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Back pain is a major health and economic problem for preventive medicine. It has been found to be significantly associated with nursing. The present paper reviews a number of epidemiological studies on back pain in nurses and examines the main confounding factors. The different approaches to back pain prevention are briefly discussed.
This paper offers a mechanistic account of back pain which attempts to incorporate all of the most important recent advances in spinal research. Anatomical and pain-provocation studies show that severe and chronic back pain most often originates in the lumbar intervertebral discs, the apophyseal joints, and the sacroiliac joints. Psychosocial factors influence many aspects of back pain behaviour but they are not important determinants of who will experience back pain in the first place. Back pain is closely (but not invariably) associated with structural pathology such as intervertebral disc prolapse and endplate fractures, although age-related biochemical changes such as those revealed by a 'dark disc' on MRI have little clinical relevance. All features of structural pathology (including disc prolapse) can be re-created in cadaveric specimens by severe or repetitive mechanical loading, with a combination of bending and compression being particularly harmful to the spine. Structural disruption alters the mechanical environment of disc cells in a manner that leads to cell-mediated degenerative changes, and animal experiments confirm that surgical disruption of a disc is followed by widespread disc degeneration. Some people are more vulnerable to spinal degeneration than others, largely because of their genetic inheritance. Age-related biochemical changes and loading history can also affect tissue vulnerability. Finally the concept of 'functional pathology' is introduced, according to which, back pain can arise because postural habits generate painful stress concentrations within innervated tissues, even though the stresses are not high enough to cause physical disruption.
Back pain is known to be very common in adults, but the prevalence in children is unknown. Furthermore, the prevalence of sacroiliac dysfunction, and its relationship to back pain has not been previously studied. In this study, we found a high percentage of school aged children had sacroiliac dysfunction and low-back pain.
The treatment of lower back pain constitutes a major problem for orthopaedic surgeons. Identifying the patients who have a non-organic component to their lower back pain is often difficult. Waddell et al. (Waddell G, McCulloch HA, Kummel E, Venner RM. Non-organic physical signs in low-back pain. Spine 1980; 5: 117-25) devised a set of five physical signs to assist in determining this. These signs are time consuming and can be difficult to interpret. We have developed a sign that is simple, quick and easy to perform. In a set of 94 patients, we have compared our sign with Waddell's signs. Our sign has a highly significant correlation with Waddell's signs (chi2 = 55.093, P < 0.001), and thus we would suggest it as an accurate alternative to Waddell's signs.
Patients with undiagnosable low back pain have been observed to differ from patients with proven low back pain in their clinical description of pain and in their psychological status. More variable and diffuse pain qualities are emphasized in their clinical reports and more psychological disturbance characterizes them as a group, suggesting an association between pain expression and psychological disturbance. One hundred and two patients with low back pain were administered a standardized pain questionnaire to determine more systematically the association between pain expression and psychological disturbance in patients with and without demonstrable organic disease. Patients with psychological disturbance differed significantly from patients without psychological disturbance in the following ways. They used more words in their description of pain, distributed these words over more pain factors, and endorsed significantly more pain of the affective and skin pressure variety. The results underscore previous clinical impressions and suggest that patients without either organic or psychological findings may be cases of undiagnosed organic disease.
BACKGROUND: Back pain is one of the most common problems encountered in primary care clinics and causes great loss of work time, economy and expenditure of medical care. Knowledge of the cause of low back pain and effective treatment are rudimentary. We studied the functional approach to treatment of back pain of two acute (M:F = 1:1) and thirty chronic (M:F = 12:18) patients with back pain seen at a rural primary care clinic in September and October 1992. METHODS: Patients were included after completing an agreement form regarding the treatment plan (emphasizing therapeutic exercise, health education and as little medication as possible) in the first interview. A primary care physician specialised in family medicine personally gave treatment to the patients with free attendance to the clinic. A functional approach was adopted in four categories-therapeutic exercise, static and dynamic body biomechanics, awareness of proprioception, and maintenance of relaxed and balanced muscle tone. The patients were encouraged to perform daily activities rather than rest. RESULTS: Two patients with acute back pain gained complete relief without medication, modalities, equipment or other treatment one and two weeks after the first visit, respectively. Among the 30 chronic patients, after eight weeks of treatment, 12/30 (40%) gained complete relief from pain, 4/30 (13.3%) obtained more than 3/4 and less than complete relief, 7/30 (23.3%) had more than 1/2 and less than 3/4 relief, 2/30 (6.7%) gained less than 1/2 pain relief, 1/30 (3.3%) had no improvement, 1/30 (3.3%) deteriorated, and 3/30 (10%) were lost during surveillance. The patients reported no loss of work time attributed to back pain. Two acute patients visited the clinic four times and three times, respectively. The former received three prescriptions for an upper respiratory infection one month after complete remission of back pain, and the latter received no prescriptions for medication. On average, each chronic patient visited the clinic 4.83 times in 8 weeks. In only 25 of 145 (17.2%) visits was medication prescribed for other indications, and in 8 of 145 (5.5%) visits vitamin B complex or Alinamin-F for placebo was prescribed. We used neither modalities nor equipment. Only 7/30 (23.3%) patients received concurrent treatment from other medical institutions. Regarding compliance with the programmed exercise at home, two acute patients complied well. Among the 30 chronic patients, 22 (73.3%) had good compliance, 3 (10%) had poor compliance, 2 (6.7%) failed to comply and 3 (10%) were lost in follow up. CONCLUSIONS: Treating patients with back pain in primary care clinics with a functional approach by physicians appropriately trained in primary care was a good, efficacious, economic, and practical way, although neglected elsewhere. Further research and practice in our society might be worth while.
