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Patients with low back pain should be evaluated on their various clinical aspects. The evaluation instruments can be classified into four types: pain measures, function measures, psychosocial measures, and composite measures. The evaluation should be done by patient self-reporting style. Since it is difficult to evaluate patients with a single measure, the evaluation should be done with combination of several instruments.
Most patients with chronic low back pain associate strenuous physical activities with increased pain. This association can cause avoidance of those activities believed to cause intolerable discomfort. This study explored the relationship of performance of physical activities with self-reported pain measures in 40 consecutive patients with disabling low back pain (mean duration 17 months) during a functional restoration rehabilitation program (mean treatment period 7 weeks). Evaluations were performed at initial presentation and at program completion. Measures included quantification of performance on eight physical tests assessing flexibility, lifting capacity and endurance. Before physical testing patients were asked to complete a pain analog scale, a quantified pain drawing, and a rating of the pain anticipated to result from the performance of each physical test. Results showed that pain measures did not generally correlate with measured physical performance. At completion of treatment, significant improvement in performance on all physical tests was found, but these were not associated with consistent changes in pain measures. These results demonstrate that subjects with chronic low back pain can increase their physical performance abilities within their same pain experiences. Medical recommendations for subjects' involvement in physical activities should not be based solely on the reported association of pain with those activities.
Low back pain is one of the most prevalent complaints in clinical medicine. Sensations from the axial skeleton and the surrounding tissues are only vaguely somatotopic and are non-specific in quality. The diagnosis of the mechanism or source of low back pain is therefore very challenging. The treatment of low back pain that recurs, persists or intensifies is also formidable, because there has been no evidence of various therapies for chronic back pain. From the prophylactic viewpoint of chronic pain, the most considerable matter is early elimination of severe pain under certain diagnosis. In this article, the mechanisms of passing into the chronic state, especially the development of neuropathic pain, and the utilities of diagnostic and therapeutic neural blockade for low back pain are discussed.
OBJECTIVE: To determine the intercorrelation between subjective disability, as assessed with the Pain Disability Index (PDI) and the Oswestry Disability Questionnaire (ODQ) and their correlation with visual analogue scale (VAS) pain intensity ratings. DESIGN AND SUBJECTS: Questionnaires were administered to 94 patients with chronic low back pain with or without radiation into the legs of at least 3 months' duration. SETTING: Tertiary care center. RESULTS: High correlations were noted between the ODQ and PDI (r = 0.83) and PDI factor 1 (r = 0.84), a subscale of the PDI. Lower correlations were noted between pain intensity (VAS) scores and the ODQ (r = 0.62) and the PDI (r = 0.69). A weaker correlation (r = 0.41) was noted between the ODQ and PDI factor 2. Intraclass correlation coefficients (ICC) for test-retest reliability in 20 patients (time interval 1 week) were for the ODQ ICC = 0.83, PDI ICC = 0.91, PDI percentage score ICC = 0.91, PDI factor 1 ICC = 0.87, and PDI factor 2 ICC = 0.73, respectively. CONCLUSIONS: The present results suggest that either the PDI or the percentage score PDI and also the even shorter-to-administer PDI factor 1 may be useful and reliable tests for the assessment of subjective disability in low back pain patients. As noted by the moderate intercorrelations with pain intensity scores, both the PDI and the ODQ address a broader concept of disability than that directly related to pain intensity.
Non specific low back pain is commonly a persistent or recurrent problem associated sometimes with impairment to return to work. In this article, we study some treatments strategies through a typical history.
Sciatica in low back pain is usually caused by lumbar disc herniation, degenerative spinal disease or lumbar spinal stenosis. Important pathogenetic factors are mechanical compression of and inflammatory changes in nerve roots caused by nucleus pulposus tissue. Decompression of nerve roots and removal of nucleus pulposus tissue are the main surgical goals. Emphasis should be placed on clinical identification of the symptomatic nerve roots. Computerized tomography (CT) and magnetic resonance (MR) imaging are the most important diagnostic tools today. Plain X-ray may be required for correct identification of the lowest mobile segment. Functional myelography combined with CT may be required to diagnose lumbar spinal stenosis. A proper selection of patients for surgery seems to be more important for a successful outcome than whether macro- or microsurgery is used, or wether the operation comprises one or several nerve roots. The combination of clear nerve root affection, mechanically provoced pain, and corresponding pathological findings at imaging are the best predictors of successful outcome. Psychosocial stability is an additional positive predictive factor. Impaired fibrinolysis occurring in smokers and in sedentary and obese patients, may be a negative predictive factor.
