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PubMed2005

Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration.

OBJECTIVES: To assess the effects of acupuncture and dry-needling for the treatment of nonspecific low back pain. BACKGROUND: Low back pain is usually a self-limiting condition that tends to improve spontaneously over time. However, for many people, back pain becomes a chronic or recurrent problem for which a large variety of therapeutic interventions are employed. SEARCH STRATEGY: We updated the searches from 1996 to February 2003 in CENTRAL, MEDLINE, and EMBASE. We also searched the Chinese Cochrane Centre database of clinical trials and Japanese databases to February 2003. SELECTION CRITERIA: Randomized controlled trials of acupuncture (that involved needling) or dry-needling for adults with nonspecific acute/subacute or chronic low back pain. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodologic quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analysis methods or levels of evidence when the data reported did not allow statistical pooling. RESULTS: Thirty-five randomized clinical trials were included: 20 were published in English, 7 in Japanese, 5 in Chinese, and 1 each in Norwegian, Polish, and German. There were only 3 trials of acupuncture for acute low back pain. These studies did not justify firm conclusions because of their small sample sizes and low methodologic quality. For chronic low back pain, there is evidence of pain relief and functional improvement for acupuncture compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and in short-term follow-up. There is also evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, the effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low back pain. No clear recommendations could be made about the most effective acupuncture technique. CONCLUSIONS: The data do not allow firm conclusions regarding the effectiveness of acupuncture for acute low back pain. For chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and "alternative" treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low back pain. Because most of the studies were of lower methodologic quality, there is a clear need for higher quality trials in this area.

Acupuncture Therapy↗
PubMed2001

Back muscle fatigability is associated with knee extensor inhibition in subjects with low back pain.

STUDY DESIGN: Cross-sectional study of 25 male golfers with chronic low back pain and 16 healthy controls of similar age. OBJECTIVES: To assess the association between functional capacity of the back extensors and the quadriceps muscles. SUMMARY OF BACKGROUND DATA: Chronic low back pain has been shown to lead to changes in muscle activation patterns of the abdominals and the gluteus maximus. The effect of chronic low back pain on lower limb function has not been investigated. METHODS: Back extensor endurance was assessed by a Biering-Sørensen test; surface EMG was measured bilaterally on the erector spinae at T12 and L4--L5. Muscle inhibition in the quadriceps was assessed by applying an electrical twitch to the maximally contracted muscle. The associations between holding time, decrease in EMG median frequency (i.e., the slope of the regression line on median frequency vs. time), and muscle inhibition were compared for study participants with chronic low back pain and controls. RESULTS: Mean back extensor holding times were 88 +/- 30 seconds for study participants with chronic low back pain and 92 +/- 17 seconds for controls. Both groups showed bilaterally similar decreases in EMG median frequency at L4--L5 and T12; however, the slopes were significantly steeper at L4--L5 than T12. Study participants with chronic low back pain with poor back endurance had significantly higher muscle inhibition compared with study participants with chronic low back pain with good back endurance, whereas such an association was not evident in healthy controls. CONCLUSIONS: In golfers with chronic low back pain reduced back endurance was associated with significant inhibition of the knee extensors, indicating that this muscle group cannot be activated to a full extent. These findings suggest a possible association between back extensor fatigability and knee extensor dysfunction in male golfers with chronic low back pain.

Adult↗
PubMedDate not supplied

Preparation of dynamic posture and occurrence of low back pain.

Improper posture is considered as one of the causes for low back pain. This study focused attention on low back pain that occurs when people adopt a dynamic posture. Low back pain in attendants was investigated as a typical example of low back pain in a dynamic posture. When multi-dimensional quantification III was applied to the results of the investigation, low back pain was found to occur in six postural patterns: bending knee posture, the posture of lifting and holding a light object, the posture of tilting the trunk, working posture to push a cart, the posture of turning or lifting a cart, and the posture of stretching. This survey found that low back pain frequently occurred when an unexpected load was imposed on the lumbar region and experiments were conducted to simulate the unexpected loading of this region. The experimental results showed that lumbar muscular activity was not fast enough to cope with the load and resulted in an increased swaying of the trunk. This swaying was considered to induce a load on the lumbar region. It is concluded that low back pain can be prevented if an appropriate preparatory set is taken.

