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PubMed2005

Effect of Iyengar yoga therapy for chronic low back pain.

Low back pain is a significant public health problem and one of the most commonly reported reasons for the use of Complementary Alternative Medicine. A randomized control trial was conducted in subjects with non-specific chronic low back pain comparing Iyengar yoga therapy to an educational control group. Both programs were 16 weeks long. Subjects were primarily self-referred and screened by primary care physicians for study of inclusion/exclusion criteria. The primary outcome for the study was functional disability. Secondary outcomes including present pain intensity, pain medication usage, pain-related attitudes and behaviors, and spinal range of motion were measured before and after the interventions. Subjects had low back pain for 11.2+/-1.54 years and 48% used pain medication. Overall, subjects presented with less pain and lower functional disability than subjects in other published intervention studies for chronic low back pain. Of the 60 subjects enrolled, 42 (70%) completed the study. Multivariate analyses of outcomes in the categories of medical, functional, psychological and behavioral factors indicated that significant differences between groups existed in functional and medical outcomes but not for the psychological or behavioral outcomes. Univariate analyses of medical and functional outcomes revealed significant reductions in pain intensity (64%), functional disability (77%) and pain medication usage (88%) in the yoga group at the post and 3-month follow-up assessments. These preliminary data indicate that the majority of self-referred persons with mild chronic low back pain will comply to and report improvement on medical and functional pain-related outcomes from Iyengar yoga therapy.

Adult↗
PubMed2005

Passive coping is a risk factor for disabling neck or low back pain.

BACKGROUND: Despite evidence suggesting that coping is an important concept in the study of pain, its role in predicting the development of disabling pain has not been previously studied. To assess the relationship between coping and the development of disabling pain. METHODS: From a random sample of adults, we formed a cohort of individuals with non-disabling neck and/or low back pain (n=571). Participants were followed 6 and 12 months after the index survey. Coping was measured with the Vanderbilt Pain Management Inventory. The Chronic Pain Questionnaire was used to measure the presence of disabling neck and/or low back pain. We used Cox proportional hazards regression analyses to investigate the role of passive coping in the development of disabling pain while controlling for confounders. RESULTS: Passive coping was a strong, independent risk factor for disabling neck and/or back pain. Those using moderate to high levels of passive coping strategies were at an over five-fold increased risk of developing disabling pain (Moderate: HRR=5.19, 95% CI=1.78-15.1; High: HRR=6.80, 95% CI=2.36-19.6). Active coping was not found to be a significant risk factor for disabling neck and/or back pain. CONCLUSION: Passive coping is a strong and independent predictor of disabling neck and/or back pain. This strong relationship identifies passive coping as a marker for risk of disability and can allow for the identification of individuals at risk and in need of intervention to aid in improving their overall adjustment.

Adaptation, Psychological↗
PubMed2006

Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study.

The effectiveness of lumbar fusion for chronic low back pain after surgery for disc herniation has not been evaluated in a randomized controlled trial. The aim of the present study was to compare the effectiveness of lumbar fusion with posterior transpedicular screws and cognitive intervention and exercises. Sixty patients aged 25-60 years with low back pain lasting longer than 1 year after previous surgery for disc herniation were randomly allocated to the two treatment groups. Experienced back surgeons performed transpedicular fusion. Cognitive intervention consisted of a lecture intended to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The primary outcome measure was the Oswestry Disability Index (ODI). Outcome data were analyzed on an intention-to-treat basis. Ninety-seven percent of the patients, including seven of eight patients who had either not attended treatment (n=5) or changed groups (n=2), completed 1-year follow-up. ODI was significantly improved from 47 to 38 after fusion and from 45 to 32 after cognitive intervention and exercises. The mean difference between treatments after adjustment for gender was -7.3 (95% CI -17.3 to 2.7, p=0.15). The success rate was 50% in the fusion group and 48% in the cognitive intervention/exercise group. For patients with chronic low back pain after previous surgery for disc herniation, lumbar fusion failed to show any benefit over cognitive intervention and exercises.

Adult↗
PubMed2006

What mediates the inverse association between education and occupational disability from back pain?--A prospective cohort study from the Nord-Trøndelag health study in Norway.

Low education is consistently associated with an increased risk of back pain disability, but the underlying mechanisms for this relationship are poorly understood. In a seven-year prospective observational study of 38,426 employed men and women between 25 and 59 years in Norway, we investigated to what extent occupational class, working conditions and individual lifestyle mediated the effect of formal education on disability pensioning from back pain. Each additional year of formal education was associated with decreased risk for disability pensioning from back pain for both men [age adjusted Hazard Ratio (HR) 0.77; (95% Confidence Interval, 0.72-0.82)] and women [HR 0.76(0.71-0.82)]. Adjustment for occupational class and factors related to working conditions (authority to plan own work, physically demanding work, concentration and attention and job satisfaction) and individual lifestyle (smoking, body mass index, physical exercise and alcohol consumption) reduced the effect of education by 39% [HR 0.86(0.79-0.93)] for men and by 21% [HR 0.81(0.73-0.89)] for women. Working conditions contributed most to the explanation for men, while occupational class, working conditions and life style factors contributed equally for women. Subgroup analyses indicate small differences between full-time and part-time employees, while some differences were found between subcategories of back diseases. The study indicates that there is a strong and unexplained effect of education on back pain disability pensioning, which is not mediated by occupational class, working conditions or individual lifestyle.

Adult↗
PubMedDate not supplied

National trends in nonoperative care for nonspecific back pain.

