A rehabilitation approach should be considered (see Table 20.2). The strength of evidence f or therapies is variable. Adherence may be a problem with rehabilitation programs but adher ence may be augmented by providing patient education literature. A study by the U.S. Preventative Services Task Force (USPSTF) concluded that there was insuf \201 cient evidence to recommend the use of exercise to pre vent back pain, although this may still be worth considering. CONDITIONS CAUSING ACUTE/SUBACUTE BACK PAIN IN ADULTS 539 Table 20.1 Warning signs for sinister pathology in back pain 1 Red- \202 ag signs: 1. First pain age <20 or >55 years 6. Immunosuppression/steroids 2. Pain at rest 7. Malaise/weight loss 3. Trauma 8. Osteoporosis 4. Progressive neurologic de \201 cit 9. Intravenous drug use 5. History of cancer 10. Failure to improve in 6 weeks Table 20.2 Therapies used in facilitating rehabilitation after acute mechanical low back pa in Manipulation Either done by an osteopath, chiropractor, or physical therapist. Some controversy about th e size of bene \201 t due to poor methodological studies. Avoid using in cases of intracta ble back pain (see Chronic back pain). McKenzie exercises Passive extension exercises designed to improve pain and stiffness associated with disc and anterior spinal structure pathology. May aggravate pain from posterior spine structures, e .g., facet joints, spinous processes. Hydrotherapy or balneotherapy Poorly studied but warmth can ease movement and augment land-based exercises. Might be cons idered after initial painful phase to regain normal movements and mobility. Obviously will only suit a few patients and resources may be limited. Graded activity programs Useful for patients who require guidance and would be unable to gain optimally from home ex ercise regime. A plan for rehabilitation with milestones is useful for some patients. Behavioral programs Focuses on psychological aspects of pain, involves moderate supervision and planned withdra wal of treatment. Differs from some other approaches in that the therapist takes on the \200\234control \200\235 of the back pain. Limited resources may restrict provision of this approach. Choice of patients for program important, although data are limited. CHAPTER 20 Back pain 540 Back pain and nerve root lesions (see also Chapter 2) \200 Root compression occurs most o ften because of acute or subacute disc prolapse or foraminal stenosis. The peak incidence i s age 30 \200\22350 years. About 70% resolve within 3 months and 90% within 6 months. \200 Root compression should be suspected if acute or subacute back pain is associated with segmental nerve or sciatic leg pain. Acute sciatic pain (affecting the outer and posterior leg) is often sharp or burning in nature, and most frequently arises from acute disc prolapse of either L 4/5 or L5/S1 (>90% cases). Sciatica is characterized by leg pain projecting past the knee, which may be more severe than the associated back pain. A patient with a herniated disc may present with complaints of sciatica; evidence of disc herniation may be elicited through physical examination by strai ght leg raise or crossed straight leg raise (i.e., elevation of unaffected leg). These test s are positive if pain is felt in the buttock or back at a leg angle of 30 \200\22360 . Pain elicited at a leg angle <10 is consistent with musculoskeletal back pain. A neurologic examination is essential: L5 root lesions give decreased strength of the foot and great toe dorsi \202 exion, standing on heel, and decreased ankle re \202 ex and sens ation over great toe. S1 root lesions give decreased strength in plantar foot \202 exion, dif \201 culty weight-bearing on toes, and decreased ankle re \202 ex and sensation on t he sole or outer part of foot. Principles of management \200 In general, 30 \200\22360% of patients recover in 1 week. \200 NSAIDs, acetaminophen, and muscle relaxants should be considered \201 rst. Some pat ients will require narcotics for pain control. Bed rest should be limited; prolonged bed re st leads to worse outcomes. \200 An epidural steroid injection can improve pain in the sh ort term, but its impact on long-term outcomes is less clear. A meta-analysis showed that 1 in 7 patients who receive a steroid epidural experience >75% improvement in pain in the short term and 1 in 13 get >50% symptom improvement in the long term. Physical therapy and supervised rehabilitation using lumbar extensor exercise regimes may be of bene \201 t. MR can characterize lesions, but 25% of asymptomatic people have frank disc protrusions; th us MR gives poor speci \201 city. MR should be used only to con \201 rm a diagnosis. The absolute indications for surgery (see Table 20.3) are cauda equina, progressive muscle weakness, and neuropathy causing functional disability. Facet hypertrophy/facet joint (FJ) syndromes \200 FJ OA of