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PubMed1996

The lack of prognostic value of computerized tomography imaging examinations in patients with chronic non-progressive back pain.

The purpose of the present study was to evaluate the prognostic value of computerized tomography (CT) in the conservative treatment of patients with chronic non-progressive back pain. The study included 73 patients with chronic non-progressive back pain in the lumbar region of at least 3-months duration who were referred to the back clinic because of pain that was non-responsive to physical therapy and analgesics. All patients underwent clinical examination and spinal CT scan. The clinical examination and imaging procedures were followed by a 4-week rehabilitation programme based on a multidisciplinary approach that included a rheumatologist, a pain specialist, back school. "Alexander" technique, acupuncture, manipulation and psychological intervention. Patients were evaluated by the same physician at the end of the 4-week programme and after 6 months follow-up using parameters of pain rating, pain frequency and analgesic drug consumption. CT examinations were evaluated separately by two radiologists. The patients were divided into three groups according to the CT findings: group 1-normal imaging: 26 patients: group 2 -spinal stenosis: 20 patients; group 3 -posterior bulging, protrusion, extrusion or sequestration of disc: 27 patients. The clinical improvement was almost the same (approximately 50%) in the three different groups. In spite of the small number of cases, the results were statistically significant. We concluded that, in contrast to the importance of modern spinal-imaging procedures before the performance of surgery, the role of these procedures in the prognosis of the conservative treatment of patients with chronic non-progressive back pain does not seem to be important.

Adult↗
PubMed1994

Kyphosis in older women and its relation to back pain, disability and osteopenia: the study of osteoporotic fractures.

To test the hypothesis that thoracic kyphosis is associated with substantial pain, disability, and height loss, we measured thoracic curvature, using an architect's flexicurve, of 610 women aged 65-91 years who were recruited from population-based listings. We assessed study subjects for back pain, back-related disability, height loss since age 25 years, perceived state of health, and bone mineral density (BMD) at the spine, calcaneus, proximal radius, and distal radius. Compared with the rest of the cohort, the 10% of women with the most severe kyphosis had 7%-17% lower BMD (p < 0.001) and had lost an additional 2.4 cm height (p < 0.001). However, kyphotic women had no greater back pain, disability caused by back problems, or poorer health. This cross-sectional study suggests that kyphosis is associated with decreased BMD and loss of height but does not cause substantial chronic back pain, disability, or poor health in older women.

Aged↗
PubMedDate not supplied

Utilization of medical services for the treatment of acute low back pain: conformance with clinical guidelines.

OBJECTIVE: To assess the utilization of diagnostic and therapeutic medical services for the management of acute low back pain in a primary care setting, and to determine whether such utilization conforms to suggested guidelines for the management of this condition. STUDY DESIGN: A retrospective chart audit of consecutive cases of acute low back pain. Specific elements of the diagnostic and therapeutic approach were judged appropriate or inappropriate based on comparison with published recommendations supported by the medical literature. SETTING: The primary care adult practice of a university-affiliated health maintenance organization. PATIENTS: One hundred eighty-three patients presenting with acute low back pain of musculoskeletal origin. MEASUREMENTS AND MAIN RESULTS: According to suggested guidelines for the care of acute low back pain, 26% of plain lumbar x-rays (10/38), 66% of computed tomography (CT) and magnetic resonance imaging (MRI) scans (12/18), and 82% (23/28) of subspecialty referrals were categorized as inappropriate. Among patients without indications for these services, 12% (10/85) had received lumbar x-rays, 7% (12/168) had received lumbar MRI or CT scans, and 14% (23/168) had received subspecialty referrals. Underutilization of these services had occurred in 71% (70/98) of patients with an indication for plain lumbar radiography, and 47% (7/15) of patients with potential indications for surgical referral or CT/MRI scanning. Neither overutilization nor underutilization had led to adverse outcomes or delays in diagnosis in this small sample. CONCLUSIONS: According to guidelines from the medical literature, the primary care physicians in this study both overutilized and underutilized diagnostic and referral services in cases of acute low back pain. It is necessary to determine whether underutilization of plain lumbar radiography adversely affects diagnostic accuracy and whether overutilization of other services improves important clinical outcomes, given the generally benign natural history of this condition.

