December 8-11, 1999

Rene Cailleit, M.D. Exercises for the Spine

Spoke of the specific exercises one should prescribe to optimize spinal stability as he believes spinal instability is a precursor to degenerative diseases but not exclusively related to it. Exercises to work the abdominal complex are important as they form a "tubular complex" or "airbag" to support the spine.

Arthur C. Croft, M.S., D.C. Crash testing at low speed, low impact, with human volunteers

Discussed implications of low speed, low impact MVA on human volunteers as it relates to "Cervical Acceleration-Deceleration" syndrome or CAD. Incidence: 3 million/year; 50% uninjured, 25% recover from injury, 25% develop chronic sx’s, 5-10% have chronic disability; 2.5x acceleration = 5 G force to head, occurs within 1^st 100 msec, 15x higher risk of poor outcome if unaware of impending collision; most injuries occur due to headrest set too far back causing head lag and pinching of z-joints as the instantaneous axis of rotation changes. Slow speed crashes often have increased risk because it does not cause a metal collapse to absorb forces. Dr. Croft drives a Mercedes.

Scott Haldeman, D.C. M.D., Ph.D. A Century of Progress in Spinal Care

The primary failure of physicians and scientists in the 20^th century has been the inability to isolate and define the cause of spinal pain. A change of thinking has taken place where "Science is King". Science is driving theory and practice. Current research shows 1) inflammatory cascade 2) plasticity and pain memory in CNS; 3) Genetic coding of disc tissues (some inherit the ability to feel more pain (at this point he gave Bill Clinton as an example); 4) Somatovisceral reflexes play a role in healthy tissues/organs; 5) Psychosocial factors play a large role in disability. Next century "Cooperation will be King"

Robin McKenzie Patient – Heal thyself!

The medical model has failed the patient. Our treatments don’t work and the day has come when insurance demands proof of efficacy. Health care providers control public perception for need of care. We cannot accelerate healing. There is only 3 causes of mechanical pain; Postural, dysfunction, and derangement (predisposes one to dysfunction). Management of the future must emphasize education for the patients to treat themselves.

Hyman Tannebaum, M.D. COX-2 Specific Inhibitors

Pharmacology of COX-2 was discussed as the "next generation of NSAID drugs." The new COX-2 inhibitors has a far greater GI safety profile in clinical trials versus Ibuprofen or naproxin and are as efficacious in relieving arthritic symptoms. This is especially significant in the elderly population.

Nikolai Bogduk, M.D. Ph.D Back Pain Research this Century

With Mixter and Barr’s disc research in 1935, the era of the prolapsed disc began. This concept was the most common basis for back pain and dominated, polluted and confounded clinical practice for the next 60 years. It spawned the application and development of CT, MRI, and discography. Although disc prolapse is the single most common cause of radicular pain, it is not the cause of back pain. This mistake generated years of misuse of expensive tests, culminating most recently with the recognition that these investigation do little more than reveal normal age changes in patients. Yet that has not prevented countless patients undergoing futile surgery for their age changes.

The Z-joint as a source of pain was introduced in the late 30’s but was not popularized until the 70’s when Rees claimed outstanding success in treating back pain. But, for 20 years there were no controlled studies until 1994 when diagnostic blocks showed that patients did have z-joint pain. The condition was uncommon accounting for not more than 15% of patients with chronic back pain and probably closer to 10%.

The concept of SI joint pain waxed and waned in popularity throughout the century. After 90 years controlled data showed that SI joint pain does occur and accounts for some 15-20% of chronic back pain. Diagnostic blocks are the only means of diagnosis. There is still no proven treatment.

Discogenic pain accounts for some 40% of patients with chronic back pain. Discogenic pain is not the same as radicular pain caused by disc prolapse. It arises from the disc itself, which is externally intact. Discographers need to be careful in their use of discography in order to avoid false-positive responses. Internal disc disruption occurs not as degeneraton bu as an acquired injury due to fatigue failure.

Fusion has long been the mainstay of surgical management for discogenic pain, but largely on the basis of habit – not evidence. New techniques of percutaneous electrocoagulation are being evaluated.

