Low Back Pain and Heat Wraps

[Diane]

http://www.hopkinsmedicine.org/Press.../01_19_06.html

I saw this today and thought I'd bring it here.

LOW-LEVEL HEAT WRAP THERAPY SAFELY REDUCES LOW BACK PAIN AND IMPROVES MOBILITY IN THE WORKPLACE

The use of continuous low-level heat wrap therapy (CLHT) significantly reduces acute low back pain and related disability and improves occupational performance of employees in physically demanding jobs suffering from acute low back pain, according to a Johns Hopkins study published in the December 2005 issue of The Journal of Occupational and Environmental Medicine.

"With recent concerns around the safety of oral pain medications, both patients and physicians are considering alternative treatment options for acute low back pain," said Edward J. Bernacki, M.D., M.P.H., associate professor of medicine at The Johns Hopkins University School of Medicine and the study’s principal investigator. "The dramatic relief we see in workers using CLHT shows that this therapy has clear benefits for low back pain and that it plays an important role in pain management. Physicians and other health care providers in an occupational environment can tell patients that CLHT is a safe and effective alternative for treating acute low back plain."

In the study, 43 patients (age 20 to 62) who visited an occupational injury clinic for low back pain were randomized into one of two intervention arms: 18 patients received education regarding back therapy and pain management alone, while 25 received education regarding back therapy and pain management combined with three consecutive days of CLHT for eight hours continuously (ThermaCare® HeatWraps). The heat wrap is a wrap worn over the lower back, under the clothing. It uses an exothermic chemical reaction to deliver a low level of topical heat for at least eight continuous hours. All groups were assessed for measures of pain intensity and pain relief levels four times a day during the three treatment days, followed by measures for pain intensity and pain relief levels obtained in three follow-up visits on days 4, 7, and 14 from the beginning of the treatment. In addition, other measures were obtained and assessed by the Roland-Morris Low Back Disability Questionnaire and the Lifeware Musculoskeletal Abbreviated Assessment Form.

Patients who received CLHT for low back pain over a three-day period in conjunction with pain management education experienced rapid and significant reduction in pain intensity and greater pain relief when compared to patients who only received pain education. Patients on CLHT showed a 52 percent reduction in pain intensity and a 43 percent improvement in pain relief within one day of treatment as compared to the reference group. Both pain intensity reduction and pain relief were maintained for the three days of treatment with CLHT at 60 percent and 41 percent, respectively. Additionally, the benefits of pain relief and pain intensity reduction were maintained at a significant level in the CLHT patients in a follow-up period on day 4 and day 14 after treatment was discontinued.

Low back pain is one of the most common and therefore costly medical problems in industrialized countries, according to Bernacki, who also directs the Hopkins Department of Health, Safety and the Environment. Approximately 50 percent of working-age people in the United States are reported to suffer from acute low back pain every year, and it is estimated that the annual productivity loss from this condition totals between $20 and $50 billion. While guidelines for treating back pain are available, little has been done to translate these recommendations into occupational management to prevent episodic disability and loss of productivity and to improve employee effectiveness in the workplace, notes Bernacki.

Sounds like it combines continual neuromodulation with activity, and that that combo is more effective than education by itself. How can all the mobilipulative technical expertise in the world beat that?

[nari]

Diane, just wondering if this study was supported by the makers of the heat wrap? Guess that bias was excluded...?

A strip of webbing (Trochanter belt) is used in Women's Health (or was) to reduce pain caused by pubic symphysis instability pre and post natally. Seems unlikely a narrow strip would actually hold the dodgy joint 'together'..so I wonder if it was a modulating factor?


Nari

[Diane]

Seems unlikely a narrow strip would actually hold the dodgy joint 'together'..so I wonder if it was a modulating factor?

Probably... different/more mechanoreceptive skin input ==>altered pain output.. I can see how that works.

Here is the actual abstract. It seems quite up and up, although there is no disclaimer at the bottom. (I think Johns Hopkins is a fairly reputable, financially independent source of medical research, isn't it? Anyone know otherwise?)

[nari]

Fair enough...Johns Hopkins is a reputable organisation, and the abstract suggest they were testing out the wrap's efficacy, rather than promoting it.
Interesting.....

Nari

[JaneS]

Hi Diane,
Sounds interesting - I'll have to have a read. Your summary of 'continuous neuromodulation & activity sounds very healthy. (Actually my model for sensory habituation fits that description as well). I wonder what the specifics of mechanism are.
Will return when I have been to the site

Jane

Jane

[flaviovitor]

Aloha! It is summer here and it's too HOT! More than this Johns Hopkins' study.

What kind of 'pain education' the authors used? Biomechanics + anatomy together or pain neurophysiology alone or pain neurophysiology together with biomechanics and anatomy?

This could have a great impact on outcome measures?

Perhaps, to encourage the patient to use this heat therapy 8 hours per day could be too much passive, and not so good in the long run. Although the result is satisfactory, it still needs better analysis of the study results. What about placebo? Well, the power of mind...

But, acute low back pain is very very much easier to manage than chronic one. It has a natural story of recovery.


Flávio.

[Jon Newman]

Flavio,

I think the heat wraps are a self management strategy versus something like massage or manipulation or a hot pack applied in a clinic. Ideally, the person can put the heat wrap on and take it off at their leisure. I think the cost of the heat wrap could be a barrier for many people however.