Acute Disease↗
PubMed2005

Both resistance and agility training reduce back pain and improve health-related quality of life in older women with low bone mass.

The purpose of the study was to compare the effects of three different types of group-based exercise programs (resistance training, agility training and general stretching) on back pain and health-related quality of life in older (aged 75-85 years) community-dwelling women with low bone mass (i.e., osteopenia or osteoporosis). The design was a 25-week randomized controlled trial. Participating were 98 community-dwelling women with low bone mass between the ages of 75 to 85 years old. We assessed back pain and its related disability and health-related quality of life. All three types of group-based exercise programs significantly reduced back pain and its related disabilities, but only resistance and agility training significantly improved health-related quality of life in community-dwelling older women with low bone mass. Baseline physical activity level and class attendance were significant predictors of change in health-related quality of life. Change in back pain and its related disabilities after 25 weeks of exercise intervention was significantly correlated with change in health-related quality of life and changes in the domains of pain and physical function. Resistance and agility training significantly enhanced health-related quality of life and may have done so by increasing social interactions and support, enhancing self-efficacy of physical abilities and modifying the experience of back pain. These data provide valuable insight into the specifics of exercise prescription for older women with low bone mass. Future studies may wish to use individualized quality of life measures to further delineate the effects of different types of exercise on quality of life in older adults with low bone mass.

Aged↗
PubMed2005

Degenerative disc disease as a cause of back pain in the thalassaemic population: a case-control study using MRI and plain radiographs.

PURPOSE: The aim of this study was to test our observation that back pain in thalassemic patients could be caused by premature and extensive lumbar degenerative disc disease, when compared to non-thalassemic patients with back pain. METHODS AND MATERIALS: Sixteen thalassemic patients with their sex- and age-matched controls were recruited into the study, 12 with thalassemia major, and 4 with thalassemia intermedia. Both the thalassemia patients and control subjects suffered from back pain, which was subjective rather than measured/pain scored. All subjects underwent magnetic resonance (MR) imaging of the lumbar spine, and 11 of the cases and 8 controls had lumbar spine radiographs. Each lumbar disc was scored for radiographic appearances and MR features of disc degeneration and disc protrusion. Proportion values for these parameters and median scores were derived at each disc level, and were analyzed and compared. RESULTS: There was a statistically-significant difference between proportion values of cases and controls for the MR features (P value=0.01, n=16) and the radiographic features (P value=0.01, n=11 cases, n=8 controls) of disc degeneration. The median disc level scores for the thalassemic group were uniformly high across all lumbar discs, and at all levels except at L 4/5. The control group conversely demonstrated a predilection for disc degeneration at L4/5 level. CONCLUSION: The distribution of lumbar disc degeneration in thalassemic patients with back pain is more extensive, severe and multi-level in nature compared to matched controls, and disc degeneration should be considered as a significant cause of back pain in this population group.

Back Pain↗
PubMed2000

[The North American Spine Society Lumbar Spine Outcome Assessment Instrument: translation and psychometric analysis of the German version in rehabilitation patients with chronic back pain].

The "Lumbar Spine Outcome Assessment Instrument", developed by the North American Spine Society (NASS), was translated into German. Its psychometric properties were tested in a group of rehabilitation patients with chronic, unspecific back pain, and in a comparison group of patients in cardiologic rehabilitation. With a Cronbach's alpha of 0.92, internal consistency was high. Principal component analysis revealed that the German version of the NASS instrument surveys the factors "back pain", "neurologic symptoms", and "impairments". A strong correlation with other measures of functional impairment (FFbH-R, IRES) indicates a high concurrent validity of the NASS instrument. After three weeks of inpatient rehabilitation, sensitivity to change could be demonstrated for the summary score of the instrument. This significant change was primarily due to moderate effects in the factor "back pain". In our study population, the factor "impairments" did not show a significant change. On the basis of these results, the German version of "The North American Spine Society Lumbar Spine Outcome Assessment Instrument" can be described as a reliable and valid instrument for measuring back pain, related neurologic symptoms, and back pain-induced impairments in rehabilitation patients. Because the factor "impairments" is not sensitive to change within three weeks of rehabilitation, the instrument is only partly suitable for measuring short-term outcome in rehabilitation patients. Further research is needed to determine if the instrument is useful for middle- and long-term outcome measurement in rehabilitation.