Back Pain↗
PubMed1995

Static back endurance and the risk of low-back pain.

Spinal physical capacity and in particular static back endurance were studied for their prediction of first-time experience of low-back pain. Of a total of 126 persons who were free from back complaints at entry, 33 developed low-back pain during a follow-up of 1 year. The static back endurance test was found to be the only physical capacity measurement that indicated an increased risk of low-back pain. Adjusted for age, sex, and occupation, the odds ratio of a new low-back pain in those with poor performance was 3.4 (95% confidence interval, 1.2-10.0) compared to those with medium or good performance. RELEVANCE--:The simple static back endurance test might have value in health examinations because of its strong predictive value of future low-back pain.

Journal Article↗
PubMed2005

[Chronic back pain in the general population in Germany 2002/2003: prevalence and highly affected population groups].

Back pain is one of the most common complaints in the general population and chronic back pain is a major Public Health burden. However, the prevalence of chronic back pain in Germany is not known. The aim of our study was to determine the prevalence of chronic back pain in the general adult population in Germany and to identify highly affected population groups. A nation-wide computer-assisted telephone interview (CATI) survey was conducted with 8,318 men and women aged 18 years and older residing in German households. Participants were selected using the Gabler-Häder telephone sampling method and the next-birthday method. The one-year prevalence of chronic back pain defined as daily or almost daily back pain over a period of three months was 16 % in men and 22 % in women, the lifetime prevalence 24 % in men and 30 % in women. The 12-months prevalence of any back pain was 66 % in women and 58 % in men. Back pain on the day preceding the interview was reported by 18 % of men and 27 % of women and had a median intensity on a 1 - 10 point scale of 5 in women and 4 in men. Factors independently associated with chronic back pain in the past 12 months were age, female sex, a history of arthritis, self-reported depression, lower educational level, current unemployment, overweight or obesity, no sports, smoking and living with a partner. In conclusion, chronic back pain is a highly prevalent complaint in the general population in Germany. The association not only with bone and joint diseases but also with depression, a lower level of education and with certain lifestyle behaviours emphasises that back pain should not be viewed only in the context of the spine.

Adolescent↗
PubMed1997

Prevalence of subtypes of low back pain in a defined population.

BACKGROUND: For two generations, some back care specialists have emphasized that clinical low back pain is composed of a number of specific syndromes, such as sacroiliitis or trigger points, but the prevalence of these syndromes outside of specialized clinics remains unknown. The purpose of this study was to describe the prevalence of subtypes of low back pain in a defined population. METHODS: The setting was a group model HMO with a population of 54,000. We used a formal group process involving clinicians from many disciplines, long interviews, critical appraisal of the literature, case discussions, and clinical audits to define a set of subtypes of low back pain. Trained physical therapists assessed subtypes in all patients referred for low back pain over a 9-month period, from July 1992 to April 1993. RESULTS: Of the 213 patients evaluated for low back pain, 72% had acute pain (< 3 months) and only 15% had work-related injury. After classification into subtypes, 32% had acute low back strain, 28% had radicular syndromes, 14% had chronic back strain, 10% had sacroiliac syndromes, 6% had posterior facet syndrome, and the remaining 10% included 12 different syndromes. Only about 10% had more than one clinical syndrome. CONCLUSIONS: A limited number of subtypes of low back pain make up the vast majority of low back pain seen in the population at large. Attention to subtypes may provide a way to improve primary care management of low back pain.

Adolescent↗
PubMed2005

Relationship of health related quality of life to prevalent and new or worsening back pain in postmenopausal women with osteoporosis.