OBJECTIVES: To determine the prevalence of back pain after delivery and its relationship to individual factors. STUDY DESIGN: A cohort of 88 pregnant women, aged 14-46 years, who had suffered from back pain during pregnancy, and delivered at Aydin Maternity Hospital was selected. They had been followed up through pregnancy, and 6 months post partum filled out a questionnaire. The data were analyzed statistically. RESULTS: Follow-up showed that back pain at the time of delivery and 6 months post partum was reported by 59.1% and 43.2% of the women, respectively. The difference in prevalence of back pain between young women and older ones was statistically significant (P=0.000). The number of previous pregnancies increased the risk of back pain (P=0.000), but there was no difference in prevalence of back pain between women with heavy work and without heavy work before pregnancy (P=0.310). Furthermore, women with a history of back pain before pregnancy were found to experience more intense pain at 6 months post partum compared to those without a history of back pain before pregnancy (2.1+/-1.0 and 0.4+/-0.4. respectively. P=0.000). CONCLUSION: These results indicate that pregnant women with a previous history of back pain had a higher prevalence of back pain, especially in young multigravid patients.
The incidence of low-back pain during pregnancy is thought to be about 50%. It occurs most commonly after the sixth month and can last until the sixth month postpartum. The major predictors are back pain prior to pregnancy and multiparity. Several biomechanical and physiologic changes during pregnancy contribute to back pain. As the woman's abdominal muscles are stretched and tone is diminished, they lose their ability to contribute to neutral posture. During pregnancy, production of the hormone relaxin increases ten-fold. The hormone creates joint laxity, which not only allows the pelvis to accommodate the enlarging uterus, but also weakens the ability of static supports in the lumbar spine to withstand shearing forces. In the pelvis, joint laxity is most prominent in the symphysis pubis and the sacroiliac joints. On physical exam, neither lumbar nor sacroiliac back pain is generally associated with any evidence of neurologic deficit or hip pathology. In cases of lumbar back pain, the physical exam will be most consistent with discogenic pain and/or facet element pain. Therefore, a pregnant woman's pain may be most pronounced on flexion and standing. Among the tests that can be used to evaluate lower-back pain are the posterior pelvic provocation test; ventral gapping test; dorsal gapping test; sacroiliac joint fixation test; Patrick's test, or FABERE's maneuver (flexion, abduction, external rotation, and extension); and Derbolowski's test. The most common types of back pain during pregnancy are lumbar pain, sacroiliac pain, and nocturnal back pain.
Thirty-nine hospital outpatients with upper abdominal pain without demonstrable organic abdominal abnormalities and 28 healthy controls were compared blindly with regard to back pain and back abnormalities when subjected to a standardized physical examination of the spine. Seventy-two per cent of the patients versus 17% of the controls were troubled with back pain (P less than 0.001). Seventy-five per cent of the patients with back pain actually had abnormalities revealed at the physical examination, indicating that some organic mechanisms are involved in back pain. Most of the findings were localized to the lower thoracic and thoracolumbar segments, the same segments that innervate the upper gastrointestinal tract. This suggests the existence of a connection between abdominal pain and back pain. Viscerosomatic or somatovisceral reflexes with trigger zones either in the viscera or in the skin, muscles, tendons, or ligaments could be part of the pathophysiology in this syndrome. Fifty-one per cent of the patients had symptoms of irritable bowel syndrome, and 41% had heartburn, which was significantly related to the experience of back pain.
