Spinal mobilisation for chronic mechanical neck and back pain – an update

Spinal mobilisation for chronic mechanical neck and back pain – an update

Nick Richards first undertook a retrospective case study looking at the effectiveness of the Springback treatment for restoring spinal function in patients with chronic low back pain in 2009, where it featured in Spinal Surgery News.

Here, he gives us an update of the treatment and looks at the continued benefits of spinal mobilisation when using the PAM device.

 

Introduction

After leaving the Royal Navy as a Medical Officer in 1992, I worked with the Army at NCO’s Tactical Wing in Brecon, later to become the School of Infantry and covered the live ranges at SENTA, where I did a MFOM dissertation based on a study into cold illnesses in the military, with help from Howard Oakley at Institute of Naval Medicine. I then worked at RAF St Athan and had to deal with more musculoskeletal injury (MSKI) in aircraft workers, fast jet pilots and sports men and women. While I was working with the physiotherapist at the Medical Centre there, I noted that she had bought a power-assisted device (PAM machine) to help her mobilise damaged spines with good effect.  After leaving the Ministry of Defence in 1999, I moved up to Shrewsbury and as an independent Consultant Occupational Physician, I still cover industry part-time in the North-West Midlands and Wales.

Almost on my doorstep I found the Springback clinic, where Bethan Riley was effectively using the PAM device; she introduced me to Robert Taylor, an engineer who designed the device that was manufactured in Japan and it was based on his long study into finding a logical solution for chronic mechanical neck and back pain.

I was so impressed with their results that I decided to conduct a case study on 58 of her last cases who had agreed to take part.  Professor Stephen Eisenstein at Orthopaedic Hospital in Oswestry agreed to assist me, as he told me a colleague of his had trialled this technique of spinal mobilisation at their hospital, but it was never published – apparently, the research team ran off with the results they were so impressed! Though quite expensive, Functional Restoration clinics (or Pain Management clinics, as they are called now), still have very good results in dealing with this chronic back problem.  Our local Pain Management clinic in Shropshire was set up in 1994 by Eisenstein and was one of the forerunners of this treatment in the UK.

I have been in touch with their senior physiotherapist and she has told me that, at the six-month assessment after this special treatment, on average 70 per cent of their patients have made a good recovery. The Springback case study found that 90 per cent of the patients felt they had a good result and at follow-up of the original cases one year later; of the 38 out of the original 58 who replied (namely 66 per cent) by 31 August 2009; 92 per cent were feeling much better, 5 per cent said that they had some help from the spinal mobilisation and only 3 per cent said it was of no help.

After publishing my case study in Spinal Surgery News in 2009, I was told that the Physical Medicine and Rehabilitation Service of the Department of Veteran Affairs Medical Center in West Palm Beach Florida had been using the PAM device and out of 219 patients, they noted that there was an improved functional outcome and reduced pain scores for 197 patients (89.9 per cent).  As more of their staff and physicians started using the device, the Supervisory Rehabilitation Therapist said that he felt they had moved from the dark ages into a new age.

After conducting my case study, we faced significant opposition from alternative practitioners, such as chiropractors, who saw it as a threat to their businesses.  We also faced scepticism from many NHS physicians, who still continue to refer their chronic neck and back pain cases to Pain clinics, where they are given spinal injections and strong morphine alkaloids; with resulting addiction and major side-effects, as well as depression due to the impact on their work and families.

Two of the back-pain cases I have seen are worth mentioning, as I still see many every week in my clinics in Telford, Birmingham and Manchester.  Both have agreed to be mentioned in this article.

The first is a 46-year-old drayman from Wolverhampton who had fallen down a hatch when delivering crates of beer. He had been off work from April 2014 with severe LBP and was taking Tramadol and Gabapentin and he had put on two stone in weight. It seemed likely that he would never return to work. Eventually he was persuaded to attend the Springback clinic that had now moved to Macchynlleth in Mid Wales. After six sessions at £60 a time, he was able to return to his work on the 12 October 2015. He has just told me that he is keeping fit and well, and is still working as a drayman.

The next case is young streetlight operative, aged 27, from Stockport, who suffered two back injuries from vehicles striking his lorry at work. He then suffered partial paralysis of his left leg when the Pain clinic doctor gave him a spinal injection. When I first saw him he was depressed and suicidal, also his employer expected me to agree to ill health retirement. He had a young family and needed to work, so I sent him to the Springback clinic and his relatives provided payment for the spinal mobilisation sessions. Eventually, with his GP’s support, we persuaded his reluctant employer to find him a suitable job in an office, monitoring the streetlight operatives. Both he and his wife are very happy now and he has been able to greatly reduce the strong analgesia that was making him very drowsy.