Back Pain↗
PubMed2002

Intra-abdominal pressure increases during exhausting back extension in humans.

The aim of this study was to investigate in humans the effect of maintained spinal load on the intra-abdominal pressure (IAP), low back kinematics and trunk muscle activity. This study consisted of two endurance tests for the low back muscles performed 3 weeks apart. Nine healthy subjects participated in the study. In the first test (upright-test), the subject had to pull with the back muscles at a constant force in an upright position, and in the second test (incline-test), the subject had to resist a constant forward pulling force while standing with a 45 degrees inclination of the back in relation to vertical. The IAP, rate of perceived exertion and electromyogram (EMG) from the erector spinae, iliocostalis lumborum, rectus abdominus and the external and internal oblique muscles were measured using surface electrodes. There was no significant difference in endurance time between the two tests. Both tests showed a significant increase in EMG amplitude with time for all muscles except the erector spinae muscle. A decrease in the median frequency for the erector spinae muscle was found indicating fatigue, and since no increase in EMG amplitude was found a decrease in force output from the muscle must be assumed. The IAP increased significantly during both tests. There was a considerable variation between the subjects in the size of this development, but the pattern was the same for all subjects. In conclusion it was found that trunk extension until exhaustion initiates an increase in the activity of the abdominal muscles and an increase in the IAP as the low back muscles become fatigued.

Abdomen↗
PubMed2006

[Severity of chronic back pain. Assessment with the Mainz Pain Staging System].

BACKGROUND: Among the possible reasons for low back pain, psychological factors are getting more attention. Early assessment of the stage of chronicity is important for successful therapy. The aim of the present study was to analyse the applicability of the Mainz Pain Staging System (MPSS) for chronic back pain outpatients. METHODS: Each of 679 back pain outpatients were assigned to one of the three MPSS stages of chronic back pain severity. Pain intensity and duration, anxiety and depression, pain sensation, impression of control and muscular capacity (isometric power of lumbal extensor), number of clinical consultations, hospitalisation, and days of work inability were also recorded. RESULTS: Males and females showed levels of chronic pain increasing with age. Patients with high MPSS levels showed significantly higher mean scores for anxiety, depression, number of consultations, hospitalisation, and days of inability to work. Furthermore, the same patients showed lower impressions of control and muscular capacity. CONCLUSIONS: The present study confirms the significance and usefulness of the MPSS applied to outpatients with back pain. To assess completely the stage of chronicity, psychological and physical/functional parameters should also be obtained.

Absenteeism↗
PubMed2001

[Problems of diagnostic assessment in low back patients].

Many different diagnostic procedures are used in patients with low back pain. Medical history and clinical examination, X-rays, computed tomography (CT)-scan, magnetic resonance imaging (MRI), diagnostic nerve root blocks and facet injections, functional tests in physiotherapy, strength tests of trunk muscles and work-related performance, and psychological and social evaluation including psychometric tests are only some of them. Despite this large number of procedures available, the scientific literature has not changed its conclusion that in about 80% of all back pain episodes the cause remains unknown. During the course of back pain episodes the relevant factors may change. The cause of the problem or the triggering factor of the pain episode may no longer be important during subacute stages, while others may be decisive for the transition to chronic stages. Thus, assessment of the cause is different from that of prognostic factors. There seems to be no consistent distribution of causes or ongoing factors in the population(s) of patients. While individual social factors may be the one important factor in one patient, functional and structural factors may be significant in another patient. Clinical examination is important, but several problems occur in the evaluation of patients with low back pain. Due to their anatomical location, important bony structures of the lumbar spine, e.g., disks or facet joints, are difficult to access by clinical examination. Additionally, there are only few diagnostic tests during clinical examination that do not rely on the patient's cooperation or communication. The term "unspecific back pain" for the majority of patients is scientifically sound, because it reflects the fact that the cause is unknown. It must be taken into consideration that this term enjoys only limited acceptance by both patients and physicians. Physicians are in charge of certifying work disability by assessing the interference of the patient's illness/disease with the specific requirements of his daily life or job. However, in clinical practice both the job tasks and the patient's abilities to perform these tasks with the given symptoms and signs is still difficult to evaluate and requires further definition.