STUDY DESIGN: A retrospective analysis of back pain claim data from two sources, a workers' compensation provider and Washington State Department of Labor and Industries. The Workers' Compensation Provider claim data were examined over a 9-year period, 1987-1995, and the Washington claim data were examined over a 5-year period, 1991-1995. In addition, a third source of data, reports of back pain from the the Bureau of Labor Statistics, was examined over a 4-year period, 1992-1995. OBJECTIVES: To characterize occupational low back pain trends in the United States. More specifically, trends in back pain rates and costs as well as back injury rates from the Bureau of Labor Statistics were discerned. SUMMARY OF BACKGROUND DATA: The literature often refers to a recent rise in occupational low back pain. However, the question is: Do empirical data support this notion? METHODS: Retrospective analysis of workers' compensation provider, Washington State, and Bureau of Labor Statistics data. RESULTS: The U.S. estimate of the annual low back pain claim rate decreased 34% between 1987 and 1995, although the trend was not monotonic. There was a sharper decrease in the U.S. estimate of the annual low back pain claim costs during this time (58%). In 1995, however, occupational low back pain remained a major problem in the U.S.: an estimated $8.8 billion was spent on low back pain claims, and the rate of filing low back pain claims was 1.8 per 100 workers. CONCLUSIONS: Evidence of a rise in occupational low back pain was not discerned for the 8-year period studied. Data from three sources support this finding. However, occupational back pain remains a major problem in the U.S.
BACKGROUND: Although acupressure has been reported to be effective in managing various types of pain, its efficacy in relieving pain associated with low back pain (LBP) remains unclear. The aim of this study is to compare the efficacy of acupressure with that of physical therapy in reducing low back pain. METHODS: A randomized controlled clinical trial in an orthopedic referral hospital in Taiwan was conducted between December 20, 2000, and March 2, 2001. A total of 146 participants with chronic low back pain were randomly assigned to the acupressure group (69) or the physical therapy group (77), each with a different treatment technique. Self-appraised pain scores were obtained before treatment as baseline and after treatment as outcomes using the Chinese version of Short-Form Pain Questionnaire (SF-PQ). RESULTS: There were no significant differences in baseline characteristics among patients randomized into the two groups. The mean of posttreatment pain score after a 4-week treatment (2.28, SD = 2.62) in the acupressure group was significantly lower than that in the physical therapy group (5.05, SD = 5.11) (P = 0.0002). At the 6-month follow-up assessment, the mean of pain score in the acupressure group (1.08, SD = 1.43) was still significantly lower than that in the physical therapy group (3.15, SD = 3.62) (P = 0.0004). CONCLUSIONS: Our results suggest that acupressure is another effective alternative medicine in reducing low back pain, although the standard operating procedures involved with acupressure treatment should be carefully assessed in the future.
An SOI-I low back pain PTE utilized 2.5 office visits with an adult medicine physician compared with 3.7 office visits with an orthopedic surgeon. Adult medicine physicians performed 1.1 tests and administered 4.6 prescriptions during an SOI-I low back pain PTE. Office visits, tests, and prescriptions were the major cost drivers for low back pain PTEs. Of all low back pain PTEs, 19% received one-drug group, and 17.2% received two-drug group treatments. Nonsteroidal anti-inflammatory drugs and central muscle relaxants were the most commonly used medication therapies for these patients.
Back pain is a common condition and in most cases is not disabling. We have investigated disabling back pain that leads to health care utilization, time lost from work, and high costs. Disabling back pain remains of obscure origin because the focus in studying it has been too narrow. Our indicator of disability is the industrial insurance claim rate for back sprain by county (N = 39) in the State of Washington. After controlling for the size of the labor force and the proportion of workers in occupations that are particularly at risk of back sprain, we determined the effect of 3 socioeconomic factors on the claim rate: the unemployment rate, percentage receiving food stamps, and per capita income. For 2 of the 3 years studied, socioeconomic factors accounted for about one-third of the variance in the claim rate. Even though claimants of industrial insurance are employed, the unemployment rate was significantly related to the claim rate in the 3 years studied. Our interpretation is that disability is a symptom of distress. Where there is a rise in job insecurity and an attendant rise in economic insecurity, there is a greater likelihood that back pain will become disabling.
The relationship betewwn compensation and three variables--psychologic disturbance, organic status, and pain report characteristics--was assessed. Patients on compensation were clinically similar to patients not on compensation in the relative frequency of cases of psychologic disturbance and nonorganic findings in each group. Patients on compensation differed only when objective evidence of organic disease and psychologic stability was present. Under these circumstances, the compensation group used 43% more words to describe their pain and endorsed more pain qualities on five independent dimensions of pain. These results indicate that compensation primarily affects the description of low-back pain in cases where objective evidence of injury is present and leads to an intensification of sensory discomfort. Little justification was found for the atmosphere of suspicion that surrounds patients on compensation who have no evidence of organic disease.