the lumbar spine is common in middle-aged/elderly adults, can be part of in \202 ammatory generalized OA, and is associa ted with spondylolytic spondylolisthesis (i.e., forward slippage of a vertebra, usually L5, in relationship to the vertebrae below). Psoriatic arthritis (see Chapter 8) can also affect FJs and is under- recognized as a cause of low back pain. CPPD arthritis (see Chapter 16) may also affect FJs. CONDITIONS CAUSING ACUTE/SUBACUTE BACK PAIN IN ADULTS 541 Table 20.3 Surgical approaches for lumbar disc prolapse Discectomy Essential for disks causing cauda equina syndrome and progressive neurological de \201 cit s. Excluding aforementioned indications, compared to conservative therapy, in a RCT 66% vs. 33% patients were satis \201 ed following surgery at 1 year, 66% vs. 51% were satis \201 ed at 4 years; thus bene \201 t of surgery in the long term is small. Adverse events with surgery include: mortality (<0.2%), dural tears (4%), permanent nerve root injuries (<1%). 70% success rate in short term. Risk of failure from surgery relates to hysteria or hypoch ondriasis scores on MMPI* and presence of litigation claims. Smaller surgical \201 eld re sults in earlier mobilization and less postoperative disability. Outcomes similar to those of conventional discectomy. Suctioning of central disc material causing disc decompression and relieving nerve root pressure. Associated with low complication rate and rapid rehabili tation. Non-RCT data suggest similar ef \201 cacy to discectomy. Injection of proteolytic enzyme into disc. RCTs suggest standard discectomy is superior. Rare but devastating neurol ogical complications and risk of anaphylaxis (0.3%). Vaporizing of part of disc by laser in troduced through a needle probe. Ef \201 cacy possible similar to discectomy. No RCT data. Microdiscectomy Percutaneous discectomy Chemonucleolysis Laser lumbar discectomy Prosthetic intervertebral disc replacement Also indicated for degenerative disc disease, post- laminectomy syndrome and nonspeci \201 c persistent low back pain. Arti \201 cial disks consist of 2 endplates separated by plia ble inner core. Anterior approach needed. Good results reported in open series for pooled p atient groups. Complication rate may be high (up to 45%). MMPI = Minnesota Multiphasic Personality Inventory. Typical symptoms include pain on hyperextension or rotation of the lower back; pain is refe rred to the upper buttocks, is worse while standing still, and eased by forward lumbar \202 exion. Facet hypertrophy itself cannot be felt, but FJ syndrome is accompanied by muscle spasm and super \201 cial soft-tissue tenderness. Arthritic FJs may be seen on oblique spinal radiographs; however, imaging in general cannot reliably identify symptomatic FJ joints. Facet joint injection wi th anesthetic may con \201 rm the diagnosis if this results in signi \201 cant pain relie f. Management options for FJ syndromes \200 Patients can be treated according to principles applied for all patients with acute mechanical back pain except that extensor exercises are contraindicated because they will aggravate symptoms. CHAPTER 20 Back pain 542 Short courses of analgesics and/or NSAIDs as for OA (see Chapter 6). \200 Generally advis e minimal bed rest. \200 Steroid injection of FJs is a frequently used treatment modality , although studies have failed to demonstrate bene \201 t over placebo injection. \200 Radio freque ncy denervation of medial branches of dorsal rami supplying FJs can help, but the procedure should only be considered if local anesthetic blo ck works \201 rst. Spinal stenosis \200 The diagnosis is frequently missed in the elderly. \200 It present s mainly with achy, stiff pains in the legs increasing on walking and eases if the patient stops walking, sits, or leans forward (neurogenic claudica tion or pseudoclaudication). Pain, numbness/tingling, and weakness are the most common symptoms. Neurological leg signs can be accentuated after exercise. The diagnosis is made using MR imaging the L-spine. \200 Nonsurgical management (includin g pain control and physical therapy) is often adequate. Emergent decompressive laminectomy is required if the patient develops rapidly progressive neurologic symptoms, bladder dysfunction, or cauda equina syndrome. Nontraumatic vertebral collapse: evaluation \200 This is usually due to osteoporosis, col lapse into an abnormal vertebra (e.g., vertebral hemangioma), or secondary to malignancy or infection. \200 The history should, therefore, focus around identifying risk factors for these conditions. Postmenopausal status or hypogonadism, previous fracture history, steroi d use, and alcoholism may all contribute to osteoporosis. Weight loss or B-type symptoms ma y indicate the presence of malignancy or infection. Kyphosis and loss of height can occur after vertebral collapse; a full examination should b e performed