Think once..twice...thrice ?

By: Charmine Kay Bartlett

 In my practice, it is not uncommon to encounter neck or back pain, may it be acute or chronic. So often, chronic condition, at least in my setting. These patients tried extensive methods of pain alleviation from complementary therapies, physiotherapy to chiropractic, not to mention opioids. The finite end is almost always surgical procedure. “Next to the common cold, low back pain is the most common reason that individuals visit a physician’s office.” In mere 2005 alone, there was $86 billion cost! I surmise, neck pain is following, which parallels popularity. In my opinion, persistent pain is a determinant for an individual to seek the fastest solution regardless of its cause and cost. Functional disability is an unavoidable eventual consequence. It is so perplexing to find out in various studies, that PT intervention with concomitant cognitive behavioral approach parallels the effect of surgical procedure in a span of 1-2 years. (Peolsson et al 2013, Lao et al 2014, Monticone et al 2014, Archer et al 2014)  There seems to have been a paradigm shift from pathoanatomical point of view to neurophysiological and biopsychosocial perception of recovery; from alleviation of that one pathoanatomical structure causing the impairment to more holistic or comprehensive approach of care, over the years. 

What seems to be a typical PT intervention/goal for musculoskeletal pain? Exercise. Goals are to strengthen, to stretch, to stabilize, to function with less to no pain and to improve the quality of life. These are outcome measures that I absolutely agree to be most paramount in an individual why he seeks intervention when in pain. The effect: short term relief when not maintained. This individual may jeopardize the length of his work ability or disability. Cascading events may follow, with more cost utilization to health care system. So, why not opt for surgery, right? Is it an absolute unnecessary treatment compared to other therapies? Isn’t it that ACDF (anterior cervical discectomy and fusion) been reportedly 80% good outcome with reduction of pain intensity and neurological deficits? Isn’t it lumbar fusion or decompressive surgery found to be moderately superior to nonsurgical therapy through 1 to 2 years? But that were prior thoughts. What is common in these surgical procedures is that its intent: supposed to “stabilize a segment of the spine that has weakened and to eliminate  motion at that segment, ideally to decrease pain associated with vertebral movement.” But another common aspect that is set on the side, which is of most importance to a patient himself is: functional goal achievement. Which, evidence says these surgical procedures e.g. ACDF have been unsuccessful at least in 12 to 24 months in this aspect. A patient may have undergone vertebral or cervical disc replacement or any surgical procedure. Success rate could be >50% in a few months but in a year or two, the most prevalent effect- opioids dependence of about 72%. Now, does surgery outweigh conservative measures? In short term, yes but in long term, there is no difference at all except additional chronic complication with post surgery. ” The differences in clinical improvement were not beyond generally accepted boundaries for clinical relevance.” (Jacobs et al 2013) 

Peolsson et al 2013, investigated differences between post ACDF + PT & cognitive behavioral approach and PT alone for CDD (cervical disc disorder) with radiculopathy. Similarly, with Chou et al 2009, reviewed lumbar fusion in comparison to intensive rehabilitation with cognitive behavioral intervention. Both concluded that in 1 or 2 years term, the effect is no longer superior to conservative treatment or no differences to effectivity as to structured PT intervention with cognitive approach. Recently, studies are dwelling into these behavioral modification techniques, which prove effectivity with patient’s adherence to recommendations and treatments. Adherence is a biopsychosocial aspect that is less paid attention to until just recently as well. Thus, there are those building up patient empowerment approach. These surgical approaches will probably never go away or should never go away in some cases, it is going to stay due to inherent gratification for an individual, much more so with pain alleviation. As physical therapist, it is our role to educate our patients the pros and cons of a surgical approach. Our patients should be empowered with this information so as to delineate the best treatment approach they can decide upon themselves.