OBJECTIVE: To examine the association between back pain and health related quality of life (HRQOL) in postmenopausal women with osteoporosis. METHODS: The Fracture Prevention Trial was a prospective double blinded, placebo controlled study designed to compare the proportion of women receiving teriparatide who experienced a new fracture to the proportion of women receiving placebo who experienced a new fracture. Subjects were ambulatory postmenopausal women with osteoporosis and prior vertebral fracture. As part of this trial, English-speaking women from Canada, New Zealand, Australia, and the United States participated in a HRQOL substudy using the Osteoporosis Assessment Questionnaire (OPAQ). OPAQ was administered at baseline, 12 months, and at study termination (median treatment duration 19 mo). Back pain data were collected as part of the adverse event monitoring during the trial. Subjects considered to have experienced back pain reported this event spontaneously and were not queried specifically. We examined the influence of prevalent back pain on HRQOL after controlling for spine deformity index score, and the influence of new or worsening back pain on HRQOL after controlling for incident vertebral fracture. RESULTS: Of 471 women who completed OPAQ at baseline, 172 reported back pain that was associated with a mean decrease in all OPAQ dimension scores (p < 0.05). Of 429 women who completed OPAQ at all timepoints, 88 experienced new or worsening back pain that was associated with a mean decrease in physical function, emotional status, and symptoms scores (p < 0.01 for each). In a subset of 65 women who experienced moderate to severe back pain, all OPAQ dimensions were significantly reduced (p < 0.05). CONCLUSION: Both prevalent back pain and new or worsening back pain affected HRQOL negatively. Osteoporosis therapies that prevent the development of back pain in postmenopausal women may also prevent decreases in HRQOL.

Affect↗
PubMed2005

The use of medication in low back pain.

The choice of medication for low back pain should be evidence based and tailored as much as possible to suit the individual patient. Acetaminophen (paracetamol), mild opioids and NSAIDs are the first-line drugs for low back pain but there is no evidence that one is more effective than the others. Non-benzodiazepine muscle relaxants (with or without pain medication) could be considered as second-line drugs in acute low back pain, and cyclic antidepressants in chronic low back pain. The risk of adverse side effects can be reduced by taking account of the patient's medical history and by using a test dose. The realization that symptoms other than pain are sometimes more important and/or easier to overcome can increase the benefits of medication. The long-term effects of medication can be improved when it is combined with non-drug interventions.

Analgesics↗
PubMed2005

Interventional pain management: when/what therapies are best for low back pain.

PURPOSE OF REVIEW: The aim of this article is to inform an interested audience on novel minimally invasive and percutaneous interventional options for reduction of lower back pain. RECENT FINDINGS: Numerous percutaneous and minimally invasive techniques for treatment of lower back pain were introduced recently. To accumulate sufficient clinical evidence in order to either dismiss or accept the new treatment modalities requires years of delay. Presented here are novel percutaneous procedures to treat discogenic pain, radiculopathies, lumbar facet syndrome, painful compressive vertebral fractures, myofascial pain and postlaminectomy syndrome. Data on efficacy of those procedures available from limited case series reports, retrospective studies and a few prospective trials are reviewed. SUMMARY: There is a wide variety of techniques introduced recently in pain management of the lower back. Some of those procedures may serve as a definite treatment; others may significantly enhance or facilitate conservative management. Careful selection of the patients may significantly improve the success rates of these procedures.

Journal Article↗
PubMed1987

Back pain and spinal deformity in cystic fibrosis.

Back pain is a common complaint of individuals with cystic fibrosis (CF). We studied back pain in our patient population in three ways: a questionnaire, an orthopedic evaluation, and a survey of chest roentgenograms. Forty-seven patients with CF reported back pain as compared with seven controls. Patients with CF showed decreased muscle strength and mobility in the trunk, chest, and shoulders. The incidence of structural kyphosis was only 8.7%, but many had vertebral wedging. Much of the back pain may be due to postural abnormalities or to vertebral wedging, not fixed structural kyphosis.

