgroup of patients was corroborated by this retrospective review of patients with
occupational low back pain. The use of thrust manipulation appeared to be more efficient than
the use of nonthrust manipulation for these patients.”70
According to a randomized clinical trial
comparing the effectiveness of thrust versus non-thrust manual therapy techniques, there was a
statistically significant decrease in pain as demonstrated by both the Oswestry Disability
Questionairre and the Numerical Pain Rating Scales at the one and four week follow-ups in the
thrust group as compared to the non-thrust group. 69
Although some believe thrust manipulation techniques are superior to non-thrust,
according to Shearar’s and Hawks’ studies, no significant difference in efficacy was found
between the two.71,72
The use of low-force adjusting techniques, in particular for the elderly and
frail, can be beneficial for reducing low-back pain, while minimizing any risk for fracture or
hematomas. Some of the most common low force techniques employed by chiropractors in the
treatment of low back pain are (in no particular order): Logan Basic, B.E.S.T, Cox Flexion-
Distraction (mechanized or non-mechanized table-assisted procedures), Activator and other
instrument-assisted procedures, SOT (pelvic blocking), and Applied Kinesiology. Activator
Methods is a technique that uses a small instrument to impart a quick and specific impulse to a
bone or tissue. “Neither mechanical-force, manually-assisted nor high-velocity, low-amplitude
adjustments were found to be more effective than the other in the treatment of this patient
population.”72
A randomized controlled trial was done comparing cox flexion distraction with
Adams, T. Low Back Pain in Older Adults 13
side posture diversified spinal manipulation and minimal conservative medical care for adults 55
years and older with subacute or chronic low back pain.73
The findings of this study were that
“biomechanically distinct forms of SM did not lead to different outcomes in older LBP patients
and both SM procedures were associated with small yet clinically important changes in
functional status by the end of treatment for this relatively healthy older population.”73
A subgroup of 26 RCTs that assessed manipulation as the sole or predominant component were
chosen from the meta-analysis completed by Assendelft W.J. in 2003. The analysis on the
subgroup of 26 RCTs found “statistically significant benefits only when spinal manipulation was
compared with sham therapies or ineffective therapies. There is no evidence that spinal
manipulation is substantially more or less effective than other conventional therapies for either
chronic or acute back pain.”74
The conventional therapies spinal manipulation was compared
with were general practitioner care, analgesics, physical therapy, exercises and back school.74
Although the mechanisms through which manipulative therapy exerts its effects upon the body is
still in question, it is widely agreed that the desired goals of spinal manipulation include
improved range of motion, decreased muscle spasm and decreased pain.75
In the treatment of
acute low back pain, it has been shown that manipulation tends to shorten the episode of pain,76
74 particularly over the short term. Longterm follow-up suggests that the initial advantage of
manipulation over other therapies is lost with time.77
“Spinal manipulation has small clinical
benefits that are equivalent to those of other commonly used therapies.”76
Eight articles were found that studied the effects of manual therapies on older patients. 34,
57,65,66,67,68,71,78
The one study that utilized mobilization was performed by a physiotherapist.78
The manipulation
studied in seven of the studies was performed by a chiropractor in four of them34,57, 71,73
and an
osteopath in three of them.79-81
Only two of the following eight studies were randomized clinical
trials involving chiropractic adjustments/manipulation and older patients.71,73
Adams, T. Low Back Pain in Older Adults 14
Interferential, TENS, traction therapy
Interferential electrical therapy, Transcutaneous Electrical Nerve Stimulation (TENS), and
traction therapy are several adjunct modalities used often by physical therapists and
chiropractors. The following are results of a study done by Werners, Roland MD. A total of 152
patients were recruited. The two treatment groups had similar demographic and clinical baseline