Before Bethan Riley and I must cease working, I do feel it is important to pass on our knowledge regarding the benefits of spinal mobilisation when using the PAM device.  Spinal mobilisation is even positively mentioned in the NICE guidelines and my information sheets for neck and back pain patients (printed below) are also printed in Polish, Latvian, Russian and Japanese for our many factory workers and for the international doctors who I teach on the MSc course at Birmingham University each year.

Robert Taylor is still living in Cornwall and has agreed to my mentioning his PAM device in this article and he was produced a film by his grateful patients that can be seen on the Springback website, explaining the mechanics of the device and why so many of us suffer mechanical back pain.  I often show this to my patients:
Visit www.springbackclinic.com 

 

The basics of neck and back care

The goals:

The main goal with the episodes of back pain, which we all get from time to time, is to recover as soon as possible and get back to one’s normal activities. The other main goal is to try and prevent further episodes of back pain or even sciatica; as due to ageing, injury, lack of fitness, poor seating or lifting technique, we are all potential sufferers of chronic neck and back pain.

 

The objectives:

The healthy spine should be like an aircraft wing; well-shaped and flexible, with the forces equally distributed.  Neck and back pain sufferers often have spines that are twisted and locked in painful spasm. The main objectives of home treatment are:

Keep moving and take adequate pain relief in order to do this.

Maintaining a good posture, whether you are lying down in bed, sitting in a chair, standing, working or just picking things up.  Try standing on the ‘balls’ of your feet, not your heels and see the difference.

Gradually increase the level of exercise you do, in order to improve your spinal flexibility and to strengthen your back and abdominal muscles, which support and protect your spine.

 

Most will recover within a week, with the simple actions above. If you have not returned to work within six weeks or have severe symptoms of sciatica, then you may need to see your doctor, an orthopaedic specialist or someone who can help you mobilise.  Ideally, you should aim to prevent back pain in the first place, by keeping yourself fit with regular exercise, reducing your weight and by maintaining a good posture.

 

Further self-help and references:

Keep mobilising and exercising your whole spine, whether you have neck or back pain.  Start gradually with a few exercises that you feel comfortable with and try to do them on rising and during the day. Gentle walking, jogging, cycling and swimming are also helpful.

 

Occupational Health Guidelines for the Management of Low Back Pain at Work, evidence review and recommendations, Faculty of Occupational Medicine March 2000. ISBN 1 86016 131 6  www.facoccmed.ac.uk

A retrospective case study looking at the effectiveness of the Springback therapy for restoring spinal function in patients with chronic mechanical low back pain by Dr N C G Richards in Spinal Surgery News, Summer 2009, p30-34. This treatment and a short film about the mechanics of back pain is available in the UK at www.springbackclinic.com  
The original article in 2009

A retrospective case study looking at the effectiveness of the ‘Springback™ treatment for restoring spinal function in patients with chronic low back pain (LBP)

The author is an independent consultant occupational physician covering a wide range of industry in the West Midlands and Wales and he is aware of the major cost of sickness absence on industry and the NHS, due to chronic back pain. He is also aware of the government’s recent drive to reduce the numbers of people in the UK on long term incapacity benefit, especially with chronic back pain. The author has seen many severe cases of chronic mechanical back pain or ‘failed backs’ that do not seem to have received optimal treatment under the current system. The evidence shows that at least 90 per cent of acute mechanical low back pain (LBP) episodes will recover well within six weeks and they will be able to return to their usual work [1]. Unfortunately many people continue to suffer severely with chronic back pain, despite receiving maximum analgesia from their doctors, excellent surgery from spinal surgeons and also many sessions of physiotherapy or manual therapy from osteopaths and chiropractors. There is strong evidence that the longer an employee is off work with low back pain, the lower are their chances of ever returning to work. After 1-2 years’ absence it is unlikely that they will return to any form of work in the foreseeable future, irrespective of any further treatment [2]. The Springback™ treatment also incorporates the use of a device; called the Power-Assisted Mobilisation (PAM) tool, which seems to assist an experienced therapist in more effectively mobilising the whole spine, while allowing the natural healing process to take place, according to its inventor, Robert Taylor. Usually there is a dramatic restoration of spinal mobility and a subsequent relief of chronic and disabling back or neck pain. The author first saw this machine or ‘tool’ demonstrated in 1997/8 at an airbase by a physiotherapist, who found it greatly helped the many chronic back cases and also the fast jet pilots with their back pain, due to prolonged sitting in cramped cockpits.

