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Smoking and LBP
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Smoking and LBP - January 3, 2003 2:54:00 AM
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Andrew M. Ball PT PhD
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Joined: July 28, 2002
From: Charlotte, NC
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Reuters Heatlh just published an article on the results of an interesting study that had results similar to those of an unpublished Meta-Analaysis on the subject of co-variate factors impacting outcome following rehabilitation for chronic occupational low back pain. At that time, Julie Sansted, Paul Beattie, Thomas Zastowny, and myself, found that (having merged the statistics
of more than 75 studies), that a history of smoking was the most predicitve factor indicating poor prognosis following rehabilitation, followed by less than a 12th grade education. We did not study the interaction effects between co-variates through multi-factoral analysis.
In any event, some British researchers, upon survey of 13,000 people, found "that smokers complain more often of discomforting or disabling musculoskeletal pain than never-smokers." I've always theorized that smoking not only de-hydrates the IVD's, but that as nicotine speeds up liver metabolism, that NSAID's taken for the pain pump through the body quicker --- doing less good --- but that the effects were most likely short-lived, and that a person's physiology would return to near-normal if they only stopped smoking.
Interestingly, these researchers found that an association was found "even in ex-smokers," suggesting that smoking may cause long-term damage to muscle tissues or changes in the neurological pain response."
According to both these researchers, as well as my own review of the literature, I'd say that pervious studies have suggested links between smoking and pain, especially chronic back pain, but most of these studies did not factor out lifestyle factors, such as on-the-job manual labor, as a possible contributing cause (e.g. there was no way to tell from the Meta-Analysis that I worked on, if smoking and less than a 12th grade education were a function of blue-collar labor, which may have been the true cause of LBP).
These researhers answered the question that I was unable to as in their study,adults fill out detailed questionnaires that covered topics such as smoking history, work activities and levels of sporadic or chronic musculoskeletal pain.
They found that, compared with those who had never smoked, current smokers had about a 50% higher incidence of reporting "pain in the past year preventing activity," meaning pain so severe it precluded the individual from going to work or performing housework or hobby activities. Pain at all sites--lower back, shoulders, elbows, hands, neck and knees--was higher in smokers than never-smokers. What's more, this association held even among respondents who had white-collar or other jobs that did not require heavy lifting or moving.
SOURCE: Annals of Rheumatic Diseases; 2002;62:33-36.
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Re: Smoking and LBP - January 3, 2003 2:58:00 AM
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Andrew M. Ball PT PhD
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From: Charlotte, NC
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I know what you must be thinking, "Why might smoking raise pain levels?"
Studies have suggested numerous explanations. First, nicotine is a powerful stimulant that "could affect the manner in which the brain processes sensory stimuli and the central perception of pain," the researchers say--effectively cranking up the smoker's pain response. In addition to "cranking up" central perception of pain, nicotine also "cranks-up" liver metablolism. As such, medications taken may have a slightly shorter half-life in the body.
Secondly, "tobacco smoking might cause general damage to musculoskeletal tissues" by reducing blood supply to these tissues, raising clotting risks, or reducing the flow of nutrients to muscles and joints. Basicially, a similar idea to the "dehydration theory."
On the other hand, those who choose to take up smoking might be psychologically predisposed to simply feel and report pain at lower thresholds than non-smokers. Previous studies that suggest that smokers react more quickly to painful stimuli than nonsmokers.
Whatever the reason, the fact that even ex-smokers reported discomfort more frequently than never-smokers leads researchers to conclude that the pain-related effects of smoking can last for years, due to "tissue damage or a prolonged resetting of the threshold for pain."
Drew
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Re: Smoking and LBP - January 3, 2003 4:35:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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Drew,
This information is becoming quite common in the literature, especially journals such as Spine. In fact, they have already shown that smokers end up with far greater failure rates of spinal fusion, prompting some surgeons to hold surgery until the patient has been off the smokes for a month.
I had learned early in my career that smoking caused small vessle constriction, and as the discs recieve their nutrients via diffusion from the surrounding tissues and endplates, the smoking indirectly starves the discs.
How many marathon runners have we treated with disc herniations? How many sedentary smokers have we?. Unfortunately, smokers also lead a lifestyle that is destructive in other ways, including obesity, lack of exercise, stress, poor diet, etc.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: Smoking and LBP - January 3, 2003 4:41:00 AM
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Diane
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From: Vancouver, B.C., Canada
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I can see why the liver would work harder; it would be trying to break down and rid the body of the endless flow of toxic stuff coming in.
Here's another possibility; how about carbon monoxide (from current time smoking, useless to the body) riding around on hemoglobin using up valuable cargo room that oxygen could be using? Nervous tissue needs huge amounts of O2, and if it can't get it, especially when it needs more than usual, like after an injury to tissue, it won't normalize as soon or as well; probably translates into more pain for longer.
Also, I remember hearing something about nicotine binding to receptors in walls of blood vessels (I think) that ordinarily would host certain hormone molecules...that these bonds last the lifetime of the cell, i.e. quite longterm, even if smoking is stopped.
Anyway, result of smoking is, every tissue in the body gets messed with, not just lung tissue.
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Re: Smoking and LBP - January 3, 2003 7:16:00 AM
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Inspired
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From: Biddeford, ME, USA
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Hmm, this is quite interesting to me on several levels (as a PT student, and as an employee of the American Cancer Society). I'm interested in your opinions; do you think that the correlation between smoking and a slower rehab rate would justify tobacco cessation assistance at rehab centers? I've not heard of any rehab centers around here offering that sort of thing, is this done elsewhere (and if not, do you think it should?) Just curious...
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Re: Smoking and LBP - January 3, 2003 3:16:00 PM
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Andrew M. Ball PT PhD
Posts: 855
Joined: July 28, 2002
From: Charlotte, NC
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Inspired,
That's a great question. As the study results seem to suggest long-term effects, it could go the other way couldn't it? Insurance companies could categorically deny coverage for any pain reduction/NMS rehabilitative care if the patient EVER a smoker --- or at least reduce benefits.
FYI --- Research Terminology Teaching moment:
The issues that Duffy and SJ raise are an important research point . . . are the results CAUSATIONAL or CORRELATIONAL?
Drew
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Re: Smoking and LBP - January 13, 2003 7:57:00 AM
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mcap56
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Joined: October 26, 2002
From: New York, NY
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Group:
I certainly agree that smoking is a huge risk factor based on many of the above mentioned points. There is an association between smoking and low back pain and poor prognosis. However we must be careful in drawing conclusions.....
It could be that people who have a number of other risk factors are the ones who are more likely to smoke. We know that psychosocial risk factors are more closely associated with poor prognosis in LBP. Are these people more likely to puff away? I don't know. When Waddell looked at the association for his book, it wasnt' as strong as I thought it was. Never evidence may say otherwise.
One thing is for sure......smoking is a killer, LBP or not.....
mcap
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Re: Smoking and LBP - January 13, 2003 2:19:00 PM
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flexion
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Joined: August 7, 2002
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Well we all know that smoking and weight are two major loads to the healthcare system. Ironically addiction and weight-loss are 2 of the more profitable industries right now below nutrition.
Its not really surprising research. I always thought that working on young kids with regards to weight and smoking would be a great way for all professions to unite healthcare and emmencely reduce the long-term debt these patients create for healthcare as they grow older.
Its such a simple thing to curb as a youth - what a shame. I totally understand why many physicians up here don't accept patients who are smokers.
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