characteristics. The mean Oswestry Disability Index before treatment was 30 for both groups (n
= 147). After treatment, this had dropped to 25, and, at 3 months, were 21 (interferential therapy)
and 22 (motorized lumbar traction and massage). The mean pain visual analog scale score before
treatment was 50 (interferential therapy) and 51 (motorized lumbar traction and massage). This
had dropped, respectively, to 46 and 44 after treatment and to 42 and 39 at 3 months.82
This
study shows a progressive fall in Oswestry Disability Index and pain visual analog scale scores
in patients with low back pain treated with either interferential therapy or motorized lumbar
traction and massage. There was no difference in the improvement between the two groups at the
end of treatment. Although there is evidence from several trials that traction alone is ineffective
in the management of low back pain, this study could not exclude some effect from the
concomitant massage.82
TENS and interferential are the two of the most common electrical therapies used in the
treatment of low back pain. A study by Facci concluded that there was no difference between
TENS and the interferential current therapy for chronic low back pain.83
Although there are few
studies to substantiate the benefits of electrical therapies in the treatment of low back pain, the
study aforementioned showed mean reductions on the visual analog scale of 39.18 mm and
44.86 mm with the treatment of interferential current. 84% of the TENS group and 75% of the
interferential current group stopped using their medications after the treatment.83
Exercise (strengthening and stretching)
A study protocol titled Chiropractic and exercise for seniors with low back pain or neck Pain
describes the design of two randomized clinical trials and states that “treatments for low back
and neck conditions will not only aim to treat the pain specifically, but will also address
Adams, T. Low Back Pain in Older Adults 15
associated strength and motion in a manner that enhances general function and improves quality
of life.”84
Research indicates that most back injuries are not due to one specific trauma, but they are caused
by a cumulative result of trivial traumas and associated improper muscle activation patterns and
joint motion.85,86
Therefore a main focus of rehabilitation exercises for low back pain concentrate
on lumbar spine extensor muscle endurance and motor control.85,86
Some believe that
strengthening the core muscles, such as the transverse abdominis, obliques, and muscles of the
pelvic floor provides the most benefit for lumbar spine stabilization. The quadratus lumborum is
also an essential muscle used to stabilize the lumbar spine. It has been shown that stabilization of
the low back should be acquired before and increase in strength.
To date, physical therapists’ protocols for treating low back pain often include the following
exercise, “drawing in”, in their treatment protocol.87,88
Drawing in is where one lies on their
back, with knees bent and attempts to approximate their belly button to their spine. This action is
very similar to just sucking in ones’ belly. They believe that this movement tenses the transverse
abdominis muscles and the tightening of the transverse abdominal muscles and its muscular and
fascial attachments helps to provide stability to the spine.87
Other physical therapists and most
chiropractors, believe that practicing abdominal bracing is a better way to help stabilize the spine.
Recent research from McGill of the US, supports this later view. McGill believes that by bracing
instead of hollowing, the obliques and transversus are activated together. This would lead to a
wider base for the contraction thereby lending better support. Abdominal bracing is usually
prescribed first, with exercises progressing to include abdominal bracing along with marching.88
It is well known that strength and balance training can improve physical function as well as help
to reduce impairments in activities of daily living.89
Stretches are a common home recommendation given by both physical therapist’s and
chiropractors. “An RCT comparing chiropractic care and physical therapy found no difference in
costs or effectiveness90
.”76
Stretches are given to lengthen chronically tight muscles, while
exercises are given to strengthen weak muscles. Achieving an equal balance bilaterally within all
of the planes of movement, allows for proper joint function and movement along the joints axis’.