Adolescent↗
PubMed1987

Medical, psychological, and social factors associated with back abnormalities and self reported back pain: a cross sectional study of male employees in a Swedish pulp and paper industry.

A medical, psychological, and sociological study of 391 male employees in a Swedish pulp and paper industry was performed in 1961. Factors associated with back pain and back abnormality were investigated. Univariate analyses showed associations of back pain with occupational status, low education, duration of employment, low performance on cognitive tests, and neuroticism. Back abnormalities evaluated on the basis of physical examination showed in principle the same associations but the strength as well as the significances were stronger. Multiple logistic regression analyses using data for manual workers showed that neuroticism and duration of employment were directly associated with back pain. The same two variables and low performance on one of the psychological tests were directly associated with back abnormalities. Age showed no direct association with back pain or back abnormalities. Strong associations between back pain and back abnormalities with both perceived health and general working capacity and the doctor's evaluation in the same areas were demonstrated.

Absenteeism↗
PubMedDate not supplied

A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain.

BACKGROUND: The adult lifetime incidence for low back pain is 75% to 85% in the United States. Investigating appropriate care has proven difficult, since, in general, acute pain subsides spontaneously and chronic pain is resistant to intervention. Subacute back pain has been rarely studied. OBJECTIVE: To compare the relative efficacy of chiropractic adjustments with muscle relaxants and placebo/sham for subacute low back pain. DESIGN: A randomized, double-blind clinical trial. METHODS: Subjects (N = 192) experiencing low back pain of 2 to 6 weeks' duration were randomly allocated to 3 groups with interventions applied over 2 weeks. Interventions were either chiropractic adjustments with placebo medicine, muscle relaxants with sham adjustments, or placebo medicine with sham adjustments. Visual Analog Scale for Pain, Oswestry Disability Questionnaire, and Modified Zung Depression Scale were assessed at baseline, 2 weeks, and 4 weeks. Schober's flexibility test, acetaminophen usage, and Global Impression of Severity Scale (GIS), a physician's clinical impression used as a secondary outcome, were assessed at baseline and 2 weeks. RESULTS: Baseline values, except GIS, were similar for all groups. When all subjects completing the protocol were combined (N = 146), the data revealed pain, disability, depression, and GIS decreased significantly (P <.0001); lumbar flexibility did not change. Statistical differences across groups were seen for pain, a primary outcome, (chiropractic group improved more than control group) and GIS (chiropractic group improved more than other groups). No significant differences were seen for disability, depression, flexibility, or acetaminophen usage across groups. CONCLUSION: Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing GIS.

Acetaminophen↗
PubMed1989

Patient-handling skill, back injuries, and back pain. An intervention study in nursing.

The aim of this intervention was to evaluate the effect of training on patient-handling skills and prospectively to assess the effect of skill on subsequent back pain and back injuries in nursing. Of a total of 255 nurses, 199 were assessed for their skill in patient-handling. One-half (control group) received traditional training in patient-handling, and the other half (trained group) received a curriculum of instruction totaling 40 hours. The skills of both groups were assessed on graduation. The control group was rated as less competent in patient-handling. Nurses in both groups were questioned about the prevalence of back pain and incidence of back injuries in the first year after graduation. In multiple regression analysis, the major risk indicators for back injuries were poor patient-handling skill, low numbers of repetitions in the sit-up test, and high work-load scores. High score on the hysteria scale of Middlesex Hospital Questionnaire was a risk indicator for all kinds of back pain. Though back pain was independent of patient-handling skill, those rated as "bad" or "poor" had more back injuries (24%) than those who had been rated as "good" or "excellent" (2%) (P less than 0.001), but the difference between the trained and control groups was not statistically significant. It was concluded that back injuries may be prevented by the teaching of patient-handling skills.

Back Injuries↗
PubMed2004

[Therapy of back pain: what is evidence-based?].