to evaluate for the possibility of cord compression or malignancy. Investigate with AP and lateral spinal X-rays, MR, bone biochemistry (intact PTH), morning LH and free testosterone, 25-OH vitamin D, TFTs, serum/urine electrophoresis, and urine cal cium. MR is good at discriminating infection and tumors from osteoporosis, but biopsy for histolo gy and culture is essential if tumor or infection has not been ruled out by MR. Nontraumatic vertebral collapse: treatment \200 The patient should be placed on bed rest and monitored for evolving neurological de \201 cits. Pain control often requires long acting narcotics, with short acting narcotics for breakthrough pain. Calcitonin 100 \200\223200 IU sq bid or 200 IU qd by nasal spray has an analgesic effect and reduces bone turnover in osteoporosis. Acetaminophen and NSAIDs alo ne are unlikely to be suf \201 cient. Osteoporosis should be treated aggressively, at minimum with calcium and vitamin D suppleme nts. Teriperatide is the only widely-available anabolic therapy for osteoporosis in the Uni ted States. The use of CONDITIONS CAUSING ACUTE/SUBACUTE BACK PAIN IN ADULTS 543 bisphosphonates in women of childbearing years is controversial due to their long half-live s and unknown impact on the fetus. Discuss any pathological malignancy-related fracture with a radiation oncologist. If conservative measures fail to relieve pain consider vertebroplasty or balloon kyphoplasty. Postsurgical back pain \200 There are numerous causes and no single entity (see Table 20. 4). \200 Imaging with gadolinium-enhanced MR may be helpful to delineate in \202 ammatory tissue around the surgical site. Persistent pain after surgery may be associated with adverse psychological and social factors and outstanding litigation or insurance claims. Nerve root blocks, epidurals, and spinal stimulators may be used. Sterile discitis \200 This is in \202 ammation of the intervertebral disc often associat ed with annulus enthesitis at the vertebral endplates and vertebral osteitis. \200 The ca uses include disc degeneration, CPPD disease (probably), AS (Romanus lesions) and other SpAs including SAPHO. The lesion should be identi \201 ed with MR and treatment should include bed rest and aggr essive analgesia. In RCTs, steroid disc injections have been shown to be little help overal l. IV bisphosphonates (e.g., pamidronate 60 \200\22390 mg) has anecdotally been shown to he lp AS and SAPHO discitis in particular. Table 20.4 Implicated causes of post-surgical back pain Recurrent disease E.g., further disc protrusion and radicular features. If re-operation not appropriate consi der nerve root block, steroid epidural, etc. Operation for wrong lesion MR appearances can highlight lesions, which may not be relevant to clinical features. More than 1 or 2 lesions can co-exist. Detailed clinical assessment prior to imaging is essentia l. Misdiagnosis originally Many rheumatologists will be familiar with cases of failed surgery undertaken for a structu ral lesion but where in \202 ammatory disease, typically SpA-related disease, was present and causes ongoing symptoms. Adverse rehabilitation conditions Resolution of symptoms and regaining functional capacity if slow has been associated with s igni \201 cant psychological and social factors. Poor result of surgery also associated wi th an outstanding insurance claim or litigation. Arachnoiditis Thought to be a direct effect of surgery. Dural tissue becomes in \202 amed. In nerve root /disc surgery often associated with sensory root symptoms for some months afterwards. Diagn osis with Gd-enhanced MR. Where associated with sensory radicular symptoms, may respond to steroid root block, epidural. If radicular symptoms, chronic and disabling, consider spinal cord (implanted) stimulator. CHAPTER 20 Back pain 544 Management of chronic back pain Chronic back pain requires a special approach, with an emph asis on psy- chological and social management. Patients are likely to have set beliefs abou t their problem, the ability of healthcare systems to help them, and are more likely to hav e developed coping strategies than patients with acute or subacute back pain. However, thos e with chronic back pain who continually seek further and different healthcare options are likely to have less successful coping strategies. Initial approach to the care of patients with chronic low back pain (see Table 20.5) \200 Be con \201 dent there is no undiagnosed condition affecting back pain and that no new ne urological lesions have evolved. If examination raises concern, use MR to rule out lesions. Establish empathy and trust, taking time to get information about the patient \200\231s: \200 social situation \200 health and illness beliefs \200 intrafa mily dynamics \200 true role and perception of their role at work \200 view on conventi onal and complementary therapies \200 view on