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PubMed1987

Predictors of low back pain disability.

Low back pain has major socioeconomic implications; much of the costs relate to disability and compensation. Theoretically, the early identification of patients at risk to become disabled from a low back episode would lead to more aggressive intervention and reduction of subsequent disability. Low back disability is related to occupational, psychosocial, diagnostic, demographic, anthropometric, health behavior, and injury factors that have been reported in the literature. The multiattribute utility model is a new experimental approach to prediction of disability. The relative weights of the various factors that might be predictive of low back disability are determined by a panel of experts. Although this model is not yet scientifically proven, it offers a promising method of answering the question, "Can low back disability be predicted?"

Adult↗
PubMed1985

The relationship between activity and chronic back pain.

Thirty chronic back pain patients participated in a study of the relationship between activity level and pain intensity. Activity is presumed to cause increases in pain. If this is true, then chronic sufferers should regulate their activities so that when they have pain, they should avoid participating in activities. This assumption was examined by comparing pain intensity with several measures of activity. The activity measures ranged from global reports to observed behaviour. The results showed that patients do report a connection between activity and pain on a global interview question, and patients with much pain tend to make lower ratings of ability to participate in daily activities. However, no significant correlation was found between pain intensity and actual activity levels as measured by self-monitoring or observed behaviour in a test situation. These findings provide little support for the idea that activity level is directly related to chronic pain intensity and they underscore the importance of comprehensive behavioural assessment.

Activities of Daily Living↗
PubMed1993

Pain, disability, and psychological functioning in chronic low back pain subgroups: myofascial versus herniated disc syndrome.

A series of patients with chronic low back pain evaluated at a tertiary referral center were the subjects for this study. Of 250 consecutive patients, 94 were diagnosed as having myofascial pain and 57 as having herniated disc syndrome. Before evaluation and diagnosis, all patients completed the McGill Pain Questionnaire, ratings of pain and disability, and the Symptom Checklist 90-R. Patients were also grouped on the basis of previous surgical history and workers' compensation benefits. Patients suffering from myofascial pain were significantly less likely to report periods of pain relief than patients with herniated disc syndrome. Those receiving workers' compensation benefits reported significantly greater levels of pain, disability, and psychological distress than those not receiving benefits, irrespective of diagnosis. Patients who underwent previous surgery did not differ significantly from those who never underwent surgery. All patients had elevated scores on the Somatization subscale of the Symptom Checklist 90-R. Patients with myofascial pain and workers' compensation benefits demonstrated the highest levels of somatization and phobia. These findings suggest that the effects of low back pain of myofascial origin have comparable, if not worse, consequences than disc herniation. These findings also reaffirm the importance of workers' compensation in understanding the differences in patients with chronic low back pain.

Adult↗
PubMed1998

Function of the hypothalamic-pituitary-adrenal axis in patients with fibromyalgia and low back pain.

OBJECTIVE: We suggested fibromyalgia (FM) is a disorder associated with an altered functioning of the stress-response system. This was concluded from hyperreactive pituitary adrenocorticotropic hormone (ACTH) release in response to corticotropin-releasing hormone (CRH) and to insulin induced hypoglycemia in patients with FM. In this study, we tested the validity and specificity of this observation compared to another painful condition, low back pain. METHODS: We recruited 40 patients with primary FM (F:M 36:4), 28 patients (25:3) with chronic noninflammatory low back pain (LBP), and 14 (12:2) healthy, sedentary controls. A standard 100 microg CRH challenge test was performed with measurement of ACTH and cortisol levels at 9 time points. They were also subjected to an overnight dexamethasone suppression test, followed by injection of synthetic ACTH1-24. At 9 AM, the patients divided in 2 groups, received either 0.025 or 0.100 microg ACTH/kg body weight to test for adrenocortical sensitivity. Basal adrenocortical function was assessed mainly by measurement of 24 h urinary excretion of free cortisol. RESULTS: Compared to the controls, the patients with FM displayed a hyperreactive ACTH release in response to CRH challenge (ANOVA interaction effect p = 0.001). The mean ACTH response of the patients with low back pain appeared enhanced also, but to a significantly lesser extent (p = 0.02 at maximum level) than observed in the patients with FM. The cortisol response was the same in the 3 groups. Following dexamethasone intake there were 2 and 4 nonsuppressors in the FM and LBP groups, respectively. The very low and low dose of exogenous ACTH1-24 evoked a dose and time dependent cortisol response, which, however, was not significantly different between the 3 groups. The 24 h urinary free cortisol levels were significantly lower (p = 0.02) than controls in both patient groups; patients with FM also displayed significantly lower (p < 0.05) basal total plasma cortisol than controls. CONCLUSION: The present data validate and substantiate our preliminary evidence for a dysregulation of the HPA axis in patients with FM, marked by mild hypocortisolemia, hyperreactivity of pituitary ACTH release to CRH, and glucocorticoid feedback resistance. Patients with LBP also display hypocortisolemia, but only a tendency toward the disrupted HPA features observed in the patients with FM. We propose that a reduced containment of the stress-response system by corticosteroid hormones is associated with the symptoms of FM.