The objectives of the study are to test the hypotheses that psychological distress affects subsequent low-back pain, and pain affects subsequent distress. Six hundred eighty-one participants in a randomized clinical trial of low-back pain treatments were followed for 18 months with assessments for pain, disability, and psychological distress at 6 weeks and 6, 12, and 18 months. Multivariable logistic regression modeling with generalized estimating equations was used to estimate effects. Current pain and disability increased the odds of subsequent psychological distress [pain: adjusted odds ratio (OR)=1.36, 95% confidence interval (CI)=1.07, 1.72; disability: adjusted OR=1.23, 95% CI=0.98, 1.55], and current distress increased the odds of subsequent pain and disability (pain: adjusted OR=1.51, 95% CI=1.24, 1.86; disability: adjusted OR=1.49; 95% CI=1.20, 1.85). Cross-sectional associations were much stronger than the longitudinal associations, suggesting bias in the former due to selection factors and/or temporal ambiguity. The longitudinal findings suggest that pain/disability and psychological distress may be causes and consequences of each other, although the associations are small.
Chronic low back pain (CLBP) patients often are described as "somatizers", who report multiple somatic complaints beyond back pain itself, but the nature and clinical significance of this observation is poorly understood. To clarify the characteristics, correlates and severity of somatization in CLBP, we rigorously assessed somatization symptoms in a sample of patients not selected for psychiatric or pain clinic referral. Male CLBP patients (N = 97), attending a primary care orthopaedic clinic, and matched healthy controls (N = 49), were assessed using the Diagnostic Interview Schedule III-A (DIS), Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), McGill Pain Questionnaire (MPQ), Sickness Impact Profile (SIP), and the Pain and Impairment Relationship Scale (PAIRS). Although none of the subjects met strict DSM-III criteria for a lifetime diagnosis of Somatization Disorder, 25.8% of CLBP patients reported a lifetime history of 12 or more somatic symptoms, as compared to only 4.1% of controls. In the less symptomatic ranges, patients still generally reported more symptoms than controls, with 51.5% of patients vs. 8.2% of controls reporting 7-11 symptoms, and 22.7% vs. 87.8% of controls reporting 0-6 symptoms (p < .001). Major depression and alcohol dependence were significantly associated with increased severity of somatization (p < .05). Lower mood and increased impairment, but not pain intensity, were related to greater number of somatic complaints. Symptoms of somatization are prevalent, but not universal, in CLBP and the pattern of these symptoms is reminiscent of the "spectrum of severity" reported in other medical populations. Recognizing this spectrum of somatization may lead to better patient-treatment matching and improved clinical outcomes.
Low back pain (LBP) is a common symptom seen by nurses who provide care for people with orthopedic problems. Many women experience their first episodes of LBP during pregnancy. Two perspectives for exploring LBP, biomedical and feminist, are described in this article. A combination of these perspectives might best serve women. Also, examples from a research project that used both perspectives is provided.
Prevention of low back pain involves action from both the healthcare system and the occupational system. These systems are essentially diverse and optimum solution of the problem relies on collaboration. The focus of this paper is on the occupational system, where summarised documentation--in spite of scientific uncertainty--in general supports the occupational health actions taken in Denmark. Furthermore, the paper points towards increased physically active lifestyle as a preventive action.
In the previous report, the author demonstrated that the electric construction workers were exposed to the high risk of low back pain, and discussed on the ways to prevent and to treat their occupational disorders. He concluded that the improvement of their working conditions, especially lessening of the working load, was necessary to prevent occupational low back pain, and that it was the most helpful effect on their low back pain to take a rest on an after the attack of the disorder, while most of the medical treatment without a rest were almost helpless. In this report, the author studied and discussed on the workers' opinions on the ways to prevent and to treat their low back pain, by means of questionnaire-method. The workers examined were classified by whether they had the disorder or not and also by the grades of their working load. The results are as follow: 1. As for preventive measures, it is the most popular opinion that they should take care not to hurt their low back; nevertheless, as a matter of fact, their low back pain has been mainly resulted from overwork. 2. As for necessary means on the attack of low back pain, many workers believe that medical treatment is the most helpful to the disorder. Fewer workers recognize the low back pain as an occupational disorder and have opinion that they should take a rest on the attack of the disorder. 3. There is much discrepancy between the workers' opinions mentioned above and the occupational health doctors' recommendations that it is most desirable to improve the working conditions and to let the workers take a rest. 4. The more seriously they suffer from the disorder, the more practical and reasonable are the contents of their opinions. 5. In order to let these workers take a rest from labour more easily, the employers should recognize their low back pain as an occupational disorder, including offjob-payment.