 

Methods

Population to be studied and the criteria for inclusion:

At this stage, the author wanted to investigate approximately 70 cases seen at the Springback clinic (between 13 June 2008 and 12 August 2008), and he found that 58 (83 per cent) agreed to take part. The last 70 cases were chosen to avoid any risk of errors in selection.

Controls:

Not required at this preliminary stage for a case study.

 

Design:

Retrospective case study using an anonymous patient identifying code.

 

Group code and chronicity:

A group code would be used to designate cases into groups 1-5, as used in a similar Oswestry study:

Group 1 – chronic mechanical backache, without evidence of degenerative changes

Group 2 – prolapsed intervertebral disc and sciatica

Group 3 – degenerative spinal disorder (Based on patient records and investigations)

Group 4 – spondylolysis and/or listhesis (Based on patient records and investigations

Group 5 – post surgical patients with chronic pain

 

The author planned to look at chronicity in years, as with the Oswestry study, i.e. whether the patients were working, not working or retired, or not working due to their back problem and he also asked them about the effects on their lifestyle; what areas were painful and their views on the likely causes.

 

Other measurements:

They were asked what areas had been affected; lower back, leg pain, neck pain etc. Also, if there was any history of accidents, either at home or work, sports injury, any diagnosis of arthritis or osteoporosis. The author asked about the types of medication and physical treatment they had received; such as surgery, physiotherapy, manipulation, acupuncture and how effective it had been.

 

Measurement of response:

The author asked how they heard about the Springback clinic; when did they start treatment; what they were told all about the treatment; had it been beneficial and how many treatments had they had. Some of these patients had been coming to Springback for a number of years from all over the UK and from abroad, for regular top up treatments.

 

Agreements:

All patients were notified of the case study and told that the results would be strictly anonymous and they were also asked how they were functioning daily at present, with the help of the questionnaire above.

 

Tools:

A letter was sent to all patients, as well as a reminder. Regarding the PAM tool; there were some details and patient information available on a DVD. The procedure employs a handheld tool. In mobilisation mode, as the tool is worked up and down the length of the spine, pneumatic air springs or cushions are employed to work each vertebra back and forth in counter-rotation with its neighbours. Due to the geometry of the joints, mobilisation by counter-rotation restores mobility in all three planes of rotation. The principle is to work away from the affected joints for the purpose of reducing the load on the affected joints. It is a gentle, passive and progressive procedure. A tool is employed because the joints of the spine are much bigger and tougher than the joints of a therapist’s fingers, as you can see in Image 1 of an American ex-football player. When a spine has been stiff for a long time; associated reflexes degrade. In reflex mode, the tool is employed to restore elasticity or rebound by repetitive and progressive stimulation of reflexes. Here again, a tool is employed because human fingers cannot come close to what is required. The proper use of the tool is a special skill and good clinical results are a function of knowledge and skill.

A special couch was used, called the ‘Spine Table’, which was made to the specifications of Robert Taylor and Bethan Riley, the Springback™ therapist. Other aspects of Springback™ treatment include the postural advice and exercise leaflet and a demonstration on a Cross-trainer. See Image 2.

 

Results:

Sex and age range of participants:

There were 24 males and 34 females who agreed to take part in this study. This was a total of 58 out of the 70 letters sent out (83 per cent response rate). The age range of the males was from 33 to 80 and for the females from age 16 to 86.

 

The group information:

This was based on the clinical records and the patients’ questionnaires, with a total of 58 cases:

Group 1 – 28 cases of chronic mechanical neck or back pain

Group 2 – 11 cases of prolapsed intervertebral disc with sciatic symptoms

Group 3 – 17 cases of degenerative spinal disorder

Group 4 – 1 case of spondylolysis or listhesis proven by x-ray

Group 5 – 1 post surgical case; she said that in 1982 she underwent surgery to excise two intervertebral discs after undergoing osteopathy

 

The chronicity or length of time they had suffered:

Who was working?

36 patients were still working and 20 were not. Two were not able to work, due to back pain. A man of 72 and one of 80 was still working. The oldest woman still working was aged 70.