Adams, T. Low Back Pain in Older Adults 16
There are several types of stretching techniques employed by chiropractors and PT’s to help
loosen tight muscles. One of which is post-isometric-relaxation or PIR. PIR is a technique that
uses reciprocal inhibition to enhance relaxation of the muscle being stretched. This can be a
vigorous or gentle technique, depending on the practitioner. Myofascial release is also a common
technique used by massage therapists, PT’s and chiropractors. There are several types of
myofascial release with trademarked names such as John Barne’s Myofascial Release and John
Upledger myofascial release. There are also techniques such as Muscle Energy Technique and
Strain-Counterstrain that have been used for years by Osteopathic Physicians in the treatment of
low back pain.91
“Strain Counterstrain (SCS) is the fourth most commonly used osteopathic
manipulative technique following soft tissue techniques, high velocity low amplitude thrust, and
muscle energy technique (Johnson and Kurtz, 2003). Also known as positional release, SCS is a
passive positional technique aimed at relieving musculoskeletal pain and dysfunction through
indirect manual manipulation (d’Amborgio and Roth, 1997).”92
“MET combined with supervised
motor control and resistance exercises may be superior to neuromuscular re-education and
resistance training for decreasing disability and improving function in patients with acute low
back pain.”93
A study that used ultrasound to assess and monitor the effective sliding motion of
fascial layers in vivo, found that myofascial release techniques “ are effective manual techniques
to release area of impaired sliding fascial mobility, and to improve pain perception over a short
term duration in people with non-specific NP or LBP.”94
All of the aforementioned techniques can be used on people of all ages under the treatment by a
qualified practitioner. “Although the elderly population appears to be under-represented in the
pertinent LBP literature,95
there does not seem to be an age limit for strengthening back muscles.
Even symptomatic geriatric women are able to increase strength with progressive resistance
exercise, which subsequently reduces LBP.96”97
An aerobic exercise program is as effective as
more expensive exercise programs in the treatment of chronic low back pain.98
Five years after
the supervised combined exercise and motivational program, patients had significant
improvements in disability, pain intensity, and working ability.99
In the long term, the combined
exercise and motivation program was superior to the standard exercise program.99
In terms of
Adams, T. Low Back Pain in Older Adults 17
costs for days on sick leave, the medical exercise therapy group saved 906,732 Norwegian Kroner
(NOK) ($122,531.00), and the conventional physiotherapy group saved NOK 1,882,560
($254,200.00), compared with the self-exercise group.23
According to Torstensen’s study, those
performing exercises in the group setting have better results than those who performed self-
exercise.100
Acupuncture
After herbal remedies, massage therapy, and chiropractic, according to patient reporting in one
study, the CAM used next most often by older patients was acupuncture.27
Cherkin’s review
concluded that the effectiveness of acupuncture is not clear, because the RCTs evaluating its
effectiveness were deemed of low quality, stating “Recent studies suggest that acupuncture is
more effective than no treatment or sham treatment, is as effective than no treatment or sham
treatment, is as effective as other medical interventions of questionable value (for example TENS
and non-steroidal anti-inflammatory drugs for chronic back pain), but is less effective than
massage.”76
Other studies show that “Patients receiving acupuncture care reported a significantly greater
reduction in worry about their back pain at 12 and 24 months compared with the usual care
group. At 24 months, the acupuncture care group was significantly more likely to report 12
months pain free and less likely to report the use of medication for pain relief.”101
Although the
literature supporting acupuncture’s benefits is limited, due to the low-risk of unwanted side and
its potential to alleviate anxiety, acupuncture is an alternative therapy worth trying.
