Selected Instructional Course Lectures   |    
Nonoperative Management of Low Back Pain and Lumbar Disc Degeneration
Darrel S. Brodke, MD1; Stephen M. Ritter, MD1
1 Department of Orthopedics, University of Utah, 30 North 1900 East 3B165, Salt Lake City, UT 84132. E-mail address for D.S. Brodke: darrel.brodke@hsc.utah.edu
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in February 2005 in Instructional Course Lectures, Volume 54. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).
Look for this and other related articles inInstructional Course Lectures,Volume 54, which will be published by the American Academy of Orthopaedic Surgeons in February 2005:
• "Nonsurgical and Surgical Management of Lumbar Spinal Stenosis," by Philip S. Yuan, MD, and Todd J. Albert, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Aug 01;86(8):1810-1818
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The approach to the management of low back pain has undergone substantial change in recent decades. Low back pain can often present as a difficult problem to solve. It is a loosely defined diagnosis that may refer to multiple patterns of pain with complex issues surrounding its pathoanatomical diagnosis and treatment. There is a paucity of evidence from the health professional literature regarding its cause, management, and prognosis. The difficulty of managing patients with low back pain stems from the fact that there often is very little association between any pathological physical findings and the patient's pain and disability. The professional must then find ways of clinically treating a syndrome that betrays the principles of basic science.
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    Darrel S. Brodke, M.D.
    Posted on December 08, 2004
    Drs. Brodke and Ritter respond to Dr Mooney
    Dept. of Orthopedics, University of Utah, Salt Lake City, UT 84132

    We appreciate Dr. Mooney's comments. We agree with Dr. Mooney that the coverage of the subject of non-operative treatment of low back pain was superficial, but our goal was to introduce as broad coverage as possible to the practicing orthopaedic surgeon within the constraints of an ICL. Those who are interested in more depth are referred to the bibliography and to the volumes of printed material available.

    We agree with Dr. Mooney that physical therapy is of value in the management of low back pain. We did attempt to indicate this in the ICL. We also felt it important to discuss other commonly used, though less well supported, treatment options. Many of these were discussed in light of their lack of scientific evidence. It is important for the readership to know that many of these commonly used treatments have little support. To leave them out of discussion would be a disservice and, in our opinion, less complete.

    Though supported here, there is not universal agreement that physical therapy is as valuable as Dr. Mooney asserts. As an example, Chetkin, Deyo, et al. in a prospective, randomized, control study found physical therapy similar to chiropractic management and only mildly better than giving a booklet to the patient in the outcomes of patients with low back pain.(1) In light of this, we find the treatment of low back pain to be an art. The most successful practitioners use a combination of therapies and do not stick to any single treatment option for anyone patient.

    We would like to acknowledge the experience and expertise of Dr. Mooney, who has made a career in the study and understanding of non- operative treatments of low back pain. The authors are pleased Dr. Mooney took the time to write a letter regarding this important topic and we hope this will stimulate others to learn more.


    Darrel S. Brodke, M.D. Stephen Ritter, M.D.

    1. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998 Oct 8;339(15):1021-9.

    Vert Mooney, M.D.
    Posted on December 08, 2004
    Non Operative Management of Low Back Pain and Lumbar Disc Degeneration
    U.S. Spine and Sport Center, University California, San Diego, CA

    To the Editor:

    I am writing to express my disappointment in the recent Instructional Course Lecture published by the Journal,"Non Operative Management of Low Back Pain and Lumbar Disc Degeneration" (1). It presents the issue of nonoperative back care at a medical student level, not at all appropriate for what an instructional course should present - the most up to date information presented by experienced experts. This is especially sad because low back pain is the most common musculoskeletal disease and, if orthopedists are expected to be the specialists knowledgeable in this area, they should at least have available to them current evidenced-based treatment programs. The superficial summary of nonoperative care presented in this article further guarantees that the orthopaedist will continue his/her drift into the role of pure surgical technician, functioning at the behest of clinicians more expert than they.

    My specific problem is in the discussion of physical therapy. In this seven and a half page article, physical therapy merits half a page. Of all the areas of nonoperative care where orthopaedic surgeons can have an opportunity for effective quality control, physical therapy is it. We are not expert in medications, injections, manipulation or braces.

    What is particularly disturbing is the authors' apparent attitude that there is no rationale for physica1 treatment. The authors imply in their half page on physical therapy that one can do this or that and it doesn't make any dllference. Their references supporting specfic exercises are very outdated. For instance, the two references discussing specifics are from 1983 and 1968. The latter, referenced by Kendall, has long been discredited and I doubt the authors ever read it - if they could even find it.

    The authors disregard a substantial literature that identifies myoelectric inhibition and atrophy of the lumbar extensors as corollaries to low back pain. This observatin leads to a rationale for care quite parallel to the rationale for care of an injured knee - progressive resistance exercises. There Is considerable recent literature to support the efficacy of this approach, totally ignored by the authors.

    The authors also ignored the literature supporting efficacy of exercises based on centra1ization of pain. There is only one reference to McKenzie exercises, compared to resistive exercises by indicating they showed no difference in reduction of disability or pain in follow-up, but failing to point out that both demonstrated considerable improvement in pain and disability when provided to the patients in the referenced group. Furthermore, there are no recent references regarding injections, IDET and chiropractic care.

    My point is that, when such a superficial, non-expert instructional course is presented, it gives the impression that orthopaedic surgeons do not have the capacity to mount a rational program in nonoperative care. Once we accept our lack of expertise as reflected by this instructional course, we will drift further into our emerging role as surgical technicians dependent upon the referrals of more expert clinicians. How sad!

    Yours truly,

    Vert Mooney, M.D. Clinical Professor of 0thopaedics University California San Diego Medical Director, Spine & Sport Centers


    1. Darrel S. Brodke and Stephen M. Ritter Nonoperative Management of Low Back Pain and Lumbar Disc Degeneration J Bone Joint Surg Am 2004; 86: 1810-1818

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