Acute Disease↗
PubMed2001

[Epidemiology and costs of chronic pain syndromes exemplified by specific and unspecific low back pain].

Low back pain is one of the most common factors leading to longtime disability. Unspecific low back pain is predominant, i. e. low back pain without an anatomic or neurophysiological correlate. The socioeconomic impact of back pain is huge. In Germany 4% of all work force is lost only due to low back pain. Psychosocial factors are essential for the chronification and must be take into account in therapy. Conventional therapy has shown low efficacy, especially once chronification has started.

Back Pain↗
PubMed2002

The clinical importance of changes in outcome scores after treatment for chronic low back pain.

When measuring treatment effect in chronic low back pain with multi-item outcome instruments, it is necessary, both for clinical decision-making and research purposes, to understand the clinical importance of the outcome scores. The aims of the present study were three-fold. Firstly, it aimed to estimate the minimal clinically important difference of three multi-item outcome instruments (the Oswestry Disability Index, the General Function Score and the Zung Depression Scale) and of the visual analogue scale (VAS) of back pain. Secondly, it aimed to estimate the error of measurement of these instruments; and its third aim was to describe the clinical meaning of score change. The study population consisted of 289 patients treated surgically or non-surgically in a randomised controlled trial. The minimal clinically important difference was estimated with patient global assessment as the external criterion. It was compared with the standard error of measurement of the instruments. The individual items of the instruments were compared for score changes related to improvement and deterioration. The standard error of measurement of the Oswestry Disability Index, the General Function Score and the Zung Depression Scale was 4, 6 and 3 units, respectively. The 95% tolerance interval was 10, 16 and 8 units, respectively. The minimal clinically important difference was 10, 12 and 8-9 units, respectively, thus not significantly exceeding the tolerance interval. The minimal clinically important difference of VAS back pain was 18-19 units, well exceeding the 95% tolerance interval, which was 15 units. Improvement after treatment for chronic low back pain tends to occur to a greater extent in sleep disturbance, ability to do usual things and psychological irritability, but to a lesser extent in the ability to sit, stand and lift. We conclude that the VAS of back pain is responsive enough to detect the minimal clinically important difference, whereas the smallest acceptable score changes of the Oswestry Disability Index, the General Function Score and the Zung Depression Scale may require an increase to exceed the 95% tolerance interval when used for clinical decision making and for power calculation. Despite improvement after treatment, the ability to sit, stand and lift, remain notable problems.

Activities of Daily Living↗
PubMed2003

Routine primary care management of acute low back pain: adherence to clinical guidelines.

One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity. A prospective study was designed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines. Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia, Basque Country (Spain), participated in the study. A total of 105 patients aged 18-65 years presenting with acute low back pain over a 6-month period were included. Immediately after consultation, a research assistant performed a structured clinical interview. The patients' care provided by the general practitioner was compared with the Agency for Health Care Policy and Research (AHCPR) guidelines and guidelines issued by the Royal College of General Practitioners. The diagnostic process showed a low rate of appropriate use of history (27%), physical examination (32%), lumbar radiographs (31%), and referral to specialized care (33%). Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization (77%) and educational advice (65%), only 23% of patients were taught about the benign course of back pain. The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines.

Adult↗
PubMed2004

The costs for persons sick-listed more than one month because of low back or neck problems. A two-year prospective study of Swedish patients.

