Symptomatic lumbar degenerative disk disease, or discogenic back pain, is difficult to treat. Patients often report transverse low back pain that radiates into the sacroiliac joints. Radicularor claudicatory symptoms are generally absent unless there is concomitant nerve compression. Physical examination findings are often unremarkable. Radiographic examination may revealdisk space narrowing, end-plate sclerosis, or vacuum phenomenon in the disk; magnetic resonance imaging is useful for revealing hydration of the disk, annular bulging, or lumbar spine end-plate (Modic) changes in the adjacent vertebral bodies. The use of diskography as a confirmatory study remains controversial. Recent prospective, randomized trials and meta-analyses of the literature have helped expand what is known about degenerative disk disease. In most patients with low back pain, symptoms resolve without surgical intervention; physical therapy and nonsteroidal anti-inflammatory drugs are the cornerstones of nonsurgical treatment. Intradiskal electrothermal treatment has not been shown to be effective, and arthrodesis remains controversial for the treatment of discogenic back pain. Nucleus replacement and motion-sparing technology are too new to have demonstrated long-term data regarding their efficacy.
Approximately 70% to 85% of adults will be affected by low back pain (LBP) at some point during their lifetimes.1,2 Numerous anatomic sites can be responsible for the pain, and accurate diagnosis is often difficult. Degenerative disk disease (DDD), internal disk disruption, lumbar disk herniation, and facet joint arthritis, as well as intra-abdominal pathology, are allpotential causes of LBP. Patients with DDD or discogenic back pain can present with aconstellation of symptoms that range from benign LBP to excruciating back pain with lower extremity symptoms. Risk factors for LBP, such as jobs requiring heavy lifting, use of a jackhammer or machine tools, or the operation of motor vehicles, have been identified in the literature.3 Continued degeneration of the affected disk can lead to secondary problems such as degenerative spondylolisthesis, lumbar stenosis, and facet arthrosis.
Journal of the American Academy of Orthopaedic Surgeons, 2009;17:102-111 – abstract
STUDY DESIGN.: A formal systematic review of the literature for conservative treatment of adult deformity was performed. OBJECTIVE.: To evaluate evidence for the efficacy and effectiveness of proposed conservative treatment options in adult deformity. SUMMARY OF BACKGROUND DATA.: Adult deformity is a major demographic health issue in the geriatric population in both the United States and the world communities. Surgeons are often very conservative in the treatment of adult scoliosis because of the complication rates associated with the surgeries and the marginal bone quality endemic to this population. A prerequisite to surgical intervention is usually failure of all appropriate conservative care. There is currently a lack of consensus on the most efficacious conservative treatments for adult deformity. METHODS.: A systematic review of clinical studies; using the key terms of adult or degenerative and scoliosis combined with any of the following: bracing, casting, physical therapy, chiropractic, and injections for treatment. The database inclusions were PubMed, OVID, and CINAHL. Articles were excluded if the primary patient populations were adolescents or the treatment options performed were primarily surgical. The methodology of the studies was graded and the evidence was classified into 1 of 5 levels based on study types. Based on this, a treatment recommendation was determined. RESULTS.: There is indeterminate, Level III/IV evidence on the effectiveness of any conservative care option. Specifically, there is Level IV evidence on the role of physical therapy, chiropractic care, and bracing. There is Level III evidence for injections in the conservative treatment of adult deformity. There is insufficient research for a treatment recommendation beyond Level 2c very weak evidence, but the available literature is supportive of further clinical research in conservative care as a treatment in adult deformity. CONCLUSION.: Conservative care in general may be a helpful option in the care of adult deformity, but evidence for this is lacking. Unfortunately, no treatment option within conservative care has support within the literature as a preferred solution. Basic clinical research at any level would be helpful to further clarify the options.
This report is written and produced by the Arthritis Research Campaign is an evidence-based report on the use of complementary and alternative medicines for arthritis and musculoskeletal conditions. It uses evidence from randomised controlled trials and aims to help people with arthritis or fibromyalgia select which complementary medicines may be beneficial for them. The report scores medicines according to their effectiveness with 1 indicating that the available evidence suggests that the compound is not effective and 5 indicating that there is consistent evidence that the compound is effective. Effectiveness is measured by improvements in pain, movement, or general well-being. The report also grades the medicines according to safety, providing traffic light classifications for each.
The authors of the report focused on compounds taken by mouth or applied to the skin. They did not look at therapies such as acupuncture and chiropractic massage, which have been commonly used for arthritis and musculoskeletal conditions. The role of these will be considered in a subsequent report.
Despite the number of complementary medicines available and used, this report found only 40 with evidence available from randomised controlled trials
- the type of studies that give the best evidence on whether a treatment is effective or not. Even for those, which had been studied, many had been tested in only a single or just a few studies. This makes it difficult to be sure whether they work or not. Rheumatoid arthritis
For people with rheumatoid arthritis (RA) the medicines researched score poorly, with 13 out of 21 complementary medicines (62 per cent) scoring just 1 point i.e. the available evidence suggests that the compound is not effective. At the other end of the scale, fish body oil scores a maximum 5 for effectiveness among people with RA, offering real benefits. It also receives a green light for safety. Osteoarthritis
Alternative medicines appear to be more promising for people with osteoarthritis (OA) with only 6 out of 27 approaches (22 per cent) scoring 1 point.
Found to be safe to use and scoring well are the herbal preparation phytodolor and nutritional supplement SAMe, both receiving a 4 for effectiveness. Capsaicin gel, made from chilli peppers, proved the most effective for OA, scoring the full 5 points.
Glucosamine is one of the most widely taken products and there have been many trials conducted. The evidence however is mixed, many trials show benefit while some do not. The evidence is stronger for glucosamine sulphate (which scored 3) compared to glucosamine hydrochloride (which scored 1). Fibromyalgia
Only four products were assessed for fibromyalgia but none of them were highly effective with three medicines scoring just 2 out of 5, and the fourth an ineffective 1.
In terms of safety, there is much less information available for complementary medicines in comparison to conventional medicines. However for approximately one quarter of the compounds considered we gave them an “amber” safety classification indicating there were important side effects which had been reported. A “red” safety classification was issued against thunder god vine.
The research studies used in the report are referenced so that you can find out more information on individual medicines should you wish to.
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