Management of Symptomatic Lumbar Degenerative Disk Disease

L Madigan, AR Vaccaro, LR Spector, R Alden Milam

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

Filed under: Conservative therapies, Lumbar spine, Surgery, Topic review

A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

A Kirkley, TB Birmingham, RB Litchfield, JR Giffin et al.

ABSTRACT

Background – The efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee is unknown.

Methods – We conducted a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. Patients were randomly assigned to surgical lavage and arthroscopic débridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone (for details please see “details of physical therapy provided” below) . The primary outcome was the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (range, 0 to 2400; higher scores indicate more severe symptoms) at 2 years of follow-up. Secondary outcomes included the Short Form-36 (SF-36) Physical Component Summary score (range, 0 to 100; higher scores indicate better quality of life).

Results – Of the 92 patients assigned to surgery, 6 did not undergo surgery. Of the 86 patients assigned to control treatment, all received only physical and medical therapy. After 2 years, the mean (±SD) WOMAC score for the surgery group was 874±624, as compared with 897±583 for the control group (absolute difference [surgery-group score minus control-group score], –23±605; 95% confidence interval [CI], –208 to 161; P=0.22 after adjustment for baseline score and grade of severity). The SF-36 Physical Component Summary scores were 37.0±11.4 and 37.2±10.6, respectively (absolute difference, –0.2±11.1; 95% CI, –3.6 to 3.2; P=0.93). Analyses of WOMAC scores at interim visits and other secondary outcomes also failed to show superiority of surgery.

Conclusions – Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy

the New England Journal of Medicine. 2008 Sep 11;359(11):1169-70.

Details of physical therapy provided: Optimized physical and medical therapy was initiated within 7 days after surgery and followed an identical program in both groups. Physical therapy was provided for 1 hour once a week for 12 consecutive weeks. The intervention was standardized and based on a review of the literature and a formal survey of university physical therapists.³¹ Information regarding a home exercise exercises program that emphasized range-of-motion and strengthening was provided to all patients. Individualized exercises were recommended on the basis of the severity of osteoarthritis, the patient’s age, and the patient’s specific needs. Instruction was also provided regarding activities of daily living, walking, use of stairs, and methods of treatment involving cold and heat. The patients were asked to perform the exercises twice daily and once on the day of a scheduled physical-therapy session. After the patients had completed 12 weeks of supervised activity, they continued an unsupervised exercise program at home for the duration of the study. The patients received additional education from attendance at local Arthritis Society workshops, from a copy of The Arthritis Helpbook³² that was provided to them, and from an educational videotape.

Filed under: Exercise therapy, Knee, Osteoarthritis, Patient education, Surgery

EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

Objectives: To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach.

Methods: The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality.

Results: 497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research.

Conclusion: The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswere

Final set of 10 recommendations based on both evidence and expert opinion    (table 6)
1.     The optimal management of knee OA requires a combination of non-pharmacological and pharmacological treatment modalities
2.     The treatment of knee OA should be tailored according to:
(a) Knee risk factors (obesity, adverse mechanical factors, physical activity)
(b) General risk factors (age, comorbidity, polypharmacy) (c) Level of pain intensity and disability
(d) Sign of inflammation—for example, effusion
(e) Location and degree of structural damage
3.     Non-pharmacological treatment of knee OA should include regular education, exercise, appliances (sticks, insoles, knee bracing), and weight reduction
4.     Paracetamol (acetaminophen) is the oral analgesic to try first and, if successful, the preferred long term oral analgesic
5.     Topical applications (NSAID, capsaicin) have clinical efficacy and are safe
6.     NSAIDs should be considered in patients unresponsive to paracetamol (acetaminophen). In patients with an increased gastrointestinal risk, non-selective
NSAIDs and effective gastroprotective agents, or selective COX 2 inhibitors should be used
7.     Opioid analgesics, with or without paracetamol (acetaminophen), are useful alternatives in patients in whom NSAIDs, including COX 2 selective inhibitors, are contraindicated, ineffective, and/or poorly tolerated
8.     SYSADOA (glucosamine sulphate, chondroitin sulphate, ASU, diacerein, hyaluronic acid) have symptomatic effects and may modify structure
9.     Intra-articular injection of long acting corticosteroid is indicated for flare of knee pain, especially if accompanied by effusion
10.     Joint replacement has to be considered in patients with radiographic evidence of knee OA who have refractory pain and disability

Annals of the Rheumatic Disease. 2003 December; 62(12): 1145–1155.

doi: 10.1136/ard.2003.011742.

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Filed under: Arthritis, Exercise therapy, Knee, Osteoarthritis, Patient education, Surgery