The total costs for patients who are sick-listed due to back and neck problems have not previously been determined prospectively on an individual basis. This study aimed to determine the total cost to a society, based on individually assessed costs of health services and loss of production in people who are sick-listed 28 days or more for back or neck problems. Detailed data on individuals' health-care consumption due to back or neck problems was collected through prospectively entered diaries and questionnaires, after 4 weeks, 3 months, 1 and 2 years, in a consecutively selected cohort of 1,822 employed persons aged between 18 and 59 years. Costs for health care and production losses due to work absenteeism were determined individually and combined to render total costs to society. The costs for all medical services during the 2-year study were 6.9% of total costs for back and neck problems. The single most expensive medical service was surgery. Transferred to a national level, annual total costs for back and neck problems corresponded to 1% of GNP. In conclusion, direct health-service costs were a small fraction of the total costs, consequently indirect costs offer the greatest potential for savings.

Adult↗
PubMed2005

Predictors for work ability and disability in men and women with low-back or neck problems.

In many countries back and neck problems are the most common reason for work incapacity. Numerous studies have looked for reliable predictors of return to work (RTW) or not return to work (NRTW) for those incapacitated, but with few exceptions their predictive and detective ability has been limited. We aimed to perform a comparative study of various commonly used health measures ability to predict RTW or NRTW in a cohort of men and women sick-listed for more than 28 days due to low-back pain (LBP) or neck pain (NP). A cohort of 1,575 men and women sick-listed more than 28 days due to back or neck problems was asked to answer ten different health measures (scales) about various aspects of health status (health related quality of life, pain, back function and depressivity) at four occasions during a 2-year period. A statistical diagnostic test was used to study how well the subject's values on these scales would serve as a predictor for work resumption. There was an improvement from day 28 up until 2 years, reflected by the different scales, more pronounced for LBP than for NP patients and for men with LBP compared with women with LBP. For all separately tested scales EuroQol (EQ-5D) had the highest overall ability to predict RTW or NRTW irrespective of gender, diagnoses or duration of the problems. When RTW or NRTW were predicted in a cohort of sick-listed low-back or neck patients, EQ-5D had outstanding properties in this respect irrespective of gender, diagnosis or elapsed time during this 2-year study.

Activities of Daily Living↗
PubMed2005

Trunk muscular activation patterns and responses to transient force perturbation in persons with self-reported low back pain.

Trunk stability requires muscle stiffness associated with appropriate timing and magnitude of activation of muscles. Abnormality of muscle function has been implicated as possible cause or consequence of back pain. This experimental study compared trunk muscle activation and responses to transient force perturbations in persons with and without self-reported history of low back pain. The objective was to determine whether or not history of back pain was associated with (1) altered anticipatory preactivation of trunk muscles or altered likelihood of muscular response to a transient force perturbation and (2) altered muscle activation patterns during a ramped effort. Twenty-one subjects who reported having back pain (LBP group) and twenty-three reporting no recent back pain (NLBP group) were tested while each subject stood in an apparatus with the pelvis immobilized. They performed 'ramped-effort' tests (to a voluntary maximum effort), and force perturbation tests. Resistance was provided by a horizontal cable from the thorax to one of five anchorage points on a wall track to the subject's right at angles of 0 degrees, 45 degrees, 90 degrees, 135 degrees and 180 degrees to the forward direction. In the perturbation tests, subjects first pulled against the cable to generate an effort nominally 15% or 30% of their maximum extension effort. The effort and the EMG activity of five right/left pairs of trunk muscles were recorded, and muscle responses were detected. In the ramped-effort tests the gradient of the EMG-effort relationship provided a measure of each muscle's activation. On average, the LBP group subjects activated their dorsal muscles more than the NLBP group subjects in a maximum effort task when the EMG values were normalized for the maximum EMG, but this finding may have resulted from lesser maximum effort generated by LBP subjects. Greater muscle preactivation was recorded in the LBP group than the NLBP group just prior to the perturbation. The likelihood of muscle responses to perturbations was not significantly different between the two groups. The findings were consistent with the hypothesis that LBP subjects employed muscle activation in a quasi-static task and preactivation prior to a perturbation in an attempt to stiffen and stabilize the trunk. However, interpretation of the findings was complicated by the fact that LBP subjects generated lesser efforts, and it was not known whether this resulted from anatomical differences (e.g., muscle atrophy) or reduced motivation (e.g., pain avoidance).

