NEWS

Costly postoperative rehabilitation programs produced no additional pain relief or function
Patients randomized to two rehabilitation programs or a control group following lumbar spinal decompression surgery experienced no further pain relief beyond that reported immediately postoperatively. According to Swiss investigators who conducted the randomised controlled study, physicians who simply advise patients to participate in physical activities that they enjoy can expect the same effect as with structured physiotherapy programs.

“Postoperative physiotherapy did not influence the course of change in pain or disability for up to 24 months after decompression surgery,” Anne F. Mannion, PhD, said. She and her co-investigators theorized that performing activities that keep the patient moving mimics a supervisory program, but without the added cost to health care providers.

Mannion presented these results at the 9th Annual Meeting of the Spine Society of Europe (SSE). She and her co-authors won the SSE Clinical Science Award 2007 for their research. Two physiotherapy groups in the study, the small subgroup of patients with a poor outcome following decompression surgery also reported no pain or disability improvements with structured rehabilitation. “Postoperative physiotherapy does not appear to be able to compensate for an initial poor surgical result,” she said.

Investigators included 159 patients who underwent lumbar decompression surgery for spinal stenosis or a herniated disc and randomised them to one of three groups (100 men, 59 women; age 65 years ± 11 years). The rehabilitation program commenced at 2 months postoperatively.

Group one consisted of 54 patients who served as controls. They were instructed to just keep active following surgery and to keep an exercise diary. Group two had 56 patients who underwent physiotherapy consisting primarily of spine stabilization exercises performed under supervision, as well as at home for up to 12 weeks. Group three consisted of 49 patients who underwent active physiotherapy involving mixed techniques and home exercises done according to the same schedule as group two.

The supervised physiotherapy programs consisted of two 30-minute sessions per week. Pain, disability measures prior to surgery, entailed all patients evaluated their own back and leg pain separately on a 0-to-10-point graphic rating scale and completed the Roland Morris Disability Questionnaire. They repeated those outcome instruments before the rehabilitation period began, immediately after it ended, and then 12 and 24 months after its conclusion. At final follow-up, 97% returned completed questionnaires, Mannion said.

Back and leg pain decreased significantly after surgery, but it did not decrease further through the 24-month follow-up, Mannion noted. “Disability declined further during the rehabilitation phase (P<.05), then stabilized, but with no significant group differences,” according to the abstract.

Mannion AF, Denzler R, Dvorak J, Muntener M, Grob D. A randomized controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine. Presented at the 9th Annual. Meeting of the Spine Society of Europe. Oct. 2-6, 2007. Brussels. Eur Spine J. 2007;16(8):1101-1117.

Popular Osteoporosis Drugs Triple Risk of Bone Necrosis
A University of British Columbia (UBC) and Vancouver Coastal Health Research Institute (VCHRI) study has found that a popular class of osteoporosis drugs nearly triples the risk of developing bone necrosis. The research is the largest study of bone necrosis and bisphosphonates, a class of drugs used by millions of women worldwide to help prevent bone fractures due to osteoporosis. It is also the first study to explore the link between bone necrosis and specific brands of bisphosphonates, such as Actonel, Didrocal and Fosamax. Researchers found that all three brands had similar outcomes.

Published online by the Journal of Rheumatology (January 2008), the findings follow a recent U.S. Food and Drug Administration alert about bisphosphonates that highlighted the possibility of severe and sometimes incapacitating bone, joint and/or muscle pain in patients taking the drugs.

“The message for women taking these medications is to pay attention to your pain,” said principal investigator Dr. Mahyar Etminan of the Centre for Clinical Epidemiology and Evaluation at UBC and VCHRI. “Given the widespread use of these drugs, it is important that women and their doctors know the risks that come with taking them.” Etminan cautions that bisphosphonate use may increase in the future as the possible link between oestrogen use and breast cancer prompts women to switch from oestrogen therapy to bisphosphonate therapy to prevent osteoporotic bone fractures. Another reason may be the availability of new bisphosphonates that come in once-a-month or once-a-year doses.

The epidemiological study, a collaboration between UBC, VCHRI and McGill University, is based on the health records of 88,000 Quebec residents from 1996 to 2003.

Insoles as Prevention of Back Pain
Tali Safar MD in a new systematic review from the Cochrane Collaboration found no evidence that insoles prevent non-specific low back pain and couldn’t come to a conclusion regarding their role in the treatment of back symptoms. This conclusion stands in contrast to laboratory studies suggesting that insoles may offer some protection against spinal problems by keeping the foot in beneficial alignment and shock absorption. Overall Safar et al found that there is strong evidence that the use of insoles does not prevent back pain among asymptomatic subjects who began wearing these orthotics. One study suggested that insoles might reduce pain while increasing symptoms in the legs. They concluded by stating that there is a need for good studies of the effect of insoles on existing or recurrent back pain, so that recommendations can be made with a greater certainty.

