This esteemed group of authors has put together a nice summary of the advances in the understanding of back and neck pain over the past decade as evidenced in the current literature.
|Study title: Advancements in the Management of Spine Disorders
Authors: Haldeman S, Kopansky-Giles D, Hurwitz EL et al.
Publication information: BBest Practice & Research Clinical Rheumatology 2012; 26: 263–280.
We have pulled out some of the points relevant to the practicing clinician. If you are interested in further elaborations we strongly recommend you take the time to read the article yourself to get the full picture (contact Dr. Shawn Thistle for this).
Trends in spinal disorders
Spinal disorders are difficult to manage due to the complexity of the spinal column and the range of disorders that may present in clinical practice. These disorders have been classified in multiple ways but the most widely accepted classification includes four well-defined clinical categories:
- Spinal disorders with serious or systemic pathology: Congenital, developmental, neoplasm, infection, serious trauma, inflammatory diseases (one to two per cent of spinal pain).
- Spinal pain with neurological deficits: Nerve root, spinal cord or cauda equina compression (five to 10 per cent of spinal pain).
- Non-specific spinal pain (mechanical pain or strain): This accounts for 90 per cent or more of those that experience spinal pain. There is growing evidence that it is not possible to identify the causative structure, pathology or source of pain in the majority of these patients.
- Spinal pain referred from non-spinal pathology: This can include systemic, abdominal and pelvic pathologies.
Research, prevention, management
Much of the research on the spine, its function and pathology has focused in the fields of anatomy, neurophysiology, pathology and biomechanics, along with their interactions with one-another. Basic science is being used to understand the mechanisms of common interventions such as spinal manipulation and its effects on spinal stiffness and muscle function.
What continues to perplex researchers is defining the pathological cause or pain generator for spinal pain in specific individuals. The association with degenerative changes that can affect the intervertebral disc and/or facet joints is the most common theory. More current research has shown that the in-growth of nociceptive neurons, expression of neurotrophic and pain-inducing molecules, increased expression of inflammatory cytokines and a progressive loss of viable disc cells have been associated with degenerative disc disease and furthered the concept of the painful disc.
Patient-centred therapies will allow for better outcomes bringing to light the differences between disc degeneration and normal aging. We may even see, some time in the not-so-far future, the use of anabolic growth factors and stem cell therapies for the treatment of degenerative disc disease.
Clinical practice guidelines
It is important for the clinician to differentiate specific local or systemic diseases from non-specific musculoskeletal disorders as this will influence treatment. Therefore, a detailed history and physical examination followed by appropriate/necessary additional studies to make the correct diagnosis is crucial prior to starting a treatment program. Clinical practice guidelines also recommend the use of screening protocols and diagnostic imaging or electrodiagnostic testing to rule out cervical spine fracture in patients presenting with neck pain and/or substantial neurologic findings.
The Bone & Joint Decade
The Bone and Joint Decade Multidisciplinary Guideline Development Committee’s goal is to aggregate guidelines from multiple disciplines and identify areas of consensus. By 2015, the goal was to develop and culturally adapt evidence-based, practical, multidisciplinary, patient-centered guidelines for prevention and management of spinal disorders. The goal was to initiate public education programs and work toward prevention. There is a concerted effort to empower patients to participate in care, as well as target primary-care physicians and home-education programs for community-based spine care.
Through this work we will hopefully see a merging of information and ideas to better address spinal disorders within our communities and around the world.
Dr. SHAWN THISTLE is founder and CEO of RRS Education (rrseducation.com), helping busy clinicians integrate current research rationally into practice. He also maintains a practice in Toronto, lectures at CMCC and provides chiropractic medicolegal consulting services. Email: firstname.lastname@example.org.
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