Adult↗
PubMed2005

A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction.

Clinical reports and research studies have documented the behavior of chronic low back and neck pain patients. A few hypotheses have attempted to explain these varied clinical and research findings. A new hypothesis, based upon the concept that subfailure injuries of ligaments (spinal ligaments, disc annulus and facet capsules) may cause chronic back pain due to muscle control dysfunction, is presented. The hypothesis has the following sequential steps. Single trauma or cumulative microtrauma causes subfailure injuries of the ligaments and embedded mechanoreceptors. The injured mechanoreceptors generate corrupted transducer signals, which lead to corrupted muscle response pattern produced by the neuromuscular control unit. Muscle coordination and individual muscle force characteristics, i.e. onset, magnitude, and shut-off, are disrupted. This results in abnormal stresses and strains in the ligaments, mechanoreceptors and muscles, and excessive loading of the facet joints. Due to inherently poor healing of spinal ligaments, accelerated degeneration of disc and facet joints may occur. The abnormal conditions may persist, and, over time, may lead to chronic back pain via inflammation of neural tissues. The hypothesis explains many of the clinical observations and research findings about the back pain patients. The hypothesis may help in a better understanding of chronic low back and neck pain patients, and in improved clinical management.

Animals↗
PubMed2006

Intradiscal methylene blue injection for the treatment of chronic discogenic low back pain.

This article was a preliminary report of prospective clinical trial of a group of patients with chronic discogenic low back pain who met the criteria for lumbar interbody fusion surgery but were treated instead with an intradiscal injection of methylene blue (MB) for the pain relief. Twenty-four patients with chronic discogenic low back pain underwent diagnostic discography with intradiscal injection of MB. The principal criteria to judge the effectiveness included alleviation of pain, assessed by visual analog scale (VAS), and improvement in disability, as assessed with the Oswestry Disability Index (ODI) for functional recovery. The mean follow-up period was 18.2 months (range 12-23 months). Of the 24 patients, 21 (87%) reported a disappearance or marked alleviation of low back pain, and experienced a definite improvement in physical function. A statistically significant and clinically meaningful improvement in the changes in the ODI and the VAS scores were obtained in the patients with chronic discogenic low back pain (P=0.0001) after the treatment. The study suggests that the injection of MB into the painful disc may be a very effective alternative for the surgical treatment of chronic discogenic low back pain.

Adult↗
PubMed2006

Quantifier variables of the back surface deformity obtained with a noninvasive structured light method: evaluation of their usefulness in idiopathic scoliosis diagnosis.

New noninvasive techniques, amongst them structured light methods, have been applied to study rachis deformities, providing a way to evaluate external back deformities in the three planes of space. These methods are aimed at reducing the number of radiographic examinations necessary to diagnose and follow-up patients with scoliosis. By projecting a grid over the patient's back, the corresponding software for image treatment provides a topography of the back in a color or gray scale. Visual inspection of back topographic images using this method immediately provides information about back deformity, but it is important to determine quantifier variables of the deformity to establish diagnostic criteria. In this paper, two topographic variables [deformity in the axial plane index (DAPI) and posterior trunk symmetry index (POTSI)] that quantify deformity in two different planes are analyzed. Although other authors have reported the POTSI variable, the DAPI variable proposed in this paper is innovative. The upper normality limit of these variables in a nonpathological group was determined. These two variables have different and complementary diagnostic characteristics, therefore we devised a combined diagnostic criterion: cases with normal DAPI and POTSI (DAPI < or = 3.9% and POTSI < or = 27.5%) were diagnosed as nonpathologic, but cases with high DAPI or POTSI were diagnosed as pathologic. When we used this criterion to analyze all the cases in the sample (56 nonpathologic and 30 with idiopathic scoliosis), we obtained 76.6% sensitivity, 91% specificity, and a positive predictive value of 82%. The interobserver, intraobserver, and interassay variability were studied by determining the variation coefficient. There was good correlation between topographic variables (DAPI and POTSI) and clinical variables (Cobb's angle and vertebral rotation angle).

Adolescent↗