Recurrences of low back pain (LBP) have been shown to be both frequent and costly, with reported recurrence rates ranging from 5 to 82%. Numerous methodological approaches have been developed to identify recurrence but there has been no standardized definition of LBP recurrence or required follow-up time. The objective of this study was to compare the methodological approaches used to analyze LBP recurrence in seminal contributions and to describe the differences in definitions of LBP recurrence and follow-up structure. Twelve seminal articles were identified for review during which four types of LBP recurrence definition and two types of follow-up structure were recognized. Definitional and follow-up differences considerably contributed to variations in computed recurrence rates due either to measurement or other methodological shortcomings, such as loss to follow-up and sick person effect. The results suggest that there is a need to develop a standardized definition of LBP recurrence and a standardized approach to follow-up to allow direct comparisons of published research findings. The use of alternative definitions is also likely to impact analyses of risk factors contributing to LBP recurrence and direct and indirect costs associated with treating LBP.
PURPOSE: Several low back pain work rehabilitation programs have been developed and evaluated for their outcomes. Unfortunately, the program impact theory for these programs is not described, and consequently, the exact mechanisms of action by which these programs intend to increase the probability of return to work remain unknown. This lack of knowledge jeopardizes the implementation of effective programs by health professionals and managers. The objective of this paper is to present the results of an exploratory study aimed at building the program impact theory for the PREVICAP work rehabilitation program. METHODS: The program impact theory was develop by conducting: unpublished documents and scientific literature analyses, individual and group discussions with multiple stakeholders and observation of program reality by reviewing the files of workers who completed the program. RESULTS: The PREVICAP program's impact theory was elaborated based on an ecological approach to work rehabilitation. Program goals and objectives were defined for the three dimensions of the model: the worker, the work environment and the interaction between the worker and his work environment. Two program action mechanisms were defined and describe how the program was intended to achieve its expected outcomes. CONCLUSIONS: This study made explicit the PREVICAP program impact theory and can help rehabilitation practitioners to address work disability according to an ecological model.
Four important domains directly related to low back pain are: pain intensity, low-back-pain-specific disability, patient satisfaction with treatment outcome, and work disability. Within each of the domains, different questionnaires have been proposed. This chapter focuses on validated and widely used questionnaires. Details of the background and the measurement properties, and of the minimally clinically important change (MCIC) using these questionnaires, are described. The MCIC can be estimated using various methods and there is no consensus in the literature on what the most appropriate technique is. This chapter focuses primarily on two adequate and frequently used methods for estimating the MCIC. We argue that the MCIC should not be considered as a fixed value and that the MCIC values presented in this chapter are used as indications. For patients with subacute or chronic low back pain, the MCIC for pain on a visual analogue scale (VAS) should at least be 20mm and for acute low back pain it seems reasonable to suggest that the MCIC should at least be at the level of approximately 35mm. If a numerical rating scale (NRS) is used it seems reasonable to suggest that the MCIC should at least be 3.5 and 2.5 for patients with acute and chronic low back pain, respectively. For functional disability as measured with the Roland Disability Questionnaire it seems reasonable that the MCIC should at least be 3.5 points, whereas an MCIC of at least 10 points when the Oswestry Disability Index is used. For global perceived effect, we argue that the MCIC is most appropriately defined in terms of at least 'much improved' or 'very satisfied', instead of including 'slightly improved'. Finally, we argue that, from the point of view of cost effectiveness, every day of earlier return to work is important. The exact value for the MCIC can be determined, taking into account the aim of the measurement, the initial scores, the target population and the method used to assess MCIC.