Sahar et al. Insoles for prevention and treatment of back pain. Cochrane Database Systematic Review, 2007; 4;CD005275.

New News?
Both physical activity and a moderate alcohol intake are important to lower the risk of fatal ischemic heart disease (IHD) and all-cause mortality, a new study shows [1].

The study was published online in the European Heart Journal on January 9, 2008, shows that people who drink moderate amounts of alcohol and are physically active have a lower risk of death from heart disease and other causes than people who don’t drink at all. And that people who neither drink alcohol nor exercise have a 30% to 49% higher risk of heart disease than those who either drink, exercise, or do both.

The study, conducted by a team of Danish researchers, is said to be the first to look at the combined influence of leisure-time physical activity and weekly alcohol intake on the risk of fatal ischemic heart disease and deaths from all causes. They examined data, over 20 years, on 11,914 Danish men and women aged 20 years or more and without IHD at baseline who were part of the Copenhagen City Heart Study.

[1] Østergaard Pedersen J, Heitmann BL, Schnohr P, Grønbæk M. The combined influence of leisure-time physical activity and weekly alcohol intake on fatal ischemic heart disease and all-cause mortality. Eur Heart J. 2008.

Migraine and the Risk of Stroke, Transient Ischemic Attack (TIA), or Death in the UK
The apparent association of a higher risk of stroke in migraine patients in previous observational studies continues to be supported in the recent literature. A recent study in the Journal of Head and Face Pain aimed to estimate the risk of stroke, transient ischemic attack (TIA), or death in migraineurs in the UK. The authors conducted a population-based follow-up study within the General Practice Research Database from 1994 to 2001. They found that the relative risk (RR) of stroke in migraineurs compared with non-migraineurs was 2.2 (95% confidence interval [CI] 1.7-2.9). It was highest for patients with a migraine diagnosis recorded within 30 days prior to a stroke (odds ratio 11:1, 95% CI 5.69-21.5). The relative risk of TIA in migraineurs compared with non-migraineurs was 2.4 (95% CI 1.8-3.3), the mortality of migraineurs was slightly decreased. They concluded that in their study, the relative risk of developing a stroke or a TIA was doubled in migraineurs as compared with non-migraineurs, while that for death was close to unity.

Becker C, et al. Headache: The Journal of Head and Face Pain. November/December 2007; Vol. 47, Iss. 10, pp. 1374-84.

Valuable Link for Evidence based interventions for Lower Back Pain (LBP)
This comes from “The Spine Journal” which is the journal of North American Spine Society (NASS) (not the same as the journal “Spine”). www.sciencedirect.com/science/journal/15299430

This particular edition of the journal is free to all and has a series of articles on interventions for chronic LBP. I think that it will prove to be useful reference as most of the clinical guidelines are for acute LBP with limited information available for chronic LBP (apart form the previous European Guidelines, www.backpaineurope.org).

Examples of articles include

• Evidence-informed management of chronic low back pain with lumbar stabilization exercises. Pages 114-20. Christopher J. Standaert, Stuart M. Weinstein and John Rumpeltes
• Evidence-informed management of chronic low back pain with the McKenzie method. Pages 134-41. Stephen May and Ronald Donelson
• Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Pages 213-25. Gert Bronfort, Mitch Haas, Roni Evans, Greg Kawchuk and Simon Dagenais.

Systematic Review Finds No Advantage in Using Arthroscopic Debridement For Treating Knee Osteoarthritis
Performing arthroscopic debridement does not appear to provide patients with greater relief of the pain and swelling caused by knee osteoarthritis compared to either lavage or placebo surgery, according to a meta-analysis published in the /Cochrane Database of Systematic Reviews/. However, “Debatable areas remain to be addressed; for example, there may be groups of patients or levels of severity of disease for which the intervention may be effective,” the study authors wrote. (January 2008. www.orthosupersite.com/view.asp?rID=26072)

Magnets as Pain Therapy
29 randomized controlled trial (RCT) studies were analysed seeking validation of the premise that magnets relieve back or other forms of pain by Pittler et al. They concluded “overall, the meta-analysis suggested no significant difference effects of static magnets for pain relief relative to placebo”.

Pittler et al. Static magnets for reducing pain; systematic review and meta-analysis of randomised trials. CMJA, 2007, 177; 736-42.