what does and doesn \200\231t work and on t heir speci \201 c view of exercise therapy. With the information just outlined, you will be able to plan a more individually tailored approach to management. Plan the management approach with the patient and establish short- to midterm goals, includ ing whether, and what type of, supervision is required (e.g., graded program of exercise) a nd how often a review is needed. Consider domains of therapy under the following headings: physical therapy \200 work/life commitments \200 psychological and social support \200 painkillers and medications \200 education (insight and coping strategies) \200 Plan to review progress at regular intervals. \200 Evaluate patients carefully at baseline if considering long-term opiate use. There may be an increased risk of dependency if the patient currently or previo usly abused drugs, if there \200\231s a high level of psychological distress, if short-acti ng opiates are used, or if drugs are prescribed as needed. Although many strategies, especially those that combine techniques, can be costly, these co sts to healthcare are likely to be offset by the saving in lost wages. MANAGEMENT OF CHRONIC BACK PAIN 545 Table 20.5 Management options for chronic low back pain Exercises RCT evidence supports use. Greater evidence of effect when combined with behavioral methods . Aerobic exercises augment effect of \200\234back school. \200\235 Should be essential pa rt of outpatient physical retraining program. Less evidence on how much should be supervise d, by whom, and how often. Manipulation Trials show ef \201 cacy on pain in the long term. Transcutaneous electric nerve stimulation (TENS) Disappointing results from 2/3 RCTs in patients with chronic back pain but ef \201 cacy fo r other speci \201 c diagnoses unknown. Posture training May be more appropriate than corset use and easy to combine training with supervised exerci se therapy. Oral medications NSAIDs best reserved for acute-on-chronic pain exacerbations. Low-dose tricyclics (e.g., am itriptyline, nortryptiline) are useful particularly if chronic neuropathic pain present. Tr y to avoid long-term opiate drugs. Chronic opiate use for chronic low back pain has not been extensively studied. A mental hea lth evaluation before long-term prescribing is essential to avoid triggering dependency (se e text); short courses initially for a trial period are sensible. Best supervised by specia list with experience in pain management. Back school Regular program carrying an educational component. Programs vary from one to many sessions. May be more effective in occupational setting. Long- term changes in behavior not extensiv ely studied. Noncompliance and relapse are problems. Psychologically oriented rehab programs Intensive courses often run by psychologists and \200\234hands-off \200\235 physical thera pists can help (highly) selected patients. Focus on learning to cope with pain and control the effects of pain on functioning and psyche. Not suitable for many patients. Courses are few and far between. Cost-effectiveness of courses not proved. Complementary therapies Increasingly used (see Chapter 21). By consensus, chiropractic has been shown to be helpful for chronic low back pain. Acupuncture has yet to be proved successful in robust studies. Poor evidence base otherwise. Intrathecal opiates Con \202 icting results from (only) noncontrolled studies. Generally, results show overall short-term improvements regarding pain perception but not function. Best reserved for pati ents where all else has failed. Spinal cord stimulator (SCS) A number of good studies show that SCS is effective for neuropathic including radicular pai n. Technique is relatively safe. Careful patient selection is important. Studies show 50% r eduction in pain long term. CHAPTER 20 Back pain 546 Management of back pain in children and adolescents Children with spinal problems present w ith deformity, back pain, limping, systemic features, neurological features, or a combinati on of effects. Back pain in children is common \200\224up to 30%. It is rare in the young < 10 years. If severe enough to warrant hospital admission there is frequently an under- lyin g cause. Age determines likelihood of cause, with infection and tumors being more common in young children compared with adolescents (see Table 20.6). The principles behind history and examination in children are discussed in Chapter 2. Nonspeci \201 c low back pain \200 The annual incidence is 10 \200\22322% in schoolchild ren. \200 Adolescent back pain is linked with familial clustering, physical inactivity, sports injuries, and psychosocial factors. Most children have self-limiting symptoms. \200 Management should focus on an explanation of the short natural history, reassurance, addressing predisposing factors (see above) that remain a trigger for recurrence and increasing