Back pain has to be classified by localisation, duration, and existence or absence of neurological deficits. Therapy mainly depends on the severity of neurological symptoms. The time period between the onset of symptoms and efficient therapy should be short in order to prevent the development of chronic pain. Therefore a sufficient, consistent and evidence-based conservative treatment should be initiated early on, with the only exception of special emergency situations as described further down in this article. Patients should not be immobilized, a better outcome is proven in patients who immediately continued practising their daily activities. First line medication consists of non-steroidal-anti-inflammatory-drugs (NSAID). If necessary, opioids and muscle-relaxants may be applied additionally. Surgical procedures are only indicated in a small number of patients. A sufficient data base with regard to the benefit of acupuncture, orthesis, and chiropractic medicine is lacking. Local injections should only be done in very special cases. Concerning chronic back pain a multimodal, multi-disciplinary pain treatment concept with physical training and behavioural therapy should be applied in order to teach the patient to avoid a passive and maladjusted attitude. Antidepressant drugs may also be indicated in chronic back pain.

Analgesics↗
PubMedDate not supplied

Exercise as a treatment for chronic low back pain.

BACKGROUND CONTEXT: Exercise is a widely prescribed treatment for chronic low back pain, with demonstrated effectiveness for improving function and work. PURPOSE: The goal of this article is to review several key aspects about the safety and efficacy of exercise that may help clinicians understand its utility in treating chronic back pain. STUDY DESIGN/SETTING: A computerized literature search of MEDLINE was conducted using "exercise," "fitness," "back pain," "backache" and "rehabilitation" as search words. Identified abstracts were scanned, and useful articles were acquired for further review. Additional references were acquired through the personal collections of research papers possessed by the authors and by reviewing prior review articles on this subject. These final papers were scrutinized for data relevant to the key aspects about exercise covered in this article. RESULTS: For people with acute, subacute or chronic low back pain, there is no evidence that exercise increases the risk of additional back problems or work disability. To the contrary, current medical literature suggests that exercise has either a neutral effect or may slightly reduce risk of future back injuries. Exercise can be prescribed for patients with chronic low back pain with three distinct goals. The first and most obvious goal is to improve or eliminate impairments in back flexibility and strength, and improve performance of endurance activities. There is a large body of evidence confirming that this goal can be accomplished for a majority of patients with chronic low back pain. The second goal of exercise is to reduce the intensity of back pain. Most studies of exercise have noted overall reduction in back pain intensity that ranges from 10% to 50% after exercise treatment. The third goal of exercise is to reduce back pain-related disability through a process of desensitization of fears and concerns, altering pain attitudes and beliefs and improving affect. The mechanisms through which exercise can accomplish this goal have been the subject of substantial research. CONCLUSIONS: Exercise is safe for individuals with back pain, because it does not increase the risk of future back injuries or work absence. Substantial evidence exists supporting the use of exercise as a therapeutic tool to improve impairments in back flexibility and strength. Most studies have observed improvements in global pain ratings after exercise programs, and many have observed that exercise can lessen the behavioral, cognitive, affect and disability aspects of back pain syndromes.

Exercise Therapy↗
PubMed2004

Cerebrospinal fluid levels of opioid peptides in fibromyalgia and chronic low back pain.

BACKGROUND: The mechanism(s) of nociceptive dysfunction and potential roles of opioid neurotransmitters are unresolved in the chronic pain syndromes of fibromyalgia and chronic low back pain. METHODS: History and physical examinations, tender point examinations, and questionnaires were used to identify 14 fibromyalgia, 10 chronic low back pain and 6 normal control subjects. Lumbar punctures were performed. Met-enkephalin-Arg6-Phe7 (MEAP) and nociceptin immunoreactive materials were measured in the cerebrospinal fluid by radioimmunoassays. RESULTS: Fibromyalgia (117.6 pg/ml; 85.9 to 149.4; mean, 95% C.I.; p = 0.009) and low back pain (92.3 pg/ml; 56.9 to 127.7; p = 0.049) groups had significantly higher MEAP than the normal control group (35.7 pg/ml; 15.0 to 56.5). MEAP was inversely correlated to systemic pain thresholds. Nociceptin was not different between groups. Systemic Complaints questionnaire responses were significantly ranked as fibromyalgia > back pain > normal. SF-36 domains demonstrated severe disability for the low back pain group, intermediate results in fibromyalgia, and high function in the normal group. CONCLUSIONS: Fibromyalgia was distinguished by higher cerebrospinal fluid MEAP, systemic complaints, and manual tender points; intermediate SF-36 scores; and lower pain thresholds compared to the low back pain and normal groups. MEAP and systemic pain thresholds were inversely correlated in low back pain subjects. Central nervous system opioid dysfunction may contribute to pain in fibromyalgia.