It would be interesting to know exactly what the education consisted of.

Placebo is likely present but I don't see that as a bad thing nor does it rule out other possible physiological contributions.

[nari]

Flavio

Nice to hear from someone else not in the Winter north who is feeling the heat!! We are also having a bad run with that cursed sun - probably close to record high temperatures over weeks on end.

I don't think it is the heat that is so effective - although it may help a bit- I reckon it is the effect of having contact with the skin as a neuromodulating effect.
Placebo is present in everything - and it is a very useful modality. We are less effective than we think.

But I agree with the education: what many PTs call education is mechanically based; talking about anatomy, discs, facets, etc. That probably is unhelpful, and might reinforce their "illness" meme. I still read many posts on other boards where they talk about facet joints / discs being 'pain generators'. I figured out about three years ago that there is no such thing as "pain input" -thanks to David Butler.

As there does not seem to be a standard (yet) on pain education, we have no idea what was said, in the study. This is crucial. Many studies which state "physiotherapy had no effect" never state what was done; if it was ultrasound and exercises and stretches...it probably didn't effect anything useful.

Nari

[Diane]

Maybe we should email the authors and find out what the education consisted of. I think there are contact emails in the study. Does someone want to take that on?

[mike]

I’ll take it! The mail is on the way and I report to you ASAP.
Mike

[Diane]

I’ll take it! The mail is on the way and I report to you ASAP.

Thank you!

[bernard]

Hi Soma Readers/Thinkers/Simplers,

My little two cents.
If the difference between the two modalities is just physical then the first conclusion I'll make is this one:

Using a mean gives good results.
Using more means gives more results.

The more you speak pleasantly to human beings, the more you have some chance they listen to you.

Nothing mysterious in these results.

[nari]

Bernard

You are a neuronut and a philosopher. Perfect combination.

Nari

[flaviovitor]

I will wait for the reply Mike.

Kind regards,


Flávio.

[Diane]

Aha! Nari smelled a rat and she was right...
http://www.medpagetoday.com/PrimaryC...ckPain/dh/2526

The ThermaCare HeatWrap, manufactured by Proctor & Gamble, is an FDA-approved class I medical device and can be purchased without a prescription, the investigators noted.

The study was supported by Proctor & Gamble.

[flaviovitor]

Has Johns Hopkins reputation been into Xeque-mate ???

Oh my God! Tha was not fun! A lt of vies?????????


Flávio.

[Jon Newman]

I think you can always be a bit suspicious when the article you're reading is a press release. Still, I've read and posted literature on the use of warming for relief of acute back pain. They did this with warming blankets in an ambulance and found decreased pain and narcotic use compared to controls if I remember correctly.

[Jon Newman]

Spine. 2004 Jul 15;29(14):1499-503.

Active warming during emergency transport relieves acute low back pain.

Nuhr M, Hoerauf K, Bertalanffy A, Bertalanffy P, Frickey N, Gore C, Gustorff B, Kober A.


STUDY DESIGN: Prospective randomized blinded trial in a prehospital emergency system. OBJECTIVES: To evaluate the effects of external active warming on acute back pain during rescue transport to hospital. BACKGROUND DATA: Acute low back pain is one of the complaints that most often entails a visit to the physician or use of the emergency system. Superficial (e.g., hydrocolloid packs) and deep heating (e.g., ultrasound) can relieve acute low back pain in a clinical setting. Recent data showed significant benefit for patients in pain from minor trauma treated by active warming during emergency transport. Accordingly, we tested the hypothesis that active warming would reduce pain and anxiety in patients with acute low back pain being transported to a hospital. METHODS: A total of 100 patients were included in our study. We selected only those suffering from acute pain > 60 mm on a visual analog scale in the lower back. Patients were randomly assigned to two groups: active warming with a carbon-fiber electric heating blanket (Group 1) versus passive warming with a woolen blanket (Group 2) during transfer to hospital. RESULTS.: Pain scores on arrival at the hospital differed significantly between Group 1 and Group 2 (P < 0.01). In Group 1, pain reduction from 74.2 +/- 8.5 mm VAS to 41.9 +/- 18.9 mm VAS (P < 0.01) was noted between departure from the emergency site and arrival at the hospital. Pain scores remained practically unchanged in Group 2 (73.3 +/- 11.9 mm VAS and 74.1 +/- 12.0 mm VAS). CONCLUSIONS: Active warming reduces acute low back pain during rescue transport.

Publication Types:
Clinical Trial
Randomized Controlled Trial

PMID: 15247569 [PubMed - indexed for MEDLINE]

Note the nearly 50% decrease in VAS scores compared to controls.

[Diane]

CONCLUSIONS: Active warming reduces acute low back pain during rescue transport.

Also abdominal pain after an internal procedure.

Flavio, some of the best advice I was ever given on sorting out what to make of "research" was to screen it by asking oneself four simple questions:
1. Who did the research?
2. Why was the research done?
3. Who paid for the research?
4. Why does this research make the world a better place?

The answers don't necessarily mean the research is bad, but the questions help put the whole thing into context, especially when there is corporate involvement, because there is likely to be a higher possibility of financial manipulation/contamination of some sort. The first press release had no disclaimer, (daily news release) but the second one (Medpage), a day later, was a different write-up; someone had taken the trouble to investigate a layer deeper and added critical "question 3." info.