general health/exercise to improve muscle strength. Idiopathic scoliosis \200 This is often vertebral malalignment in the coronal plane assoc iated with spinal rotation accentuated on spinal \202 exion. It occurs in up to 3% of schoolchildren. \200 Most (70%) are asymptomatic. Progression is more likely in the presence of pain or thoracic curve convex to the left \200\224conditions that should be inv estigated for more serious underlying spinal pathology. Progressive scoliosis (see Figure 20.1) requires bracing or surgery. Usually curves of 25 \200\22345 are braced and those >45 are best considered for surgery. Congenital (CS) and neuromuscular (NMS) scoliosis \200 CS is associated with genitourinar y malformations (20%) and, rarely, congenital heart disease. CS is associated with spinal dysraphism (20%), myelodysplasia, an d Klippel-Feil syndrome. NMS is associated with cerebral palsy, muscular dystrophy, spinomuscular atrophy, and myelodysplasia. To avoid rapid progression and increased long-term morbidity and disability, refer for prompt correction of progressive curves. Orthotic treatment is an adj unct to, not a substitute for, surgery. MANAGEMENT OF BACK PAIN IN CHILDREN AND ADOLESCENTS 547 Table 20.6 Causes of back pain in children Developmental Painful scoliosis Spondylolysis and spondylolisthesis Scheuermann disease Infection Discitis Vertebral osteomyelitis Spinal epidural abscess In \202 ammation Juvenile arthritis Osteoporosis Mechanical Herniated disk Muscle strain Fractures Neoplasms Benign (osteoid osteomas, osteoblastoma, aneurysmal bone cyst) Malignant (leukemia, lymphoma, sarcoma) Visceral Pyelonephritis, appendicitis, retroperitoneal abscess Scheuermann \200\231s osteochondritis \200 This is perhaps the most common cause of spina l deformity and back pain in children and adolescents (3 \200\2235% of all adolescents, usually 13 \200\22317 ye ars). The etiology is unknown. If severe, it can lead to kyphosis and then frequently becomes symptomatic. Compensatory lumbar lordosis evolves. The typical radiographic pattern is one of wedge deformities (<10 ) of contiguous thorac ic vertebrae with irregular vertebral end-plates. Management of symptomatic disease \200 Avoid repetitive stress-loading activities such as running. \200 Extensor exercises for the back and abdominal muscle exercises may improve symptoms but will not correct kyphosis. Brace treatment usually prevents progression of kyphosis. \200 Surgery is reserved for se vere persistent pain, if there are severe or progressive deformities (>70 ) or there is great concern about the appearance. CHAPTER 20 Back pain 548 3 4 A 2 1 Fig. 20.1 Measurement of the degree of scoliosis by the Cobb method: 1, the lowest vertebra whose bottom tilts to the concavity of curve; 2, the erect perpendicular to line 1; 3, the highest vertebra whose top tilts to the concavity of curve; 4, the drop perpendicular to l ine 3; A , the intersecting angle. Curves less than 20 are considered to be mild, 20 \200 \22340 are moderate, and above 40 are severe. Spondylolysis and spondylolisthesis \200 Spondylolysis is a defect in the pars interartic ularis, most commonly seen at L5. It commonly appears as an isolated \201 nding (4% presc hool children and 6% at age 18 years). Spondylolysis is a risk factor for asymptomatic and symptomatic spondylolisthesis (slippage of one vertebra on another, see Figure 20.2). Progressive slippage is rare in children but can occur during the adolescent growth spurt. Management \200 On serial radiographs, if slippage is >25% (Grade II, III, or IV), then a dvise against contact sports or sports involving lumbar hyperextension. Advice should be given on regular abdominal muscle exercises, avoiding gaining abdominal ob esity, and consider regular bracing. \200 Surgery is considered for progressive vertebral slippage or Grade III/IV slip. MANAGEMENT OF BACK PAIN IN CHILDREN AND ADOLESCENTS 549 A B lV lll ll l Fig. 20.2 Spondylolisthesis measured as a % slip of L4 on L5 ( A / B ). Grade I <25%, Grade II 25 \200\22350%, Grade III 50 \200\22375%, and Grade IV >75%. Herniated disc \200 This is infrequent in children. Most occur in children older than 11 years, and are often associated with scoliosis. Diagnose disc herniation by MR but be cautious in interpreting normal developmental changes in the growing spine. Management \200 Without nerve root impingement, management is conservative: short period of bed rest, adequate analgesics and NSAIDs, with early exercise-based rehabil itation regime. Over 50% improve with conservative treatment but reported results from surgery for signi \201 cant nerve root lesion (i.e., persistent severe pain or neurological de \201 cit) are very good. Spinal tumors \200 Although rare in children, spinal tumors frequently present with back pain (80% cases). It is important to recognize that painful scoliosis, radicular