Massage
“Initial studies have found massage to be effective for persistent back pain.”76 “
Preliminary
evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the
costs of care after an initial course of therapy.” 76
“Three trials designed to evaluate massage as a
treatment for subacute and chronic back pain have all found positive effects, especially on
patient function.” 76
“Initial studies suggest that massage is effective for persistent back pain” 76
A randomized controlled trial comparing Swedish relaxation massage with structural massage
and a control group receiving usual care, produced favorable results for massage.102
There was
Adams, T. Low Back Pain in Older Adults 18
no significant difference between the relaxation massage and the structural massage in relieving
disability of symptoms.102
The results of the study are as follows. “The massage groups had
similar functional outcomes at 10 weeks. The adjusted mean RDQ score was 2.9 points (95% CI,
1.8 to 4.0 points) lower in the relaxation group and 2.5 points (CI, 1.4 to 3.5 points) lower in the
structural massage group than in the usual care group, and adjusted mean symptom
bothersomeness scores were 1.7 points (CI, 1.2 to 2.2 points) lower with relaxation massage and
1.4 points (CI, 0.8 to 1.9 points) lower with structural massage. The beneficial effects of
relaxation massage on function (but not on symptom reduction) persisted at 52 weeks but were
small.”102
Counseling and education
Cognitive-behavioral and self-regulatory treatments were specifically found to be efficacious in
the treatment of low back pain. Multidisciplinary approaches that included a psychological
component, when compared with active control conditions, were also found to have positive
short-term effects on pain interference and positive long-term effects on return to work. The
results demonstrated positive effects of psychological interventions for CLBP.103
It has been
shown to be helpful for physicians to reinforce to their patients in the initial exam “that pain did
not signal harm, to maintain a consistent activity pace, and to stay as active as tolerable.”88
Chronic pain and depression are thought to go hand in hand. This is true for both the elderly and
the non-elderly. The impact of pain on activities of daily living, functional abilities and
perceived control over life should be considered when associating pain with depression.82
“Interference in activities demonstrated the strongest relationship with depressed mood in both
age groups.”104
A randomized controlled trial performed by Francisco Kovacs, MD et al. showed
that among three groups of institutionalized elderly subjects, the greatest improvement in
disability (3.0 (95% CI 1.5–4.5) at the 180 day evaluation) was achieved by the group who
received active education, as compared to the group who received a postural educational talk
followed by a 20 minute group talk, and the control group who received no intervention. The
Adams, T. Low Back Pain in Older Adults 19
intervention that focused on active management education also showed improved disability 6
months later and had an even greater effect on subjects with low back pain.105
Drugs, Surgery and Procedures
When people do not receive timely and effective conservative care for their condition, they are
left with much fewer treatment options. When conservative measures such as the ones discussed
above are not sought or do not help to relieve low back pain, more invasive drugs, surgeries, and
procedures are the next options. A common medical procedure for low back pain is injections.
One study found that nerve-root injections were effective in preventing the need for an operation
in more than half of the operative candidates.106
Twenty-nine of the fifty-five patients who had
requested operative intervention and who were considered to be operative candidates by their
treating spine surgeons avoided an operation.106
Compared with injection of bupivacaine alone,
injection of bupivacaine with the steroids was significantly (p < 0.004) more likely to result in
the avoidance of an operation.106
Interestingly, nine of the twenty-seven patients who had
received bupivacaine alone still managed to avoid an operation.106
For people with facet joint arthrosis, injection with depot methylprednisolone or a combination
of a local anesthetic such as lidocaine or bupivacaine and the steroid medication
methylprednisolone are often used. Short term effects of this procedure are a sore back for a day
or two due to the inflammation process caused by the insertion of the needle and the steroid
itself. It usually takes about 5 days or so before pain relief is noted. According to the
MetroHealth Pain Management Group’s website, although the procedure is relatively safe, there
can be some adverse side effects and risks. Several of these are “infection, bleeding, worsening
of symptoms, spinal block, epidural block etc…The risks related to the side effects of cortisone
include weight gain, increase in blood sugar (mainly in diabetics) water retention, suppression of
body’s own natural production of cortisone etc.”107
They also state that “serious side effects and
complications are uncommon.”107
Several other procedures used in the treatment of low back
pain performed at this center are epidurolysis, corticosteroids, intrathecal pump implant (spinal
Adams, T. Low Back Pain in Older Adults 20
pain pump), lumbar sympathetic block, sacro-iliac joint injection, radio frequency lesioning,
medial branch blocks for facet joints, spinal cord stimulator, and stellate ganglion injection.
More invasive treatments of discogenic low-back pain include “ablation of intradiscal
nociceptors, lowering intranuclear pressure, removal of herniated nucleus, and radiofrequency
ablation of the nociceptors. Unfortunately, most of these strategies do not meet the minimal
criteria for a positive treatment advice. In particular, single-needle radiofrequency
thermocoagulation of the discus is not recommended for patients with discogenic pain (2 B-).