Lagging behind in terms of evidence are prevailing concepts of segmental dysfunction, muscle imbalance, and subluxation as causes of back pain. There are neither biological nor empirical clinical data to validate these concepts; yet they prevail, probably to justify the practice habits of many practitioners.

The 80’s saw the emergence of psychosocial models. While attractive in theory, this notion has not been shown to reduce chronicity and morbidity. New means of treatment are threatening to overtake the psychosocial nihilism.

One clear message has arisen in the 1990’s. After nearly a century of various investigations and treatments being applied to acute patients, it has been shown that minimal intervention, with confident, caring conviction, explanation and assurance, together with an insistence to resume normal activities, is as good as any other treatment, and is the only treatment with 5 years of follow-up with success.

Clarence Nicodemus, Ph.D. Biomechanical Study on the Efficacy of Exercise Machines.

With 5-6 weeks of training on MedX, Cybex extension, Roman Chair, or counterbalanced assisted pull-ups, found no significant difference between MedX and Cybex extension, the fixed 45-degree roman chair approached 50% of the values attained by MedX and surprisingly, the pull-ups achieved 75% of the medX results. These were added into the study after a personal experienced of not being able to do any pullups due to weakness after a medX bout of working the lumbar extensors. Pull-ups may have an advantage in rehab as there is no flex/extension, decreased intradiscal pressure, and it may centralize symptoms.

Ronald G. Donelson, M.D. Reducing the variation in the findings and diagnosis among the disciplines in spinal evaluation.

The 1987 Quebec task force stated: "There is so much variability in making a diagnosis that this initial step of clinical assessment routinely introduces inaccuracies which are further confounded with each succeeding step in care" adding that the resultant terminology used for diagnosis "is the fundamental source of error….faced with uncertainty, physicians become inventive."

The 1994 AHCPR guidelines described only the neurological and "red flag" exams representing less than 10% of the LBP population. No help was provided in how to exam the other 90%.

Meanwhile there is a body of literature that has been unappreciated, even ignored, that sheds considerable light on the nature of the underlying problem and how to treat it. Many studies now document the intertester reliability, validity, and usefulness of evaluating patterns of pain response experienced and described by the patient in response to positions, movements, and activities. Despite the more familiar body of literature documenting the value of patterns of pain response to provocative and anesthetizing diagnostic injections, studies of non-invasive, pain provocative/abolishing test are unknown to many prominent in the field and the majority of guideline panels.

Despite strong evidence to show palpation to be unreliable, it remains common as a patient assessment tool. Manual tests using pain provocation have shown to be reliable. Centralization as described by McKenzie has been the basis for rapid growth in the use of these assessment methods. The Danish Acute LBP guidelines now differentiate the McKenzie assessment from treatment to conclude that the scientific support for the use of McKenzie assessment methods reached their highest level of acknowledgment.

Pain provocation/abolishing mechanical tests are proving to be reliable, valid, and strong predictors of treatment outcomes. They are being used to greatly reduce the variation in patient assessment and will reduce the variation in the use of diagnostic studies as well as both non-operative and operative treatments.

John C. Chiu, M.D. Minimally Invasive Spine surgery with Advanced Techniqe for Herniated disc.

The new Holmium laser thermodiskoplasty technique in laser percutaneous microdecompressive endoscopic spinal discectomy appears to be easy, safe and efficacious. This less traumatic, easier outpatient treatment leads to excellent results, faster recovery, and significant economic savings.

Ted Dreisinger, Ph.D. Injury Prevention

It is clear that if we don’t develop and implement clear, decisive and objective strategies we will continue to spend and spend and spend without really reducing injury. The demonstration of strong fiscal return on investment is a critical element in the success of any prevention program.

Stephen I Esses, M.D. The Place for surgery in Back disorders.

There is no panacea for back pain disorders. Appropriate treatment depends on accurate diagnosis. There are clearly specific disorders for which surgery provides excellent treatment. This includes herniated nucleus polposus and spinal stenosis. Other back disorders, surgery is sub-optimal. The role and results of arthrodesis for degnerative disc disease remains controversial.