BACKGROUND: Low back pain is common during labor. Our randomized controlled trial compared the effectiveness of 3 nonpharmacologic approaches for relief of back pain. METHODS: A total of 34 women suffering from low back pain during labor were randomly assigned to receive 1 of 3 treatments: (1) intracutaneous sterile water injections (ISW); (2) transcutaneous electrical nerve stimulation (TENS); and (3) standard care, including back massage, whirlpool bath, and liberal mobilization. Women self-evaluated both intensity and affective dimensions of pain using visual analog scales. Their evaluations of control and satisfaction were assessed using adapted versions of the Labour Agentry Scale and the Labor and Delivery Satisfaction Index. RESULTS: Women in the ISW group rated the intensity and unpleasantness of pain during the experimental period significantly lower than women in the standard care group or the TENS group, (P = .001 and P = .003, respectively). Similar results were observed for intensity (P = .01) and unpleasantness (P = .03) of pain assessed just before delivery or request for an epidural. Mean pain intensity at 15 and 60 minutes after randomization was significantly reduced in the ISW group compared with the 2 other groups. There was no significant difference in the 3 groups in the level of control and satisfaction with labor and delivery, but less women in the ISW group indicated that they would like to receive the same treatment for back pain during another delivery. CONCLUSIONS: Intracutaneous sterile water injections are more effective than standard care (back massage, bath, and mobilization) or transcutaneous electrical nerve stimulation for relieving low back pain during labor.
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OBJECTIVES: The aim of this study was to investigate potential associations between the Acute Low Back Pain Screening Questionnaire (ALBPSQ), a biopsychosocial screening instrument for identifying patients at risk of chronicity, and relevant variables at 1-year follow-up in a cohort of patients with low back pain. STUDY DESIGN: A 1-year prospective study was conducted in which patients who had previously received treatment in the Northern Ireland National Health Service (n = 118) were requested to complete a follow-up questionnaire package of pain and functional disability measures and a patient-centered questionnaire of seven variables considered relevant from the patient's perspective. PATIENTS: Ninety patients (76% response rate) returned the completed questionnaire package. RESULTS: The ALBPSQ total score and cutoff score of 112 were significantly positively associated with the pain and functional disability questionnaire scores at follow-up but did not significantly discriminate for difference scores on these measures. Although six of the seven patient-centered variables were significantly associated with the screening questionnaire total score, the cutoff score was strongly predictive of only one variable (work loss) and failed to demonstrate high levels of sensitivity for other variables (i.e., medication use, additional treatment, poor exercise participation). CONCLUSIONS: The findings of this study demonstrate that scores on the ALBPSQ were positively correlated with patients' levels of pain and functional disability at 1-year follow-up and correctly classified all patients reporting some degree of work loss but had minimal predictive strength for the other patient-centered variables evaluated.
OBJECTIVE: To assess low back pain (LBP) intensity and subjective disability during pregnancy and compare the pain scores with lumbar motion patterns. DESIGN: A prospective study of pregnant back pain sufferers and healthy controls. SETTING: Kuopio University Hospital, Kuopio, Finland. PARTICIPANTS: Study group consisted of 32 pregnant women with LBP; control group consisted of 21 healthy pregnant women. MAIN OUTCOME MEASURES: Back pain intensity was assessed by visual analog scale (VAS), and subjective disability index was measured by Oswestry Low Back Disability Questionnaire, at 20 and 36 weeks of pregnancy. Back muscle activities were recorded by surface electromyography, and movement sensors were used to detect lumbar motion. RESULTS: In the study group current pain scores (VAS) at first and last trimester correlated strongly (r = .82, p < .00). Pain scores correlated with body weight at the first trimester (r = .54, p = .003) and at the last trimester (r = .67, p < .00). Significant correlation was noted between current pain intensity and back muscle activity level during forward body flexion at first trimester (r = .704, p < .00). Back muscle activity during bending measured at first trimester significantly correlated with pain intensity at last trimester (r = .703, p < .00). Back muscle activity during the first trimester of pregnancy had a negative correlation with current (r = -.57, p = .002) and later subjective disability index (r = -.42, p = .02). It correlated inversely (r = -.54, p = .003) with pain score at last trimester of pregnancy, ie, the lower the back muscle activity at the beginning of pregnancy, the more pain and disability throughout pregnancy. In the control group, three women developed LBP and disability feelings during pregnancy. They had increased muscle activity during flexion at delivery, ie, disturbed flexion relaxation. CONCLUSIONS: Prepregnancy LBP predicts renewed pain during pregnancy, and dysfunction of back muscles has been established in LBP. In this study, disturbance in the relaxation of the back muscles was linearly related to current, and also to later, pain scores. In addition, back muscle activity level was inversely related to the disability index. For the first time, it has been shown prospectively that the function pattern of back extensors seems to predict, and is related to, future back pain. Simple function testing is promising and might be valuable in identifying mothers with a high risk of pregnancy-related back pain and in directing preventive intervention to high risk women by making them aware of self-treatment methods.