Neck Solutions Blog

The clinical aspects of the acute facet syndrome: results from a structured discussion among European chiropractors

From: Chiropr Osteopat. 2009 Feb 5;17(1):2. [Epub ahead of print]

The term ‘facet joint’ became common in the 1970s, when surgeons developed an interest in the small joints of the lumbar spine as a source of low back pain. The formal name for these joints is the zygapophyseal joints, as endorsed by The International Anatomical Nomenclature Committee. They were suggested as a source of pain as early as 1911 and the term ‘facet syndrome’ was introduced by Ghormley in 1936. However, due to the discovery of the lumbar disc as a source of low back pain, the facet joints did not receive much further attention until the 1970s. In 1976, Mooney and Robertson demonstrated that the facet joints could be a source of pain and that certain patients could be relieved from pain by anesthetizing these joints. These findings were later reproduced and thus confirmed the basis for the concept of ‘facet syndrome’, ‘facet joint pain’ or ‘zygapophyseal joint pain’. The term ‘facet syndrome’ is really a contradiction in terms. A syndrome is characterized by a set of detectable characteristics, usually used when the pathophysiology has not yet been discovered. In the case of ‘facet syndrome’, the source of pain is identified but the clinical presentation is poorly defined. Nevertheless, the term is widely used.

During the past three decades, there have been numerous studies of the frequency of facet joint pain in chronic low back pain patients. In these studies, various types of facet joint injections were used to determine whether the facet joints were the source of pain. These included injection of local anaesthetic into the joint itself or the nerves that innervate them, resulting in relief from pain if the pain originated from these joints (diagnostic blocks). Prevalence rates of facet joint pain among those patients with chronic low back pain vary widely in the literature, ranging from 5% to 90% but there is a problem with a high false positive rate in many studies. Therefore, when confirmatory blocks are used, the prevalence rates are somewhat lower, ranging from 9% to 45%. As these studies investigated chronic low back pain, these prevalence rates indicate that the facet joints might be important contributors to the burden of chronic low back pain. However, there does not appear to be any studies describing the prevalence of facet joint pain in acute low back pain.

The etiology of pain from the facet joints has been investigated from several perspectives. Osteoarthrosis has been considered as a source of facet joint pain. Facet joint osteoarthrosis is very common in the general population; the frequency increases with age and the highest prevalence is at the L4-5 spinal level. However, the presence of osteoarthrosis in the facet joints, as seen on plain radiography, does not seem to be associated with low back pain. In contrast, facet joint oedema visualised by MRI correlated with back pain intensity in at least two studies. A common explanation in chiropractic textbooks is that small meniscoids formed of synovial folds and continuous with the periarticular tissues become entrapped or extrapped and through a cascade of events lead to acute locked low back. This is described as being amenable to manipulative therapy. Garges, White and Koestler offer an alternative or supplementary explanation of pain from the facet joints. They describe how inflammatory adhesions of the facet joints and their capsules may cause a painful reduction in motion.

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The Nordic back pain subpopulation program: predicting outcome among chiropractic patients in Finland

From: Chiropr Osteopat. 2008 Nov 7;16(1):13 [Epub ahead of print]

The causes of non specific low back pain are largely unknown. Obviously, this is a hindrance to a rational approach to both prevention and treatment. In general, both etiologic studies and randomized controlled clinical trials are based on the concept that non specific low back pain is one single entity. However, most clinicians with an interest in back pain probably consider it to consist of several specific conditions, which have not been properly recognized, understood and described.

Chiropractors in the Nordic countries use predominantly spinal manipulative therapy in their treatment of back problems, frequently in combination with soft tissue therapy, advice on exercise, ergonomic precautions, and lifestyle changes. Randomized controlled clinical trials have shown that spinal manipulative therapy has a positive effect on low back pain. However, overall, the magnitude of the effect seems to be relatively small. Those, who believe that back pain consists of several specific but (as yet) undefined subgroups, obviously think that the recognition of these would improve the quality of care and that the selection of homogeneous study populations in etiological studies and clinical trials would improve the quality of research.

Until recently it has not been documented which patients with low back pain are most likely to benefit from the chiropractic approach. However, the predictive value of a set of clinical observations has been previously studied in patients with low back pain receiving chiropractic care. This research, conducted in Norway and Sweden under the Nordic Back Pain Subpopulation Program, has been running over the past years, in which specific subgroups of patients with low back pain are systematically studied. For instance, it was shown that it is possible to predict which chiropractic patients with persistent low back pain will not report definite improvement early in the course of treatment, making it possible to exclude from treatment those who are unlikely to become low back pain free. Furthermore, early recovery at the 4th visit was noted to be a predictor for outcome 3 and 12 months later and the status already by the second visit predicted status at the fourth visit.

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Satisfaction with low back pain care

From: Spine J. 2008 May-Jun;8(3):510-21. Epub 2007 May 25

By using a unique, prospective study of occupational back pain claims, they examined health care satisfaction by provider type and its effect on return to work. They estimated satisfaction differentials by provider type, decomposing overall satisfaction into two components: bedside manner and effectiveness of care. They also examined how health care satisfaction affects the duration of jobless claims. The Arizona State University Healthy Back Study is a prospective study of work related back pain; 1,831 workers completed a baseline interview, with follow-up interviews at 1 month, 6 months, and 1 year. The Arizona State University Healthy Back Study merged demographic and claim characteristics from the workers’ compensation claim files with self-reported severity measures, measures of satisfaction, and postonset employment from worker interviews.

Overall and detailed satisfaction with treatment and workers’ compensation claim duration. They performed a nonparametric descriptive analysis of satisfaction by provider type and used multivariate regressions to decompose overall satisfaction into component parts. The duration analysis links differentials in health care satisfaction to differences in claim durations. Workers treated by surgeons, chiropractors (DCs), or physical therapists are more satisfied with their health care than those treated by MDs. Workers are more concerned with the effectiveness of care than with the bedside manner of their provider. A one standard deviation improvement in satisfaction with the health care provider reduces claim duration by about 25%.

A comparison between chiropractic management and pain clinic management for chronic low back pain in a national health service outpatient clinic

From: J Altern Complement Med. 2008 Jun;14(5):465-73

To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low back pain when managed in a hospital by either a regional pain clinic or a chiropractor. Design: The study was a pragmatic, randomized, controlled trial. The trial was performed at a National Health Service hospital outpatient clinic (pain clinic) in the United Kingdom. Subjects and interventions: Patients with chronic low back pain (i.e., symptom duration of >12 weeks) referred to a regional pain clinic (outpatient hospital clinic) were assessed and randomized to either chiropractic or pain-clinic management for a period of 8 weeks. The study was pragmatic, allowing for normal treatment protocols to be used. Treatment was administered in an National Health Service hospital setting. Outcome measures: The Roland-Morris Disability Questionnaire (RMDQ) and Numerical Rating Scale were used to assess changes in perceived disability and pain. Mean values at weeks 0, 2, 4, 6, and 8 were calculated. The mean differences between week 0 and week 8 were compared across the two treatment groups using Student’s t-tests. Ninety-five percent (95%) confidence intervals (CIs) for the differences between groups were calculated.

Randomization placed 12 patients in the pain clinic and 18 in the chiropractic group, of which 11 and 16, respectively, completed the trial. At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023).

This study suggests that chiropractic management administered in an National Health Service setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with chronic low back pain.