Module 2
FACILITATOR NOTES
Week 2
SP Taped Interview
Problem list- includes any current, past, or potential future medical conditions,
psychosocial problems, or behaviors that predispose to health risks. (see SP
history for problem list)
Physical examination-In addition to the routine screening exam other maneuvers
one may wish to perform would be detailed assessment of muscle strength
particularly in lower extremities, deep tendon reflexes, straight leg raising test
and gait. These would be examined to ascertain if nerve root compression was
present and would suggest a herniated disc or less likely a tumor in or near the
spinal column. Palpation of the muscle of the lower back (paraspinal specifically)
for tenderness or contraction indicative of muscle strain and spasm. Percussion
of the lumbar spine for tenderness suggestive of compression fracture.
Secondarily, one would carefully exam the fundi because of history of
hypertension and diabetes, palpate and auscultate the heart for evidence of LVH,
left ventricular failure and gallops. Peripheral vasculature would be noted for
bruits and diminished pulses. For the female with stress incontinence a pelvic
examination is warranted.
Based on this information the differential diagnosis of the back pain includes
muscle strain, herniated disc, or compression fracture and the physical will
dictate which is present or most likely.
Background on CAM
History should be obtained in a non-judgemental manner and open-minded.
Most physicians ask about CAM during interviewing about medication use and
allergies.
Whether you agree or not with the other forms of therapy the patient utilizes
several major points need to be brought out;
1. Need to incorporate use of these other modalities into traditional practice to
avoid harm to the patient.
2. Patient education that includes their ability to understand and accept is
fundamental.
Scientific verification (evidence-based medicine) is the cornerstone of traditional
medicine and should be criteria to accept or reject alternative therapies. Even if
rejected, the patient may continue to utilize the modality and this reality should
be included in your on-going care, education, and learning regarding this patient.
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Taped Interview
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Week 2
Demographics
56 year-old married male/female who lives with his/her wife/husband and two
children in an affluent section of Galveston.
Chief Complaint
“I’ve had pain in my low back for the last 10 days”
HPI
Patient describes pain in the lower mid-section of his/her back. The pain is a dull
ache in nature. It is a constant pain. A heating pad helps reduce, but does not
totally relieve, the pain. He/She went to a chiropractor for spinal manipulation,
but states it does not seem to have helped very much like it did 4 years ago with
a similar episode.
Answers to specific questions:
 Pain first occurred acutely when he/she was lifting a heavy box in
the garage
 Pain is a 5/10 intensity, bending or lifting exacerbate the pain
 Bedrest improves the pain
 Pain does not radiate down his/her legs
 Pain is partially relieved by 1000mg Tylenol
 There are not paresthesias (abnormal sensations) in his/her legs
 No abnormal/spontaneous movements of his/her legs
 No previous trauma to the lumbar area
PMH
He/She has had diabetes for the last 20 years controlled on “pills” called
glipizide.
He/She does not check his/her blood sugars regularly.
Has
hypertension for the past 20 years controlled with a diuretic, hydrochlorothiazide.
He/She sees his/her doctor once or twice a year. He/She doesn’t remember
when he/she had his/her last immunizations. He/She has no known drug
allergies.
FH
Father is 77 and has diabetes and hypertension. Mother is 74 and had breast
cancer treated with surgery 10 years ago. Once brother 44 years with diabetes
and one sister 42 alive and well. One son age 11 alive and well and a daughter
age 7 alive and well.
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SH
Works as a manager of the local K-Mart. Lives in a house with his/her
wife/husband of 20 years and two children. Smoked 1 ppd cigarettes for 10
years, but quit 6 years ago. Drinks a beer with dinner. No illicit drug use. Bowls
with his/her friends in a league once a week and spends of his/her off time with
his/her family. He/She works 60 hours a week at the K-Mart. His/Her sexual
relations with his/her wife/husband have been progressively less frequent, “I just
don’t have the same desire I used to, maybe I am getting old”.