 

Causes for the neck/back pain:

This is what the patients reported and it seems that 34 cases (62 per cent) were due to some sort of acute trauma or accident.

 

Past treatments and their effects:

We asked all the patients about a wide variety of therapies; acupuncture, Alexander technique, chiropractic, exercise therapy (Pilates or yoga), homeopathy, hospital injections and surgery, osteopathy, pain management programmes, physiotherapy and any thing else they had tried. They were also asked about any long-term benefit from these therapies; did it hurt and why did they stop them; with any personal comments. The outcomes were as follows:

 

The Springback case study results on the last 58 patients treated:

Title: Final graph with comments of the last 58 patients on their past treatments

Those who were not sure or had little help – 2 (3.4 per cent) Those who said they had some help – 4 (6.9 per cent) Those who said they were better, had no pain, more mobile, “cured”, could work again or walk more or even “had a new life”; they numbered 52 cases (89.7 per cent)

 

Discussion:

There appears to have been a very good response to this treatment from the many patients who would normally be labelled as ‘failed back’ cases, also the results appear to speak for themselves and are very promising. It seems that the results answer the main aim of this study; namely, they demonstrate the ability of the Springback™ method to restore spinal mobility and function, as well as relieve chronic back pain. Admittedly the numbers are small and do not include some cases who may have had successful results from surgery or other conventional back treatments or even the many failed back patients, who do not want any further therapy and may have adopted the chronic invalid role.

graph-1

The Power-Assisted Micro-mobilisation tool was first invented by Robert Taylor, an engineer who lives in Cornwall, who having suffered himself and having sat in on many consultations with medical colleagues; conceived the idea of this electromechanical device; based on engineering principles and his analysis of the mechanics of the spine in both health and disease [3]. Along with Mr Robert Taylor, Mrs Bethan Riley at Springback has developed a more comprehensive package of back treatment, incorporating this new technology. Since then, the author has referred a number of serious back pain cases to this clinic and has also discussed this device with Professor Stephen Eisenstein of the Robert Jones and Agnes Hunt Orthopaedic Hospital at Oswestry, who has confirmed that it had been used in their physiotherapy department eight years ago. A pilot trial was carried out on an earlier version of this PAM tool, by a spinal orthopaedic consultant and a senior physiotherapist. Surprisingly this seems to have been the only medical trial so far and it was not published. The author has managed to obtain their results and they reported that of the 64 chronic back pain patients in this trial; 54 per cent of the out of work group could return to work and were still in their employment one year on (84.4 per cent).

The Oswestry Disability Index (ODI) scores were in all cases significantly reduced across the board, from a pre treatment average of 42 per cent, down to a post treatment average of ODI of 10 per cent. Not only this; these patients were the worst cases, who had been referred to Oswestry for specialist conventional treatment [4].

The author feels the study suggests that other current treatments available for chronic failed backs can, at best, only give very short term relief, while this method of treatment appears to last longer, with a few patients requiring annual top-up sessions at Springback™. This is borne out by other research evidence; namely, that the various conventional treatments may produce only very short term clinical improvement for those with chronic back pain and there is currently strong evidence that most clinical interventions are quite ineffective at returning people to work once they have been off work for a protracted period with chronic LBP [5]. With a future prospective study the author does need to address the question of how many patients return to their work because of this treatment, since this question was not asked in this case study.

Other systematic reviews on conservative non-pharmacological interventions for chronic back pain found strong evidence that, in addition to exercise prescription, intensive multidisciplinary programmes also reduce chronic back pain [6]. Professor Maurits van Tulder in an editorial in the BMJ on the 23 August 2008 stated that though few guidelines exist on the management of chronic low back pain, recently published European clinical guidelines recommend cognitive behaviour therapy, supervised exercise therapy, brief educational interventions and multidisciplinary (biopsychosocial) treatment for chronic back pain. Prior to this, there was a large ‘back pain exercise and manipulation trial’ (BEAM) in primary care in the UK in 2004, which found that relative to current best care; manipulation followed by exercise achieved a moderate benefit at three months and a small benefit at twelve months in 1300 patients [7].

It is interesting to note a later study from Australia in 2007. It found no difference between medication and physical treatments in the first 12 weeks with LBP; it doesn’t really matter what one does, as 99 per cent of acute mechanical back pain episodes will recover [8].