Adult↗
PubMed2006

Nordic walking and chronic low back pain: design of a randomized clinical trial.

BACKGROUND: Low Back Pain is a major public health problem all over the western world. Active approaches including exercise in the treatment of low back pain results in better outcomes for patients, but it is not known exactly which types of back exercises are most beneficial or whether general physical activity provide similar benefits. Nordic Walking is a popular and fast growing type of exercise in Northern Europe. Initial studies have demonstrated that persons performing Nordic Walking are able to exercise longer and harder compared to normal walking thereby increasing their cardiovascular metabolism. Until now no studies have been performed to investigate whether Nordic Walking has beneficial effects in relation to low back pain. The primary aim of this study is to investigate whether supervised Nordic Walking can reduce pain and improve function in a population of chronic low back pain patients when compared to unsupervised Nordic Walking and advice to stay active. In addition we investigate whether there is an increase in the cardiovascular metabolism in persons performing supervised Nordic Walking compared to persons who are advised to stay active. Finally, we investigate whether there is a difference in compliance between persons receiving supervised Nordic Walking and persons doing unsupervised Nordic Walking. METHODS: One hundred and fifty patients with low back pain for at least eight weeks and referred to a specialized secondary sector outpatient back pain clinic are included in the study. After completion of the standard back centre treatment patients are randomized into one of three groups: A) Nordic Walking twice a week for eight weeks under supervision of a specially trained instructor; B) Unsupervised Nordic Walking for eight weeks after one training session with an instructor; C) A one hour motivational talk including advice to stay active. Outcome measures are pain, function, overall health, cardiovascular ability and activity level. RESULTS: No results available at this point. DISCUSSION: This study will investigate the effect of Nordic Walking on pain and function in a population of people with chronic LBP.

Chronic Disease↗
PubMed1999

Water-gymnastics reduced the intensity of back/low back pain in pregnant women.

OBJECTIVE: To investigate if water-gymnastics during pregnancy may reduce the intensity of back/low back pain and the number of days on sick-leave. METHODS: A prospective, randomized study. One hundred and twenty-nine women were randomized to participate in water-gymnastics once a week during the second half of pregnancy and 129 were randomized to a control group. The women in both groups filled in questionnaires in gestational weeks 18, 34 and within the first postpartum week. Every day from week 18 to labor they assessed the intensity of back/low back pain. RESULTS: Back pain intensity increased during pregnancy. No excess risk for the pregnancy associated with water-gymnastics was observed. The women participating in water-gymnastics recorded a lower intensity of back/low back pain. The total number of days on sick-leave because of back/low back pain was 982 in the water-gymnastics group (124 women) compared with 1484 in the control group (120 women). After weeks 32 33, seven women in the water-gymnastics group compared with 17 in the control group were on sickleave because of back/ low back pain (p=0.031). CONCLUSIONS: Intensity of back/low back pain increased with advancing pregnancy. There was no excess risk for urinary or vaginal infections associated with water-gymnastics. Water-gymnastics during the second half of pregnancy significantly reduced the intensity of back/ low back pain. Water-gymnastics decreased the number of women on sick-leave because of back/low back pain. Water-gymnastics during pregnancy can be recommended as a method to relieve back pain and may reduce the need for sick-leave.

Absenteeism↗