ROS
Patient has been overweight all of his/her life. He/She has gained 25 pounds
over the last 18 months and now weighs 268 pounds (223 for female). He/She
has been trying to lose weight but eats a lot of junk food at work. He/She has
“stress headaches” almost every day that he/she treats with Tylenol. He/She
attributes this to his/her job. No other problems.
Pertinent Review of Systems
Decreased energy
Allergic rhinitis
Lower dentures
Dyspepsia (heartburn) after spicy or heavy meals and sometimes when lying
supine
Pain in both knees if stands too long or walks too far
History of UTIs x 4 if female and with stress incontinence
Dyspnea on exertion
Discussion
1. Problem List
a. Low back pain
b. Headaches
c. Obesity
d. Diabetes Mellitus
e. Essential hypertension
f. Knee pain
g. UTI (female)
h. Stress incontinence (female)
i. Allergic rhinitis
j. Dyspepsia
k. History of tobacco use
l. Alcohol use
m. FH of diabetes, hypertension, breast cancer
2. Differential Diagnosis (Low back pain only)
a. Muscle strain-exacerbated by body habitus
b. Herniated inter-vertebral disc
c. Compression fracture of vertebral bodyPhilip LaBarbera, MD
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Evidence-Based Curriculum in Alternative Therapies
Victor S. Sierpina, MD
CATEGORIES OF ALTERNATIVE MEDICINE
The National Institutes of Health and its National Center for Complementary and
Alternative Medicine define 5 areas of alternative medicine for the purposes of research
and clinical care. These are briefly described and listed as follows:

Alternative Medicine Systems are complete systems of theory and practice
that have developed outside of the western medical approach, e.g. traditional
oriental medicine (including practices such as acupuncture) ayurvedic
medicine, homeopathy, naturopathy.

Mind-Body Therapies employ a variety of non-mainstream techniques
intended to facilitate the mind’s capacity to affect bodily function and
symptoms, e.g. meditation, dance therapy, prayer, mental healing, relaxation
therapies, stress management.

Biological-based Therapies include natural and biologically based practices,
interventions, and products, e.g., herbal, special dietary, orthomolecular, and
individual biological therapies, nutritional supplements.

Manipulative and Body Based Therapies include methods based on
manipulation and or movement of the body, e.g., chiropractic, osteopathy,
massage therapy, or other body work.

Energy Therapies focus on energy fields originating from within the body
(biofields) or those from other sources (electromagnetic fields), e.g., Qi
Gong, Reiki, Therapeutic Touch, and use of pulsed fields or magnet fields.
RESEARCH ISSUESAND CLINICAL USE OF ALTERNATIVE THERAPIES
While each of these areas has been used clinically, some such as acupuncture or ayurveda
for thousands of years, research on the benefits, safety, cost, and efficacy continues to
evolve. Many studies on these alternative therapies have historically been poorly
designed, lack adequate sample size, controls, clearly defined inclusion and exclusion
criteria, experimenter blinding, and so on that we consider essential to reliable study
design. This is largely why these therapies continue to be considered “alternative.” With
increased public awareness and use of these therapies along with federal and other
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funding for research, it is becoming increasingly clear which of these therapies are useful,
cost-efficient or cost-additive, and how and if they should be integrated within our health
care systems.
Despite conclusive studies, however, between 40-50% of adults in the US use alternative
therapies. They make more visits to alternative practitioners than to primary care
physicians. And they spend $28 billion annually, mostly out-of-pocket, for these
services, a figure that approximates their expense for all other medical services
(Eisenberg 1993, 1998).
THE ROLE OF ALTERNATIVE THERAPIES IN LOW BACK PAIN: A Brief Review
of Opposing Evidence
The most commonly used alternative therapies for back pain are: 1) spinal manipulation,
e.g., chiropractic or osteopathy, 2) acupuncture, 3) massage. These are in the categories
of manipulative or body-based therapies (chiropractic, osteopathy, and massage) and
alternative systems of care (acupuncture).
Low back problems are one of the most common causes of both acute and chronic pain.