Interestingly, a little used procedure, radiofrequency ablation of the ramus communicans, does
meet the (2 B+) level for endorsement. There is currently insufficient proof to recommend
intradiscal electrothermal therapy (2 B±) and intradiscal biacuplasty (0). It is advised that ozone
discolysis, nucleoplasty, and targeted disc decompression should only be performed as part of a
study protocol.”108
A separate study revealed that “When conservative treatment fails, in
subacute lumbosacral radicular pain under the level L3 as the result of a contained herniation,
transforaminal corticosteroid administration is recommended (2 B+). In chronic lumbosacral
radicular pain, (pulsed) radiofrequency treatment adjacent to the spinal ganglion (DRG) can be
considered (2 C+). For refractory lumbosacral radicular pain, adhesiolysis and epiduroscopy can
be considered (2 B+/-), preferentially study-related. In patients with a therapy-resistant radicular
pain in the context of a Failed Back Surgery Syndrome, spinal cord stimulation is recommended
(2 A+). This treatment should be performed in specialized centers.”109
A concensus among
literature states that surgery is often more risky for older individuals, and that conservative care
of low back pain for that age group is a viable option.
Surgery vs Conservative Care
Lumbar spinal stenosis is a commonly diagnosed condition in the elderly. Below are results of
two studies performed on the elderly, one study group was treated with conservative care and the
other with surgery. Most literature agrees that conservative measures should be employed first.
The study done by Murphy, Donald R. et al. studies 57 patients with diagnosed spinal stenosis.
Although the age range of patients was from 32-80, this study was included because the mean
Adams, T. Low Back Pain in Older Adults 21
age was 65 years old. The interventions employed with all of the patients in the study included
Cox flexion distraction technique and neural mobilization. Some of the patients were also given
the “cat and camel” exercise as well as nerve flossing exercises to do at home. The study also
states that some patients may have also “had other modalities included in their individual
programs, such as mobilization exercises and spinal stabilization exercise”.110
Outcomes were
measured using the Roland Morris Disability Questionnaire and pain levels were obtained with
the Three Level Numerical Rating Scale. Patients were also asked to estimate their percent of
overall improvement. “The mean patient-rated percentage improvement from baseline to the end
to treatment was 65.1%. The mean improvement in disability from baseline to the end of
treatment was 5.1 points….improvement in disability from baseline to the end of treatment was
seen in 66.7% of patients. The mean improvement in "at worst" pain was 3.1 points….The mean
duration of FU was 16.5 months. The mean patient-rated percentage improvement from baseline
to long term FU was 75.6%. The mean improvement in disability was 5.2 points…..improvement
in disability was seen in 73.2% of patients. The mean improvement in "on average" pain
intensity from baseline to long term FU was 3.0 points. The mean improvement in "at worst"
pain was 4.2 points. Only two patients went on to require surgery.”110
The only non-clinically
meaningful improvement statistic was the mean improvement of 1.6 points in "on average" pain
intensity.110
When conservative care for lumbar stenosis fails to produces the wanted results, surgery can be
an option. A study done by Shabat, Shay, concludes subjects with a “mean age of 83.7 years at
the time of surgery, with a follow-up period of 36.8 months on average (minimal follow-up of 1
year), 76% of the operated patients reported that they were very or somewhat satisfied with the
surgical results.”111
The study also states that 52% of the patients suffered complications from
the surgery, but 48% of those who suffered complications, had only minor complications that did
not extend their hospital stay.111
There were many limitations of this study, one of the greatest
being that only 64% of the original 39 patients were able to be followed.111
“The patients
reported VAS score of 8.84 + 1.91 prior to surgery, which improved to 3.6 + 2.35 on latest
Adams, T. Low Back Pain in Older Adults 22
follow-up (P\0.001). Furthermore, patients reported a significant (P\0.001) subjective
improvement in the ability to perform daily activities (the Barthel index improved from 62.8 ±
11.46 points before the surgery to 77.0 ± 11.9 points after the surgery (P\0.001). The number of
patients who had limitation in walking distance up to 50 m decreased by 28% (v2 = 3.74, P =
0.053), and the number of patients having no walking limitation increased by 32% (v2 = 5.37, P
= 0.02).”111
Lumbar stenosis can be treated either surgically or conservatively. Although both studies report
generally positive outcomes, it is not possible to statististically compare the results of the two
studies. Different outcome measures were employed and each study reported several limitations.