Adolescent↗
PubMed2006

Affective components and intensity of pain correlate with structural differences in gray matter in chronic back pain patients.

Although chronic back pain is one of the most frequent reasons for permanent impairment in people under 65, the neurobiological mechanisms of chronification remain vague. Evidence suggests that cortical reorganisation, so-called functional plasticity, may play a role in chronic back pain patients. In the search for the structural counterpart of such functional changes in the CNS, we examined 18 patients suffering from chronic back pain with voxel-based morphometry and compared them to 18 sex and age matched healthy controls. We found a significant decrease of gray matter in the brainstem and the somatosensory cortex. Correlation analysis of pain unpleasantness and the intensity of pain on the day of scanning revealed a strong negative correlation (i.e. a decrease in gray matter with increasing unpleasantness/increasing intensity of pain) in these areas. Additionally, we found a significant increase in gray matter bilaterally in the basal ganglia and the left thalamus. These data support the hypothesis that ongoing nociception is associated with cortical and subcortical reorganisation on a structural level, which may play an important role in the process of the chronification of pain.

Adult↗
PubMed1980

The language of low back pain: factor structure of the McGill pain questionnaire.

Low back pain patients' responses to the McGill Pain Questionnaire were factor analyzed using a method of factor extraction which, relative to the procedures employed in previous investigations, minimized distortion of the factor solution. Four factors were found which accounted for 51% of the total variance. Three of the factors were composed solely of sensory, affective and evaluative descriptor subclasses, respectively. The fourth was defined by both sensory and affective subclasses. The results provided strong support for the continued use of the sensory, affective and evaluative pain rating indices. Suggestions regarding replication of the present study and use of pain language factor scales for predictive purposes were discussed.

Adolescent↗
PubMed1990

Interdisciplinary perspectives on mechanisms and management of low back pain.

Chronic low back pain (CLBP) is one of the most pervasive and costly problems facing medicine today. In addition to personal suffering, CLBP accounts for a greatly disproportionate amount of consumer health care over-utilization, employee absenteeism, lowered work productivity, disability and compensation payments. Recent research in the area has called attention to the complex nature of the problem and the need for an interdisciplinary approach to identification and management. Toward this end, a panel of health care professionals with skill in the assessment and treatment of chronic pain was convened on November 17, 1988. Sponsored by the Institute for Behavioral Medicine in Providence and with funding from the National Institute for Neurological Disorders and Stroke, Stroke and Trauma Program, the purpose of the panel discussion was to bring together clinicians and researchers from distinctly different specialties but who all work with CLBP patients. Topics of discussion included etiology, current status of medical diagnostics and treatments for chronic pain, conceptual and systems issues, and directions for future research.

Back Pain↗
PubMed1988

The Minnesota Multiphasic Personality Inventory (MMPI) Hysteria (Hy) scale: scoring bodily concern and psychological denial subscales in chronic back pain patients.

Chronic back pain patients were compared to two nonpain comparison groups on Minnesota Multiphasic Personality Inventory (MMPI) Hysteria (Hy) scores and scores on two Hy subscales: Bodily Concern and Psychological Denial. Pain subjects had significantly higher scores on the Bodily Concern Subscale and lower scores on the Psychological Denial Subscale than nonpain subjects with similar elevated Hy scores. However, pain subjects had Psychological Denial scores similar to those of subjects with normal MMPI profiles, despite significantly higher Hy scores. These findings are interpreted to support the hypothesis that, among pain patients, Hy elevations are partially accounted for by the endorsement of a disproportionate number of Bodily Concern items. Finally, within pain patients, scores on the Bodily Concern subscale were significantly related to more indices of pain duration and severity than were scores on the Psychological Denial subscale. The potential clinical utility of scoring these subscales is discussed.

Adult↗
PubMed1997

Bridging the gap: support groups do not enhance long-term outcome in chronic back pain.