What new facts have emerged from this study? The author has learned some new facts from this study; namely, the large number of patients who have suffered ‘injuries’ and also the large number suffering from neck as well as back pain. Previously the author has noted in his occupational health work that very many otherwise fit young persons were suffering from recurrent back pain episodes, due to sitting on unsuitable seats in their offices, cars or fork lift trucks or even lying on inadequate beds. There is strong evidence that physical demands of work (manual handling, lifting, bending, twisting and whole body vibration) are a risk factor for the incidence (onset) of low back pain, but overall it appears that the size of the effect is less than that of other individual, non-occupational or unidentified factors [9].

The author believes that this study of the Springback™ method of treatment emphasises the importance of the initial consultation, the full spinal mobilisation by an experienced therapist, as well as remaining active.

So how does the Springback™ therapy work? According to Robert Taylor, Springback’s philosophy states those patients who are in the category of ‘failed back’ typically present with a rigid spine; the spine feels set like cement.

Attempts to restore mobility through exercise fail, because exercise exacerbates the overwork and overstressing of the affected joints. Thus passive mobilisation is indicated.

Ideally, supple elasticity should be maintained or restored before structural damage occurs. Failing that, the restoration of supple elasticity will allow the natural processes of healing and adaptation to do their work unhampered by the continual overwork and overstressing of the affected joints. Patients are recovering who would not otherwise recover.

There was discussion about a controlled trial, but the idea was dismissed for three reasons. Firstly, these patients provide their own control. There is no pattern of spontaneous recovery with patients who have suffered years of debilitating pain; numerous interventions having failed to resolve the complaint. Secondly, a trial label would be misleading, given that this is a skill-based procedure. The clinical results of one practitioner cannot attest to the skill of another. These results are specific to Springback. Thirdly, it is the fate of patients in a control group to receive a placebo. Patients who have suffered debilitating pain for years feel let down by everyone and could not cope with another disappointment. Few if any would agree to participate in such a study. The author feels that clinical audit is the right methodology and a continuous program of clinical audit is planned in the future.

 

Tables:

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Acknowledgements

The author would like to thank Robert Taylor for his assistance in explaining in very great detail his theories on chronic mechanical spinal pain and the actual practicalities of his power assisted micro-manipulation tool, with the aid of a DVD that was produced by some of the Springback™ patients. The author would also like to thank the staff at the Springback clinic for allowing him to study their treatment method, with the practical application of Mr Taylor’s theories and inventions within a clinical environment. The author would also like to thank the many patients for providing their consent and cooperation in allowing access to their clinical records, also for completing the questionnaires and in some cases, verbally providing him with their personal experiences of the Springback™ treatment. Finally, the author has much appreciated the support and professional advice of Professor Stephen Eisenstein at the Robert Jones and Agnes Hunt Orthopaedic hospital at Oswestry in Shropshire, who has kindly agreed to assess this case report.

 

References

  1. Clinical Standards Advisory Group. Back Pain. HMSO London 1994.
  2. The Epidemiology of Spinal Disorders, Andersson GBJ 1997. The Adult Spine; Principles and Practice. 93-141. Philadelphia. Lippincott-Raven plus Waddell G; the Back Pain Revolution, 1998. Edinburgh, Churchill Livingstone.
  3. The Back Problem: Logical Treatment Based on the Identification of the Cause, by Robert Taylor (Available from the author).
  4. Unpublished trial of Power Assisted Manipulation in 2000 at Oswestry, by Mr D Jaffray & Mrs H Callaghan.
  5. Van Tulder MW, Goossens M, Waddell G, Nachemson A 2000. Conservative treatment of chronic low back pain. Swedish SBU report on evidence based treatment for low back pain.
  6. Van Tulder MW, Koes BW. Low back pain: chronic. Clin Evid 2006; 15:1634-53.
  7. BMJ, doi: 10.1136/bmj.38282.669225.AE, (Published 19 November 2004).
  8. Evidence based management of acute low back pain. Bart W Koes. The Lancet – Vol 370, issue 9599, 10 November 2007, pages 1595 -1596.
  9. Macfarlane GJ, Thomas E, Papageorgiou AC, Croft PR, Jayson MIV, Silman AJ 1997. Employment and physical work activities as predictors of future low back pain. Spine; 22: 1143-1149.

 

Author information

Dr N C G Richards MBBS DIH DRCOG MRCGP MFOM Serving Brother of St John

Surgeon Lieutenant Commander Royal Navy retired

Medical Director of the Telford Occupational Health Service

Medical Adviser to Medigold Health Ltd

Appointed Doctor for HSE

 

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