pain, night pain, stiffness, and effectiveness of NSAIDs are all features of spinal tumors (although none are speci \201 c). CHAPTER 20 Back pain 550 Management \200 Urgent radiographs (may be negative in early disease) and MRI are needed to delineate the nature of the problem and the clinician should consider bone scinti graphy or focal CT to identify posterior element tumors (e.g., osteoid osteoma). Adequate analgesia is required: NSAIDs \200\224ibuprofen in recommended doses for weight ma y not be suf \201 cient, consider naproxen 30 mg/kg/d for adolescents. Bed rest is not essential, but is wise if scans show there is risk of vertebral collapse or cord compression. If the latter is a worry, this should be discussed urgently with a pediatric spinal surgeon and radiation oncologist. Initiate a search for other tumors known to metastasize to spine (see Table 20.7). Investigation of adolescents on speci \201 c adolescent units is advisable, given the speci \201 c multidisciplinary input often needed. MANAGEMENT OF BACK PAIN IN CHILDREN AND ADOLESCENTS 551 Table 20.7 Primary spinal tumors in children and adolescents (see also Table 2.16) Osteoid osteomas Benign. Not uncommon. Mainly adolescents. Posterior vertebral bone usually . Pain can be severe. Discriminated from osteoblastomas by size (osteomas are <1.5 cm, oste oblastomas >1.5 cm) as histology is often identical. Lesions are associated with scoliosis (63% cases). Surgical excision is treatment of choice. Aneurysmal bone cyst Benign. Symptoms often triggered by vertebral collapse. Care when considering biopsy to dis criminate from malignant lesions. Discuss in detail with musculoskeletal radiologist. Eosinophilic granulomas Benign \200\224often occurs around age 10 years. Rare. Lytic lesion. May occasionally be mu ltiple/disseminated \200\224staging important. Symptoms often triggered by vertebral collap se. Cord and radicular compression can occur. Biopsy essential to discriminate from maligna nt lesions. Surgical excision or internal spine \201 xation not usually needed. Consider radiotherapy if cord compression threatened. Consider external brace \201 xation in all a nd monitor for spontaneous resolution. Disseminated lesions can be treated with chemotherap y. Ewing sarcoma Overall rarely affects spine ( 10% cases). Can affect any part of spine including sacrum (l atter cases often delayed diagnosis). Suspicion of it requires biopsy. Treat with combinati on chemotherapy and local radiotherapy. 5-years survival 50%. Outcome better for tumor siz es <8 cm or localized disease. Leukemia Consider both ALL and AML in all cases of spinal osteopenia or single/ multiple vertebral c ollapse. Notorious association with delayed diagnosis. Associated systemic symptoms may not necessarily be present but normal CBC at presentation unlikely ( 10% cases only). Also loo k for eosinophilia and hypercalcemia and consider bone marrow aspirate. Lymphomas Rarely presents with back pain; however, known cause of persistent back pain. MR is imaging of choice. MR can show vertebral collapse and/or soft tissue paraspinal mass. Biopsy is di agnostic. Case reports of plasmacytomas presenting similarly. Secondary malignant tumors Neuroblastoma, rhabdomyosarcoma, Wilms tumor, retinoblastoma and teratoblastoma are known t o present with back pain. Usually, biopsy triggers a search for the underlying primary neop lasm. This page intentionally left blank 553 Chapter 21 Complementary and alternative medicine in rheumatology Introduction 554 Herbal remedies (phytotherapy) 555 Physical and hands-on therapies 556 Hom eopathy 557 Other CAMs 558 CHAPTER 21 Complementary and alternative medicine 554 Introduction The popularity of complementary and alternative medicine (CAM) among people wi th chronic diseases, including arthritis, is widely recognized. A 2002 study conducted by t he National Center for Complementary and Alternative Medicine found that three out of every four adults in the United States have used CAM at some point. In some areas, up to one- th ird of arthritis sufferers have received CAM from CAM practitioners, 1 and the prevalence o f CAM use has been reported at between 30 \200\223100% of patients with rheumatic disease. 2 Among the most popular are dietary approaches, herbalism, and acupuncture. Few interventi ons, however, have been studied in a robust way. The prevalence of CAM use for chronic arthritis and pain chie \202 y mir- rors that in oth er chronic diseases, and appears to be consistent across Western populations. CAM is very popular despite a paucity of data. Using homeopathy, com- plementary medicine a nd arthritis to search for articles on CAM and arthri- tis in PubMed yields 1,080 articles (1950 \200\2232006); however, a Google search for \200\234homeopathy \200\235 alone yields over 21 million hits (2012). There may be no universal explanation for why patients use CAMs. Gender, age, income, educa tion, degree of underlying psychological stress, and desire to regain greater self-control may all in \202 uence use. Published suggestions for CAM use also include dissatisfaction with conventional medicine or the belief that a philosophy associated with a particular CAM is desirable and aligns with the patient \200\231s own philosophy. 