March 2001

Triumph Over Low Back Pain

By Liz Finch

Triumph Over Low Back Pain

Despite many years of research and numerous improvements in terms of surgical procedures, medications, and exercise programs, chronic low back pain remains notoriously difficult to treat. Sixty to 80% of all Americans will experience low back pain at some point during their lives and it is second only to colds (upper respiratory infections) in causing the most workdays lost every year in the United States.¹

Over the years, many interventions have been developed to control chronic low back pain, and thus assist rehabilitation professionals in meeting their therapeutic goals. Transcutaneous electrical nerve stimulation (TENS) and dorsal column stimulation are two modalities that have an impact on chronic low back pain.

TENS

TENS involves placing electrodes on the back to send electrical signals through the skin, which mask the pain signal as it rises up the spinal cord to the brain. Instead of experiencing pain, the patient merely experiences a tingling sensation. Once stimulation is removed, patients do not feel any lasting effect beyond approximately 30 minutes.

Gad Alon, PhD, PT, associate professor at the Department of Physical Therapy, University of Maryland School of Medicine, Baltimore, believes that TENS could otherwise be used to address chronic low back pain. In fact, he was recently invited to present a case study on this approach at the combined section meeting of the American Physical Therapy Association in San Antonio, Tex. The essence of Alon's case study was not to target the pain, but to use the stimulation to force the muscles of the low back area to contract. Alon's proposed protocol requires different type of stimulators, different sizes of electrodes, and placement of the electrodes in different locations. Artificially activating the muscles of the low back area would lead to a variety of other physiological responses, including augmentation of arterial, venous, and lymphatic flow to the myofascial region.

"Those with chronic low back syndrome have many concurrent impairments, including myofascial adhesions, fibrosis, and restriction of motion in multiple joints," he says. "These are problems the electrical stimulation could address if it were used differently. The approach I am advocating is likely to loosen up myofascial restriction, and to promote both micro and macro circulation and mobility of the low back area," Alon explains.

"We end up not just helping the mobility of the area and strengthening the musculature in the lumbar region, but we also minimize some of those problems and eliminate the pain."

Alon's test case for this application was a woman who had suffered from chronic low back pain for at least 13 years and had gone through standard and nonstandard interventions without success. The 9?week study, which was nonsponsored, involved the patient using a battery?operated unit to perform self?treatment at home.

"A home?based intervention is very important," Alon says. "I try to remind colleagues that chronic low back pain does not occur for 20 minutes, three times a week, when the patient goes to the clinic."

After the study, the patient became painfree and able to move around much better. At follow?up 1 year later, she was still free of low back pain. Although these initial results are promising, Alon admits that a onepatient study is hardly adequate proof of the efficacy of this approach.

"You never know if something else happened in this one case to lead to improvement," he says. "Chronic low back pain does spontaneously get better after many years, and that certainly could be the case here."

Since this approach began to be considered in the past few years, Alon says he has received calls from therapists around the world who have used TENS in this manner and have reported much faster improvement in their patients when combined with other interventions.

"Clinicians really have to look beyond the traditional use of TENS and understand that the approach I am suggesting offers so much more," he says. "This proposed method seeks long?term, not temporary relief, but in the process we also are achieving pain relief. I wanted more from this modality, particularly when the goal is to get the patient as functional as possible, as quickly as possible. Because not all low back pain sufferers are candidates for this approach, they must be evaluated by clinicians familiar with this new protocol and the proper use of electrical stimulation.

"The bottom line is that a lot of Americans who live with pain run the course of all options, and are still looking for help," Alon notes. "I am merely presenting an alternative that?from the understanding of the pathophysiology of low back problems and an understanding of the contribution of electrical stimulation?is much better than the classic approach of pain management."

ELECTRICAL SPINAL STIMULATION

Dorsal column stimulation, also known as electrical spinal stimulation, was developed in 1967 to temporarily manage acute or chronic pain. The modality is considered an end?of?the?line therapy, and is commonly used in instances of chronic low back pain once all reasonable conservative therapies have been tried and are determined unsuccessful.

Electrical spinal stimulation works in a similar manner to TENS; however, the lead containing multiple electrical contacts is implanted subcutaneously, into the epidural space. The patient then controls the lead with a remote control device.

There are two kinds of systems available in spinal cord stimulation. The more commonly used unit is entirely self?contained within the patient's body, and utilizes a pulse generator in a pack with a nonrechargeable battery that must be replaced about every 3 years. The second system relies on radio frequency, and consists of a transmitter and an antenna, which are located outside the body, with a passive receiver located inside the body.

Regardless of which system is used, the first phase in implantation is a trial period to see if the modality demonstrates efficacy and if the patient can tolerate the sensation of stimulation. If a patient experiences greater than 50% improvement in pain without intolerable side effects, then permanent implantation is viable.

"The trial period is very critical and practitioners should look for more than pain relief [during that time]," says Joshua P Prager, MD, MS, director of the California Pain Medicine Centers at Beverly Hills and University of California Los Angeles (UCLA), and assistant clinical professor at UCLA. Prager also runs the Reflex Sympathetic Dystrophy Institute, located on the UCLA campus, and he utilizes spinal stimulation at each of his office locations.

"Practitioners should look for significant functional improvement and patient perception of the trial. The patient's overall behavior can be used as an indicator or predictor of appropriate and reasonable expectations,” he says.

Rigorous patient selection by a multidisciplinary team is also key in achieving positive outcomes. “It is not the goal to put in as many devices as possible,” Prager says. “It is the goal to place as many successful devices as possible, and that relies on appropriate patient selection.”

The development of new, totally implantable systems and systems that contain multiple leads with multiple capabilities has helped broaden the number of potential applications of spinal stimulation. Prager says he expects that soon the modality will be able to stimulate in multiple directions and with more complex configurations to achieve greater success.

The past few years have seen more possible uses for spinal stimulation. The technology can treat occipital neuralgia, pelvic pain, bladder dysfunction, and vascular deficiency in the legs. Acceptance is widespread to the point that the Food and Drug Administration has approved spinal stimulation as therapy for treating back pain.

“To implant something that causes no systemic neurological side effects provides a great contribution to the overall quality of life,” Prager says, noting that spinal stimulation has been particularly successful in meeting the needs of reflex sympathetic dystrophy patients. “An article in the New England Journal of Medicine last summer actually presented the strongest argument thus far to indicate that spinal stimulation is an effective modality in treating complex regional pain syndrome.² “These modalities have in many ways made my career. I have been able to provide dramatic relief to people with severe, intractable pain for whom all else has failed,” he says. “To me, the results I achieve in my patient population from implanting these devices are extremely gratifying and provide me with the force to proceed, and to deal with a multitude of difficult pain patients,” Prager continues. “I feel privileged to be able to provide this service.”

Liz Finch is a contributing writer for Rehab Management.

References

1. Health information library. Covenant Health Web site. Available at:
   www.covenanthealth.com/Features/Health/back/back4203.htm.

2. Kemler MA, Barendse GAM, van Kleef M, et al. Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med. 2000;343:618-24.

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