They form a heterogeneous group of disorders often lumped together as “low back pain,”
“sciatica,” or “lumbago.” Though serious conditions such as ruptured intervertebral discs,
fractures, tumors, and infections can cause low back pain, the majority of cases defy
precise anatomical definition. Treatments, therefore, are often used that either seem to
work or offer hope of improvement while the back pain resolves, often on its own. This
makes the study of the benefits of any therapy complex.
A recent review article (NHS Centre, 2000) utilized the Cochrane Collaboration
systematic reviews to assess the “best evidence” for the treatment of both acute and
chronic back pain. (See Tables 1 & 2). While they described a wide variety of
approaches, evidence for effectiveness was strongest in acute back pain for: 1) advice to
stay active, 2) non-steroidal anti-inflammatory drugs (NSAID’s), 3) muscle relaxants, 4)
analgesics. For chronic back pain, best evidence favored: 1) back schools, 2) behavioural
treatments, 3) exercise therapy, 4) multidisciplinary programmes, 5) NSAID’s.
What are we to make of the failure the most commonly used alternative therapies for
back pain, spinal manipulation, acupuncture, and massage to be proven as effective?
Indeed, they are described in this review as having either “unclear effectiveness” or
“evidence for ineffectiveness.”
One explanation is that methodology of studies on these therapies was often poor, failing
to support the benefits many individual patients claim for relief. Indeed, there are some
studies showing the adverse events of such therapies such as cerebrovascular accidents
with spinal manipulation and pneumothorax with acupuncture. This clearly indicates as
need for more and better studies before these therapies can be considered mainstream
medicine. Yet patients continue to seek these therapies despite final scientific
documentation of clinical effectiveness for personal reasons, and perhaps because of
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individualized benefits that cannot be adequately supported by the randomized controlled
trial.
Other studies, do show suggestion of effectiveness for such alternative therapies. For
example, a prospective, randomized study comparing acupuncture with physiotherapy for
low back pain in pregnant women showed significant decrease in pain in the acupuncture
group over the physiotherapy group as rated by the Visual Analog Scale (VAS). It also
showed a significant decrease in the Disability Rating Index (DRI) in the acupuncture
group (Wedenberg, 2000). Though a small study, this suggests some benefit for
acupuncture in this population.
Chiropractic has certainly found a major place in our health care system both here and
abroad is reimbursed by major insurance carriers, including Medicare. To reach this level
of acceptance by third-party payors, clearly some scientific support was required and
many studies do show a place for this modality in back pain(Waddel, 1996, Manga,
1993). An outcomes study on chiropractic treatment for low back pain vs. treatment by
family physicians showed 31% of patients had reduction of pain after 1 month in the
manipulation group compared to 6% in the physician group (Nyiendo, 2000). This
indicated that perhaps those choosing chiropractic care may be more likely to recover
from back pain, though by no means proved it.
Massage has been widely studied and is the most frequently used treatment for back pain
on the European continent. Results using massage therapy as a control show its
effectiveness in systematic review but fall short of conclusive evidence (Ernst 1999). A
study comparing comprehensive massage (soft tissue work, remedial exercise, and
posture education) with soft tissue massage only, remedial exercise with posture
education, and sham-laser therapy showed significant improvement in decreased pain in
the comprehensive massage therapy group compared to any of the other groups (Preyde,
2000).
CONCLUSION:
Clearly, these alternative therapies for back pain have not only wide usage but are
supported by some clinical studies. While the overall evidence for their effectiveness
remains inconclusive, clinical trials suggest benefit in some populations. A wide range of
other alternative therapies are also used for back pain and other musculoskeletal
disorders, again with a varying level of evidence for their effectiveness (see Table 3).
POTENTIAL QUESTIONS FOR SMALL GROUPS:
1) If a patient presented with chronic back pain and insurance plan that covered
acupuncture, chiropractic, or massage, which, if any would you recommend?
What if the patient demanded a referral? What would you say?
2) How can the results of a randomized controlled clinical trial differ from a
systematic review or meta-analysis?