1 Resch KL, Hill S, Ernst E. Use of complementary therapies by individuals with \200\230ar thritis \200\231. Clin Rheumatol 1997; 16: 391 \200\2235. 2 Ernst E. Usage of complementary therapies in rheumatology: a systematic review. Clin Rheumatol 1998; 17: 301 \200\2235. 3 Ernst E. Musculoskeletal conditions and complementary/alternative medicine. Best Pract Res Clin Rheumatol 2004; 18(4): 539 \200\22356. 4 Weiner DK, Ernst E. Complementary and alterna tive approaches to the treatment of persistent Musculoskeletal pain. Clin J Pain 2004; 20(4 ): 244 \200\22355. HERBAL REMEDIES (PHYTOTHERAPY) 555 Herbal remedies (phytotherapy) 1 \200 The likely mechanism of effect of most agents is on eicosanoid metabolism inhibiting either cyclooxygenase or lipoxygenase pathways. Most ef \201 cacy studies have methodological \202 aws \200\224notably the failure to power studies suf \201 ciently, given small differences in outcome versus placebo. Risk \200\223bene \201 t pro \201 les are generally unknown. Adverse reactions similar to those from conventional medicines can occur, and include allergy and drug interactions. In most countries, few legal controls exist to ensure quality of herbal medicine constituen ts, and no legislative \200\234medicine development \200\235 framework exists to reliably ensure safety and ef \201 cacy. Phytodolor This is a standardized extract of Populus tremula marketed for rheumatic pain. R eviews suggest studies overall show a reduction in pain in patients with OA (see Chapter 6) compared with placebo. St. John \200\231s wort (Hypericum perforatum) \200 St. John \200\231s wort has been show n in relatively robust trials to improve mild depression. This may relate to its effect on inhibiting synaptosomal uptake of 5-HT, d opamine, normetanephrine, glutamate, and GABA. Response in patients with arthritis or chronic pain may be due to improvements in mood, pai n perception or coping strategies. St. John \200\231s wort increases the activity of cytochrome P450 3A4, which is responsible for the metabolism of many drugs. Concomitant administration results in decr eased serum levels of cyclosporine and digoxin. St. John \200\231s Wort also decreases the anticoagulant effect of warfarin, and patients may require dose adjustment as a result. Gamma linoleic acid (GLA) \200 GLA is a plant-seed-oil derived, unsaturated fatty acid th at suppresses production of Il-1 B . It is contained in many different plant-seed oils (e.g ., black currant-seed oil). Compared with placebo, 2.8 g/d GLA signi \201 cantly improves symptoms and signs of active RA over 6 months. 2 However, virtually all plant- seed oil preparations that contain GLA a re often taken at lower daily doses than those shown to be effective. Devil \200\231s Claw (Harpagophytum procumbens) \200 This may work by inhibiting cyclooxy genase or iNO synthase in joint tissues or by suppressing matrix metalloproteinase production. At 60 \200\223100 mg/day, Harpagophytum extract (harpagoside) has moderate but signi \201 cant effects on back and joint pain associated with OA. 3 1 Soeken KL, Miller SA, Ernst E. Herbal medicines for the treatment of Rheumatoid arthritis : a systematic review. Rheumatology 2003; 42(5): 652 \200\2239. 2 Zurier RB, Rossetti RG, J acobson EW et al. Gamma-linolenic acid treatment of rheumatoid arthri- tis. A randomized pl acebo-controlled trial. Arthitis Rheum 1996; 39: 1808 \200\22317. 3 Gagnier JJ, Chrubasik S , Manheimer E. Harpgophytum procumbens for osteo-carthritis and low back pain: a systematic review. BMC complement Altern Med 2004; 4: 13 \200\22323. CHAPTER 21 Complementary and alternative medicine 556 Physical and hands-on therapies Acupuncture \200 Acupuncture is commonly used to treat ne ck and back pain and is easily incorporated into primary care consultations. Meta-analyzes suggest short-term ef \201 cacy for low back pain 1 but no overall effect for neck pain. 2 Controversy exists among acupuncturists as to the adequacy of acupuncture techniques used f or back pain in published trials. No convincing evidence exists to suggest acupuncture should be used for long-term relief of symptoms in OA or RA. Serious complications of acupuncture exist (e.g., pneumothorax, hepatitis B, spinal cord injury, infection) but are rare. Complications may be underreporte d. 3, 4 Tai Chi \200 In RA, tai chi has been shown to increase plantar \202 exion range and is associated with a higher level of participant enjoyment. Trials have shown few bene \201 ts in terms of outcome measures. It appears not to exacerb ate RA, 5 and may help with \201 bromyalgia. Re \202 exology \200 This is one of the most frequently used CAMs. \200 From the few c ontrolled trials taken together, results do not suggest there is any speci \201 c therapeutic effect. Spinal manipulation \200 Of the most rigorous sham-controlled studies of manipulation (fo r any indication of back pain), none showed bene \201 t compared with placebo. \200 Stud ies suggest that about 50% of patients have side effects, although these are chie \202 y mild or transient. 