OBJECTIVE: Because back pain patients often relapse within months of treatment, the effects of two types of support groups as a complement to usual medical treatment was investigated on long-term outcome. DESIGN: Regular treatment was compared with an "educational" support group and a professional support group before and 1 year after intervention in a randomized controlled trial. PATIENTS: A total of 76 women and 27 men, average age of 50 years and with an accumulated sick leave for musculoskeletal pain of 2-24 weeks during the past year, were randomly assigned to the three groups. OUTCOME MEASURES: Sick leave records were obtained from the National Insurance Authority. A battery of standardized instruments was employed, which featured the Sickness Impact Profile, the Coping Strategies Questionnaire, the Multidimensional Pain Inventory, the Pain and Impairment Relationship Scale, the Pain and Discomfort Scale, the Pain Beliefs and Perceptions Inventory, and the Outcome Evaluation Questionnaire. RESULTS: The Educational Support Group demonstrated greater attendance than did the Professional Support Group. However, long-term outcome was not significantly different between any of the groups for sick leave, coping, function, or experienced pain. Both support groups, relative to the Regular Treatment Group, made greater improvements on the Sickness Impact Profile. CONCLUSION: This study provides little evidence that support groups, as a complement to regular treatment, enhance long-term outcome for subacute musculoskeletal pain problems. Specific treatment techniques, matched to the patient's needs, stringently taught, and delivered in a more compact form, may be necessary for enhancing outcome.

Adolescent↗
PubMed2006

Repeat assessment improves the prediction of prognosis in patients with low back pain in primary care.

Low back pain is considered to fluctuate over time, and related prognostic factors may behave similarly, therefore classification of prognosis may be affected by timing of assessment. We aimed to investigate the implications of timing of assessment of prognosis in low back pain. In a prospective cohort of primary care low back pain consulters aged 30-59 years, 359 returned questionnaires at baseline, one-month and one-year. The stability of selected prognostic indicators between baseline and one-month later was assessed, and relative risks for their association with outcome (individually and in combination) were calculated. Reported absence of most outcome indicators was stable between baseline and one-month. However, among people reporting presence of indicators at baseline, only around half still reported them a month later. There were no important differences between the prognostic strength of indicators measured at baseline or one-month. People reporting presence of indicators at either point had significantly higher risk of poor outcome than people not reporting the indicator at all. Presence of the indicators at both time points was associated with even higher risk; people with persistent high pain intensity had 15 times the risk of a poor outcome (relative risk 15.1; 95% confidence interval 6.7-33.8) compared with people not reporting high pain at either point. Combining information on prognostic indicators from two time points provides better classification of low back pain patients' eventual outcome than a single measurement alone. This increased accuracy in predicting prognosis is relevant to both clinical and research practice.

Adult↗
PubMed1997

[Pain intensity, mood and pain-alleviating actions in pre-chronic low back pain patients].

INTRODUCTION: The present study examines the correlations between pain intensity, mood and pain-alleviating actions in pre-chronic low back pain patients. The three variables were obtained with the Ulm Pain Diary (Ulmer Schmerztagebuch, UST). METHODS: Thirty-eight patients with low back pain described pain intensity, effect of pain on mood and medication as well as other therapies over a 3-week period (21 days). The patients had a history of pain for between 6 weeks and 6 months. Clinical and orthopedic examinations revealed no relevant organic findings explaining the pain process. RESULTS: Pain occurred on 18.1 (of 21) days. Half of the patients (n=19) used medication or took other actions against their pain. Correlations between the three variables demonstrated that all three were significantly related. Partial correlations showed in addition to a high correlation between pain intensity and mood, that the frequency of pain-relieving actions was far less related to pain intensity than to mood. The group that took actions against their pain had a higher level of pain intensity than the no-action group. Furthermore, the effect of pain on mood was significantly greater in this group than in the no-action group. CONCLUSION: The findings indicate that pain intensity, mood and actions against pain are highly correlated. When pain intensity is statistically controlled, the influence of mood on taking medication or other actions against pain becomes more pronounced. It can be concluded that self-initiated actions against pain depend much more on mood than on pain intensity in pre-chronic low back pain patients.

English Abstract↗
PubMed1992

Factors important in the genesis and prevention of occupational back pain and disability.

Back injuries in the work place are rarely caused by direct trauma; typically, they are the result of overexertion. Although problems exist in epidemiological studies of risk factors for low back pain and sciatica, there are seven occupational factors that have been associated with an increased risk in several studies: six physical and one psychological and psychosocial. Of individual factors, age is the most important, while sex and smoking are probable risk factors.

Back Pain↗
PubMed1999

Evaluating back pain in older patients.