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3) How do you make rational clinical decisions in the face of conflicting or
inconclusive data from the medical literature, as illustrated in this discussion?
4) What has been your real-life experience with any of these alternative therapies?
Have friends or members of your family used them, been benefited or relieved?
Have any sustained an injury or other adverse outcome with these alternative
therapies? Answer these same questions for conventional medical or surgical
interventions?
REFERENCES:
Eisenberg D, et al. 1993. Unconventional medicine in the United States. Prevalence,
costs, and patterns of use. N Engl J Med 328:246–242.
——, et al. 1998. Trends in alternative medicine use in the United States, 1990–1997:
results of a follow-up national survey. JAMA 280:1569–1575.
Ernst E. Massage. 1999. Massage therapy for low back pain: a systematic review. Pain
Symptom Manage 17:65-69.
Manga P, et al.1993. The effectiveness and cost effectiveness of chiropractic
management of low back pain. Toronto: Ontario Ministry of Health.
NHS Centre for Reviews and Dissemination. Acute and chronic low back pain. 2000.
Effective Health Care 6(5): 1-8.
Nyiendo J et al. 2000 Patient characteristics, practice activities, and one-month outcomes
for chronic, recurrent low back pain treated by chiropractors and family medicine
physicians: a practice-based feasibility study. J Manipulative Physiol Ther 4:239-245.
Preyde M. 2000 Effectiveness of massage therapy for suacute low-back pain: a
randomized controlled trial. Can Med Assoc J 162: 1815-20.
Waddel G, et al. 1996. Low Back Pain Evidence Review. London: Royal College of
General Practitioners.
Wedenberg K, et al. 2000. A prospective randomized study comparing acupuncture with
physiotherapy for low-back and pelvic pain in pregnancy. Acta Obstet Gynecol Scand 79:
331-35.
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Box 1 – Summary of the effectiveness of conservative treatments for acute
low back pain (adapted from Van Tulder et al. 2000)*
Evidence for effectiveness
Advice to stay active
NSAIDs
Muscle relaxants
Analgesics
Unclear effectiveness (no,
limited or contradictory
evidence for effectiveness)
Acupuncture
Back schools
Behavioural treatments
Colchicine
Electro myographic biofeedback
Epidural steroid injections
Facet joint injections
Ligamental injections
Lumbar supports
Multidisciplinary programmes
Physical treatments
Spinal manipulations
Traction
Transcutaneous electrical nerve stimulation
(TENS)
Trigger point injections
Evidence for ineffectiveness
Bedrest
Exercise therapy
*Tulder M, van, Koes B, Assendelft W, et al. Acute low back pain: activity, NSAID’s
and muscle relaxants effective; bedrest and targeted exercise not effective; results of
systematic reviews. Ned Tijdschr Geneeskd 2000;144:1484-9. Cited from: Acute and
Chronic Low Back Pain in Effective Health Care. 2000;6(5):1-8.
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Box 2 – Summary of the effectiveness of conservative treatments for
chronic low back pain (adapted from Van Tulder et al. 2000)*
Evidence for effectiveness
Back schools
Behavioural treatments
Exercise therapy
Multidisciplinary programmes
NSAIDs
Unclear effectiveness (no,
limited or contradictory
evidence for effectiveness)
Advice to stay active
Analgesics
Antidepressants
Bedrest
Colchicine
Epidural steroid injections
Ligamental injections
Lumbar supports
Muscle relaxants
Physical treatments
Spinal manipulations
Transcutaneous electrical nerve stimulation (TENS)
Trigger point injections
Evidence for ineffectiveness
Acupuncture
Electro myographic biofeedback
Facet joint injections
Traction
*Tulder M, van, Koes B, Assendelft W, et al. Acute low back pain: activity, NSAID’s
and muscle relaxants effective; bedrest and targeted exercise not effective; results of
systematic reviews. Ned Tijdschr Geneeskd 2000;144:1489-94. Cited from: Acute and
Chronic Low Back Pain in Effective Health Care. 2000;6(5):1-8.