6, 7 Reliable estimates of the incidence of serious adverse effects do not exist. Reported effec ts include vertebral arterial dissection, strokes, disc herniation, spinal fracture, cauda equina syndrome and worsening of undisclosed spinal in \202 ammatory conditions (e.g., AS/ SpA, discitis). Reports from neurologists suggest serious neurological lesions occurring after neck chiropractic are not infrequent. There is concern over excess radiation risk from overuse of radiographs ordered by practitioners. 1 Ernst E, White AR. Acupuncture for backpain: a meta-analysis of randomized controlled tri als. Arch Intern Med 1998 ; 158: 2235 \200\22341. 2 White AR, Ernst E. A systematic review of randomized controlled trials of acupuncture for neck pain. Rheumatology 1999; 38: 143 \200\2237. 3 Ernst E, White AR. Life-threatening adverse reactions after acupuncture? A sys tematic review. Pain 1998; 71: 123 \200\2236. 4 Ernst E. Acupuncture \200\224a critical app raisal. J Intern Med 2006; 259(2): 125 \200\22337. 5 The Cochrane library. Issue 4. 2004. 6 Ernst E. Prospective investigations into the safety of spinal manipulation. J Pain Symptom Manage 2001; 21: 238 \200\22342. 7 Ernst E, Canter PH. A Systematic review of systematic r eviews of spirial manipulation. J R Soc Med 2006; 99(4): 192 \200\2236. HOMEOPATHY 557 Homeopathy Homeopathy stems from the belief that tiny quantities of substances have a holis tic therapeutic effect. There has been a great publicized debate about whether homeopathy i s genuinely more effective than placebo, and whether conventional randomized studies are a relevant way of evaluating its effect. Reports in the medical and scienti \201 c literatur e invariably gener- ate prolonged and sometimes \201 erce debate in the letters-to-the-ed itor pages for some time afterwards! Nevertheless, homeopaths are among the most frequently visited CAM practitioners by patients with arthritis. \200 Meta-analyzes of therapeutic trials suggest the clinical effects of homeopathic remedies cannot be fully explained by placebo effects alone. 1 However, the mos t robust methodological studies do not show any positive effects compared to placebo. 2 , 3 There is some evidence that short-term improvement in RA symptoms is superior to placebo. 4 A more robust methodological study, however, suggested no symptomatic improvement in RA ov er 3 months in patients stabilized on DMARDs and NSAIDs. 5 Summarizing four RCTs of homeopathy use in OA, there appears to be a positive effect, altho ugh \201 rm conclusions cannot be reached. 6 \200 One of the most frequently used homeo pathic remedies is Arnica montana . A systematic review of its effects 7 suggests there is no proof of its effect. Preparations of Echinacea are believed by some to have signi \201 cant immunomodulatory properties. Although this is a traditional treatment for a variety of ailm ents, some CAM practitioners advise that patients with autoimmune diseases avoid this suppl ement. 1 Linde K, Melchart D. Randomized controlled trials of individualized homeopathy: a state-o f-the- art review. J Altern Complement Med 1998; 4: 371 \200\22388. 2 Ernst E, Pittler MH. Ef \201 cacy of homeopathic arnica: a systematic review of placebo-controlled clinical tri als. Arch Surg 1998; 133: 1187 \200\22390. 3 Ernst E. Are highly dilute homeopathic remedie s placebos? Perfusion 1998; 1: 291 \200\2232. 4 Jonas WB, Linde K, Ramirez G. Homeopathy an d rheumatic disease. Rheum Dis Clin 2000; 26: 117 \200\22323. 5 Fisher P, Scott DL. A rando mized controlled trial of homeopathy in rheumatoid arthritis. Rheumatology 2001; 40: 1052 \200\2235. 6 Long L, Ernst E. Homeopathic remedies for the treatment of osteoarthritis: a s ystematic review. Br Homeopath J 2001; 90: 37 \200\22343. 7 Ernst E, Pittler MH. Ef \201 c acy of homeopathic arnica: a systematic review of placebo-controlled clinical trials. Arch Surg 1998; 133: 1187 \200\22390. CHAPTER 21 Complementary and alternative medicine 558 Other CAMs Magnet therapy \200 In one randomized study, patients wearing a magnet bracele t experienced reduction of hip and knee pain associated with osteoarthritis when compared t o patients wearing dummy bracelets. 1 \200 Other studies have indicated that magnets may relieve some forms of musculoskeletal pain, although this is controversial.