Low back pain in the elderly has a much wider range of possible causes than in younger patients. In addition to nonspecific mechanical causes, malignancy presenting as back pain occurs more often in older patients. Other systemic and visceral causes of back pain such as polymyalgia rheumatica, aortic aneurysm, Paget disease, Parkinson disease, and osteoporosis with compression fracture occur almost exclusively in persons over age 50. Keys to diagnosis and management of low back pain in older patients are presented.

Age Factors↗
PubMed1984

Back pain in children.

Back pain in children and adolescents must be regarded as a significant complaint, and the physician must be aware that minimal symptoms may be associated with major problems. This article outlines an aggressive and comprehensive diagnostic approach in order to prevent overlooking a serious problem.

Back Pain↗
PubMed2000

Diagnosis and management of acute low back pain.

Acute low back pain is commonly encountered in primary care practice but the specific cause often cannot be identified. This ailment has a benign course in 90 percent of patients. Recurrences and functional limitations can be minimized with appropriate conservative management, including medications, physical therapy modalities, exercise and patient education. Radiographs and laboratory tests are generally unnecessary, except in the few patients in whom a serious cause is suspected based on a comprehensive history and physical examination. Serious causes that need to be considered include infection, malignancy, rheumatologic diseases and neurologic disorders. Patients with suspected cauda equina lesions should undergo immediate surgical investigation. Surgical evaluation is also indicated in patients with worsening neurologic deficits or intractable pain that is resistant to conservative treatment. The current recommendation is two or three days of bed rest for patients with acute radiculopathy. The treatment plan should be reassessed in patients who do not return to normal activity within four to six weeks.

Acute Disease↗
PubMed1983

Hypnosis compared to relaxation in the outpatient management of chronic low back pain.

Chronic low back pain (CLBP) presents a problem of massive dimensions. While inpatient approaches have been evaluated, outpatient treatment programs have received relatively little examination. Hypnosis and relaxation are two powerful techniques amenable to outpatient use. Seventeen outpatient subjects suffering from CLBP were assigned to either Self-Hypnosis (n = 9) or Relaxation (n = 8) treatments. Following pretreatment assessment, all subjects attended a single placebo session in which they received minimal EMG feedback. One week later the subjects began eight individual weekly treatment sessions. Subjects were assessed on a number of dependent variables at pretreatment, following the placebo phase, one week after the completion of treatment, and three months after treatment ended. Subjects in both groups showed significant decrements in such measures as average pain rating, pain as measured by derivations from the McGill Pain Questionnaire, level of depression, and length of pain analog line. Self-Hypnosis subjects reported less time to sleep onset, and physicians rated their use of medication as less problematic after treatment. While both treatments were effective, neither proved superior to the other. The placebo treatment produced nonsignificant improvement.

Back Pain↗
PubMed2006

Postural control in nurses with and without low back pain.

BACKGROUND: Low back pain (LBP) is common in nurses, but it is unclear if the pain is associated with measurements of postural control. Objective measurements of function might be useful in the evaluation of patients with LBP in order to evaluate and predict disability, and in the study of the pathophysiology of chronic LBP. METHODS: In a cross-sectional study, we measured the number of postural adjustments, and degree of posterior-lateral sway in 81 nurses, using a computerized postural sway four-platter measurement system. RESULTS: There were 41 (56.6%) nurses who complained of LBP at the time of testing, and another 12 (14.8%) with a past history of LBP. Nurses with LBP consistently used more postural adjustments to keep their balance (p<0.003), and in some positions postural adjustments were positively associated with the degree of past and present pain. LBP was not significantly associated with the degree of lateral sway. CONCLUSIONS: Nurses either with present or a past history of LBP use an increased number of postural adjustments to maintain balance. Studies are warranted to determine if postural testing can predict the development of LBP or aid in determining appropriate preventive measures.

Adult↗
PubMed1999

Assessment and management of acute low back pain.

Acute low back pain is commonly treated by family physicians. In most cases, only conservative therapy is needed. However, the history and physical examination may elicit warning signals that indicate the need for further work-up and treatment. These "red flags" include a history of trauma, fever, incontinence, unexplained weight loss, a cancer history, long-term steroid use, parenteral drug abuse, and intense localized pain and an inability to get into a comfortable position. Treatment usually consists of nonsteroidal anti-inflammatory agents or acetaminophen and a gradual return to usual activities. Surgery is reserved for use in patients with severe neurologic deficits and, possibly, those with severe symptoms that persist despite adequate conservative treatment.

Acute Disease↗