UNLABELLED: Electronic data collection for monitoring pain has become increasingly popular in clinical research. Past research has shown that electronic diaries improve the timeliness of receipt of data, contribute to higher rates of compliance, and are preferred by patients over paper diaries, and this research suggests that electronic diaries that capture current pain at the moment of reporting result in more reliable ratings than recalled pain ratings. This study compared differences of momentary pain intensity ratings on an electronic visual analog scale (VAS) with weekly recalled pain on a 0 to 10 scale. We asked 21 patients with chronic low back pain to monitor their current pain at least once a day by using a VAS for up to 1 year with a palmtop computer. They were also called once a week and asked to rate their recalled weekly pain orally on a numeric scale from 0 to 10. Patients entered data electronically on average 357 times, for an average of 7.8 times a week. We found that (1) weekly recalled pain agreed highly (r > .90) with averaged momentary pain assessments, (2) neither frequency of electronic monitoring nor variability in momentary pain ratings (high standard deviations) contributed to degree of agreement between momentary and recalled pain, and (3) a ceiling effect was observed in VAS pain ratings as compared with numeric pain ratings. These findings suggest that, among many individuals, weekly recalled pain might be just as useful as momentary data collected through electronic data entry. PERSPECTIVE: Some believe that remembered pain is problematic because of recall bias and that data from frequent momentary pain ratings with electronic diaries are more valid. This study demonstrates that recalled pain is as valid as momentary data for many patients.
Low back pain is a common reason for hospital referral but little is known of the resulting workload in different specialties. All new outpatient attendances for conditions with low back pain were recorded over one month in a teaching hospital and a district general hospital. The patients were seen in at least ten specialties and two-fifths of them had been seen previously with the same symptom in another department. In the two hospitals, low back pain accounted for 15% and 12% of all new outpatient attendances. A more coherent referral policy is needed.
BACKGROUND AND PURPOSE: Palpation is often utilized in the physical examination of patients with low back pain. The purpose of this study was to compare the pressure pain detection threshold (PPDT) of people with chronic low back pain (CLBP) and subjects without pain. SUBJECTS AND METHODS: Thirty female subjects with CLBP were recruited from the offices of primary care physicians and physical therapists and compared with 30 female volunteers without pain for differences in PPDT at 6 sites tested bilaterally. RESULTS: A significantly lower mean PPDT was found for all test site groups in subjects with CLBP compared with subjects without pain. A lower global PPDT was found in subjects with CLBP compared with subjects without pain (5.6 lb/cm(2) versus 6.9 lb/cm2). This also was the case for PPDT for the group of test sites unrelated to the lumbar spine (5.1 lb/cm(2) versus 6.1 lb/cm(2)) and for PPDT related to the lumbar spine (5.9 lb/cm(2) versus 8.0 lb/cm(2)). DISCUSSION AND CONCLUSION: Neurobiological or biopsychosocial influences may have contributed to the lower PPDT evident in subjects with CLBP. Subjects with CLBP demonstrated a lower global PPDT compared with subjects without pain, which should be taken into account when interpreting findings of pain or tenderness from palpation.
CONTEXT: Chronic low back pain is one of the most prevalent and costly medical conditions in the United States. Permanent magnets have become a popular treatment for various musculoskeletal conditions, including low back pain, despite little scientific support for therapeutic benefit. OBJECTIVE: To compare the effectiveness of 1 type of therapeutic magnet, a bipolar permanent magnet, with a matching placebo device for patients with chronic low back pain. DESIGN: Randomized, double-blind, placebo-controlled, crossover pilot study conducted from February 1998 to May 1999. SETTING: An ambulatory care physical medicine and rehabilitation clinic at a Veterans Affairs hospital. PATIENTS: Nineteen men and 1 woman with stable low back pain of a mean of 19 years' duration, with no past use of magnet therapy for low back pain. Twenty patients were determined to provide 80% power in the study at P<.05 to detect a difference of 2 points (the difference believed to be clinically significant) on a visual analog scale (VAS). INTERVENTIONS: For each patient, real and sham bipolar permanent magnets were applied, on alternate weeks, for 6 hours per day, 3 days per week for 1 week, with a 1-week washout period between the 2 treatment weeks. MAIN OUTCOME MEASURES: Pretreatment and posttreatment pain intensity on a VAS; sensory and affective components of pain on the Pain Rating Index (PRI) of the McGill Pain Questionnaire; and range of motion (ROM) measurements of the lumbosacral spine, compared by real vs sham treatment. RESULTS: Mean VAS scores declined by 0.49 (SD, 0.96) points for real magnet treatment and by 0.44 (SD, 1.4) points for sham treatment (P = .90). No statistically significant differences were noted in the effect between real and sham magnets with any of the other outcome measures (ROM, P = .66; PRI, P = .55). CONCLUSIONS: Application of 1 variety of permanent magnet had no effect on our small group of subjects with chronic low back pain.