The conclusions of both studies state that conservative care should always be employed prior to
surgical intervention. “It should be remembered that elderly patients might deteriorate following
surgery. Therefore surgery should be done only after measuring the potential benefits of the
surgery versus the potential risks.111
CONCLUSION
Over 100 articles consisting of literature reviews, systematic reviews, selective reviews and
comparative studies, and case reports were reviewed. Conservative care for low back pain
provides similar improvements in decreased pain as invasive care, with less cost to the insurance
companies in the long run, and less risk to elderly patients for complications. According to the
literature, the conservative care intervention for acute low back pain that offered the best
outcomes, such as decreased pain and decreased numbers of subsequent visits to healthcare
providers, was short term use of pain medicines and massage. The effect size of NSAID use and
manipulation for acute low back pain was shown to be modest.112
Spinal manipulation was
shown to decrease pain, mainly in the acute stages of low back pain, where-as education and
exercise programs focusing on strengthening the core and lumbar spine extensors was most
beneficial to chronic low back pain patients. Spinal manipulation is a slightly more expensive in
the short-term but an equally effective option for treatment of acute low back pain as medicinal
Adams, T. Low Back Pain in Older Adults 23
interventions such as pain relieving medicine.113,114
Spinal manipulation has less unwanted side
effects than pharmaceutical management of low back pain in the elderly.
According to the 2011 update of a Cochrane review regarding spinal manipulative therapy for
chronic low back pain, as cited by the article “The Psychology of Chronic Back Pain –
Psychological risk factors for chronicity and our challenge as clinicians: finding the right
treatment mix by David J. Brunarski, DC, MSc, FCCS (C), states that “There was no clinically
relevant difference between spinal manipulative therapy and other interventions for reducing
pain and improving function in patients with chronic low-back pain.”115
Results from most
studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent
or superior improvement in pain and function when compared with other commonly used
interventions, such as physical modalities, medication, education, or exercise, for short,
intermediate, and long-term follow-up.116
A recommendation, although weak recommendation,
stated that chronic LBP patients with depression, neuroticism, and certain personality disorders
should preferentially be treated nonoperatively.117
A systematic review on the effectiveness of physical and rehabilitation interventions for chronic
nonspecific low back pain, published this year in the European Spine Journal, concluded that
"only multidisciplinary treatment, behavioural treatment, and exercise therapy should be
provided as conservative treatments in daily practice in the treatment of chronic low back
pain."113
A June 2011 update of a Cochrane review regarding spinal manipulative therapy for
chronic low back pain stated: "There was no clinically relevant difference between spinal
manipulative therapy and other interventions for reducing pain and improving function in
patients with chronic low-back pain."113,114
“An understanding of the mechanisms behind MT could assist in the identification of individuals
likely to respond to MT by allowing a priori hypotheses as to pertinent predictive factors for
future clinical prediction rules and a better understanding of the factors which are determined as
predictive. A second benefit of the identification of MT mechanisms is the potential for
increased acceptance of these techniques by healthcare providers. Despite the literature
Adams, T. Low Back Pain in Older Adults 24
supporting the effectiveness of MT in specific musculoskeletal conditions, healthcare
practitioners at times provide or refer for MT at a lower than expected rate (Jette and Delitto,
1997; Li and Bombardier, 2001; Bishop and Wing, 2003). The lack of an identifiable mechanism
of action for MT may limit the acceptability of these techniques as they may be viewed as less
scientific. Knowledge of mechanisms may promote more appropriate use of MT by healthcare
providers.” 118
According to the clinical guidelines detailed by the National Collaborating Centre for Primary
Care, a course of conservative management is recommended before considering surgery as an
option. They recommend physicians or therapists to “provide people with advice and
information to promote self-management of their low back pain…offer educational advice that
includes information on the nature of non-specific low back pain….encourages the person to be
physically active and continue with normal activities as far as possible.”119
They also recommend offering “one of the following treatment options, taking into account
