Terminology and Subtypes

Practitioners often use medical or technical jargon that can be misunderstood even by highly trained health providers from slightly different disciplines. This can create a barrier to effective communication and lead to misunderstandings about the concepts being discussed. This segment is intended to list and define any special terminology that may be important to understanding the interventions reviewed, including commonly used synonyms. This segment should also make readers aware of any subtypes that may be relevant to understanding how a particular intervention fits within the broader context of other similar approaches.

History and Frequency of Use

Some of the interventions used for LBP can trace their origins back to approaches used thousands of years ago (e.g., spinal manipulation), whereas others are based on relatively recent discoveries or inventions (e.g., X-STOP).¹ Interventions that were once in favor may be discarded, only to be rediscovered decades later (e.g., manipulation under anesthesia).² Understanding the genesis and evolution of interventions can be helpful to evaluating their role in the management of LBP. This segment is intended to briefly describe the origins and important milestones of an intervention. This segment is also intended to provide some estimate about the frequency of use for a particular intervention to give some idea of how commonly it is employed by those with LBP, often based on health care utilization surveys, if available.

Practitioner, Setting, and Availability

Numerous clinicians are involved in the management of LBP, few of whom know much about the specific interventions offered by those outside their specialty. Although some clinicians are primarily associated with one type of therapy (e.g., surgeons and surgery), others may in fact be trained to offer a multitude of therapies but do not routinely practice all of them (e.g., physiatrists and medication, injections, and minimally invasive interventions). Some interventions are widely offered by a variety of clinicians (e.g., spinal manipulation and chiropractors, physical therapists, and osteopaths), whereas others are fairly atypical with few qualified practitioners (e.g., prolotherapy). This segment is intended to describe the type of clinician most commonly associated with a particular intervention, as well as the clinical setting in which it is administered, and provide some estimate of its availability across the United States.

Procedure

Some of the interventions used for LBP have nomenclature that is fairly descriptive and provides a general idea about what is actually involved (e.g., artificial disc replacement), whereas others have names that may seem somewhat misleading when details are sought about the procedure (e.g., minimally invasive interventions). Others may have names that do not provide any information about the nature of the treatment (e.g., X-STOP). Clinicians may therefore be acquainted with the names of many interventions, but may not be familiar with their precise nature. This segment is intended to provide a broad description of how the intervention is actually performed, although it is not intended to be a teaching manual for those interested in learning new techniques.

Regulatory Status

Many of the interventions used for LBP are techniques or procedures practiced by licensed health care professionals (e.g., massage therapy given by massage therapists) that are not subject to specific regulatory approval by federal authorities, such as the US Food and Drug Administration (FDA). In the United States, only medications and medical devices used to address specific health conditions are subject to regulation and approval by the FDA.³ The regulatory approval process for medications in the United States is fairly rigorous. Manufacturers must first submit an investigational new drug application to the FDA summarizing the results of preclinical studies demonstrating safety and efficacy in different species of animals.⁴ They can then obtain permission to conduct progressively larger clinical studies in healthy humans or participants with the targeted disease using different medication doses and lengths of follow-up (e.g., phase 1, 2, and 3).⁴ Final approval is then sought from the FDA to market a medication for the defined indication studied in the clinical trials through a new drug application.⁴

The regulatory approval process for medical devices depends on the three classes recognized by the FDA (e.g., class I, II, and III).⁵ Class I medical devices generally pose a very low risk of harms when used correctly (e.g., bandages, thermometers).⁵ Class II medical devices are more complex and require greater training and prudence in their usage (e.g., x-ray machine, surgical sutures).⁵ Class III medical devices include implants (e.g., joint replacement) and equipment used to monitor life-preserving function (e.g., pacemaker).⁵ The supporting information required by the FDA increases substantially for each class. Medical devices may also be approved based on their similarity to previously approved medical devices, although greater latitude is used in the interpretation of this tenet for medical devices than medications.

Use of a medication for conditions other than its FDA approved indication is termed “off-label” and is generally left to the prescribing physician’s discretion.⁶ However, off-label use cannot be promoted by its manufacturer and supporting information must be provided to the FDA to formally expand the approved indication for a medication that is already on the market. Because manufacturers often pursue the indication most likely to be approved based on the supporting evidence provided, it can be revealing to discover that a medication often used for one purpose (e.g., sciatica) was in fact approved for another (e.g., postherpetic neuralgia).

Mechanism of Action

Interventions are often developed in response to the specific etiology of a medical condition (e.g., antipyretic medication for acute fever). Understanding the disease process can therefore provide some insight into its appropriate management by matching the intervention to the observed pathophysiology. However, this process can be quite challenging for a condition such as common LBP whose etiology is so poorly understood. Numerous anatomic structures have been implicated in the development of LBP (e.g., intervertebral discs, vertebrae, nerve roots) with corresponding interventions aimed at their eradication (e.g., discectomy, laminectomy, rhizotomy). Similarly, many disease constructs have been proposed to explain the presence of LBP (e.g., poor motor control or strength, hypomobility, emotional distress), also with analogous interventions (e.g., exercise therapy, spinal manipulation, cognitive behavioral therapy). This segment is intended to discuss the proposed mechanism of action for various interventions, if known, and to discuss any basic science studies supporting that mechanism.

Indication

Although this book is focused on the management of LBP, not every treatment discussed is appropriate for each patient with LBP. It is reasonable to assume that interventions intended to alleviate instability (e.g., arthrodesis) should be targeting a different group of patients with LBP than those that aim to improve hypomobility (e.g., spinal manipulation under anesthesia). Expert clinicians who routinely manage LBP often develop specific indications for the interventions they offer. This segment is intended to highlight some of the specific indications (if any) for the interventions discussed beyond simply having LBP.

Assessment

Despite the difficulty faced by clinicians who attempt to pursue a specific anatomic source for common LBP, many interventions do in fact require some form of diagnostic testing before being implemented. It is assumed that all interventions discussed in this book require a clinician to first rule out the possibility that symptoms may be related to potentially serious spinal or other pathology. Rather than repeating the steps involved in the basic assessment of LBP for each intervention, that process is described in detail in one of the introductory chapters. This segment is intended to describe any specific diagnostic testing required before initiating a particular intervention once a basic assessment has been conducted to rule out serious or specific pathologies related to LBP.

Clinical Practice Guidelines

An SR was recently conducted to identify clinical practice guidelines (CPGs) related to the diagnosis and management of LBP, that had been sponsored by national organizations and for which English language reports had been published in the past decade; 10 such CPGs were found (Table 2-1).⁷ This segment of the section on efficacy is intended to provide a succinct summary of the conclusions from these CPGs on the interventions reviewed. Not all CPGs reviewed each of the interventions in this book, and not all interventions were in fact evaluated in any of these CPGs; some chapters also discussed conclusions from CPGs other than those listed in Table 2-1.

TABLE 2-1 Recent National Clinical Practice Guidelines

Systematic Reviews

The Cochrane Back Review Group (CBRG) is one of 50 review groups focused on specific topics, which together form the Cochrane Collaboration.⁸ As of February 2010, the CBRG has conducted 45 SRs on a variety of topics related to spinal disorders, including 31 related to interventions for LBP. In addition, the two CPGs related to LBP that were sponsored by the American Pain Society (APS) and the American College of Physicians (ACP) were each accompanied by two SRs that evaluated and summarized the best available scientific evidence for many interventions.^9–14 This segment of the section on efficacy is intended to briefly summarize the conclusions from these specific SRs, which are summarized in Table 2-2

Related posts:

Conclusion Watchful Waiting and Brief Education Functional Restoration Adjunctive Analgesics Medicine-Assisted Manipulation Therapy Assessment of Low Back Pain

Stay updated, free articles. Join our Telegram channel

Join