patient preference: an exercise programme, a course of manual therapy or a course of
acupuncture. Consider offering another of these options if the chosen treatment does not result in
satisfactory improvement.” 119
Those with low back pain should be advised to stay physically
active or begin physical activities. Recommended exercise programs can include the following:
aerobic activity, movement instruction, muscle strengthening, postural control, and stretching. 119
They also suggest offering a course of manual therapy, including spinal manipulation. They do
not suggest offering patients laser or interferential therapy, therapeutic ultrasound, TENS, lumbar
supports or traction. They also recommend offering a course of acupuncture needling. When
conservative measures fail, injections of therapeutic substances are not recommended for non-
specific low back pain. 119
“Consider referral for a combined physical and psychological
treatment programme, comprising around 100 hours over a maximum of 8 weeks, for people
who: have received at least one less intensive treatment and have high disability and/or
significant psychological distress…..Combined physical and psychological treatment
programmes should include a cognitive behavioural approach and exercise.” 119
“Two
Adams, T. Low Back Pain in Older Adults 25
independent reviewers screened search results and extracted data. Data extracted included the
type and perspective of the economic evaluation, the treatment comparators, and the relative
cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies
found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or
cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP.”120
The following pharmaceutical interventions are recommended. “Advise the person to take
regular paracetamol as the first medication option. When paracetamol alone provides
insufficient pain relief, offer: non-steroidal anti-inflammatory drugs (NSAIDs) and/or weak
opiods. Give due consideration to the risk of side effects from NSAIDs, especially in: older
people and other people at increased risk of experiencing side effects. When offering treatment
with an oral NSAID/COX-2 (cyclooxygenase 2) inhibitor, the first choice should be either a
standard NSAID or a COX-2 inhibitor. In either case, for people over 45 these should be co-
prescribed with a PPI (proton pump inhibitor), choosing the one with the lowest acquisition
cost.”119
“Consider offering tricyclic antidepressants if other medications provide insufficient pain relief.
Start at a low dosage and increase up to the maximum antidepressant dosage until therapeutic
effect is achieved or unacceptable side effects prevent further increase. Short-term use of strong
opioids can be used for severe pain.” 119
“Consider referral for specialist assessment for people
who may require prolonged use of strong opioids. Give due consideration to the risk of opioid
dependence and side effects for both strong and weak opioids. Base decisions on continuation of
medications on individual response. They believe that selective serotonin reuptake inhibitors
(SSRIs) should not be used for treating pain.” 119
“Consider referral for an opinion on spinal fusion for people who: have completed an optimal
package of care, including a combined physical and psychological treatment programme and still
have severe non-specific low back pain for which they would consider surgery. Offer anyone
with psychological distress appropriate treatment for this before referral for an opinion on spinal
fusion. Refer the patient to a specialist spinal surgical service if spinal fusion is being
Adams, T. Low Back Pain in Older Adults 26
considered. Give due consideration to the possible risks for that patient.” 119
Their conclusion
was that people should not be recommended for the following procedures: intradiscal
electrothermal therapy (IDET), percutaneous intradiscal radiofrequency thermocoagulation
(PIRFT), radiofrequency facet joint denervation. 119
No matter the chosen therapy, it is important
for doctors to take into account patient preference. “There is growing evidence that patient
expectations affect outcomes121-123
, allowing patients to choose the treatment they believe will be
most helpful may improve results.” 76
“Evidence-based medicine is not kind to the elderly. This movement trusts only the products of
randomized clinical trial or, preferentially, meta-analyses of those trials. But subjects over the
age of 75 years are rarely found in such trials, thus rendering this population invisible to
scientific medicine. If we teach only what we know, and if we know only what we can measure
in clinical trials, then we can say little of importance about the care of the elderly. The most
important resources required in caring for the old – sufficient time and empathy – are not
included in the critical pathways of managed care”124
Adams, T. Low Back Pain in Older Adults 27
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