BACKGROUND CONTEXT: Few empirical data are available that document changes in population-based rates for the evaluation and treatment of nonspecific back pain. PURPOSE: To determine the extent of change in the pattern of outpatient evaluation and treatment of nonspecific low back pain in the United States between 1987 and 1997. STUDY DESIGN AND SETTING: The 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey, two nationally representative surveys with similar sampling methods and questions, were used. PATIENT SAMPLE: Noninstitutionalized adults in the United States. OUTCOME MEASURES: Changes in rates of any health service for nonspecific back pain and occurrence of provider-specific care and types of services provided. Changes in the prescription of specific medication classes (ie, nonsteroidal anti-inflammatory drugs [NSAIDs], muscle relaxants, nonnarcotic and narcotic analgesics) were also investigated. RESULTS: Overall rate for outpatient treatment for nonspecific back pain in the US population was relatively stable over the decade (4.48% in 1987, 4.53% in 1997, p=.85). Among those receiving care, the proportion receiving physician care increased from 64% in 1987 to 74% in 1997 (p<.001), whereas those obtaining care from physical therapists increased from 5% to 9% during the same time period (p<.01). The proportion of respondents receiving NSAIDs, muscle relaxants, nonnarcotic analgesics and narcotic analgesics remained stable. However, the mean number of patient visits in which these medications were prescribed increased from 2.0 to 3.9 over the decade (p<.001). The proportion of individuals receiving chiropractic care (p<.01) and X- rays (p<.001) were lower in 1997 than 1987. CONCLUSIONS: The national pattern of health care for nonspecific low back pain observed in the present study serves as a basis for future investigations into the management of this major public health problem. Findings suggest that perhaps a duplication of care is partly responsible for the high degree of health care utilization in this population.

Adolescent↗
PubMed1997

A selective approach to the management of gunshot wounds to the back.

BACKGROUND: Gunshot wounds to the back with retroperitoneal trajectories have been traditionally managed under the same guidelines as anterior gunshot wounds. Recent work has suggested that selective nonoperative management of anterior abdominal gunshot wounds is safe. The role of this policy in gunshot wounds to the back, where retroperitoneal organ injuries may be more difficult to detect clinically, has not been investigated. OBJECTIVE: To examine if selective nonoperative management based on clinical assessment is a safe alternative to mandatory exploration for gunshot wounds to the back. DESIGN: Prospective study. SETTING: Large-volume level-1 university affiliated trauma center. PATIENTS AND METHODS: Two hundred and three consecutive patients with gunshot wounds to the back were managed according to a protocol during a 12-month period. Patients with hemodynamic instability or peritonitis underwent urgent operation. The rest of the patients were observed with careful serial clinical examinations. RESULTS: Eleven patients underwent an emergency room thoracotomy and were excluded. Four more patients were operated upon, despite the absence of abdominal findings, because of associated spinal cord injuries (2 patients), inability to observe due to need for repair of an associated peripheral vascular injury (1 patient), and participation in another protocol of aggressive evaluation of asymptomatic patients with suspected diaphragmatic injuries (1 patient). Of the remaining 188 patients, 58 (31%) underwent laparotomy (56 therapeutic, 2 negative) and 130 (69%) were initially observed owing to negative clinical examination. Following the development of increasing abdominal tenderness, 4 of these 130 (3%) underwent delayed explorations, which were all nontherapeutic. The sensitivity and specificity of initial clinical examination in detecting significant intraabdominal injuries were 100% and 95%, respectively. CONCLUSIONS: Mandatory laparotomy is not necessary for gunshot wounds of the back. Clinical examination is a safe method of selecting patients for nonoperative management. An observation period of 24 hours is adequate for patients with no abdominal symptoms.

Abdominal Injuries↗
PubMed2002

Tractor-driving hours and their relation to self-reported low-back and hip symptoms.

Tractor driving might be one causal risk factor in the incidence of low-back and hip symptoms among farmers. Information on the annual exposure to tractor driving and its distribution among different work operations is scarce. The purpose of this study was to quantify the total and the annual time driving tractors among Swedish farmers and its distribution into different work operations, and to investigate the risk of low-back and hip symptoms in relation to tractor driving within different work operations. The data were collected from a questionnaire study sent to all farms with acreage more than 10 ha in a county in Sweden. Farmers having farming and/or forestry as their main occupation in 1995 were included in the analysis. The annual tractor-driving time and the percentage distribution within different work operations were calculated for females, males, the total group and four production groups. The risk calculations for low-back and hip symptoms from the variables related to tractor driving were performed on the total group. The results showed that the mean annual tractor-driving time was 472 h. Ploughing was the single most time-consuming work operation but it had no influence on the risk for low-back or hip pain. The results showed that some of the variables investigated related to tractor driving influenced the risk for low-back and hip symptoms.

Agricultural Workers' Diseases↗
PubMedDate not supplied

Differences in low back load between kneeling and seated working at ground level.

The effects of the load on the low back when working in a kneeling posture were compared to those when working on a chair designed to alleviate work load in harvesting radish. In 10 male subjects data regarding back muscle fatigue and length changes of the spine, and estimates of experienced discomfort were collected. The results show that for all three effects of back load working on the chair leads to lower levels as compared to working kneeling. However, back load and discomfort were lower when working on the chair, back discomfort still increased substantially during the work on the chair. It is thus a sub-optimal solution from an ergonomic point of view, but at present it could be recommended to allow for variation with the conventional working method.

Adult↗
PubMed1997

Acute low back pain secondary to retroperitoneal hemorrhage in an elderly man.

Acute low back pain is a common complaint heard in the emergency room and in a physiatrist's practice. It is important to rule out occult pathology in patients with an atypical presentation. In the case presented here, the patient was elderly, developed back pain without preceding trauma or lifting, had a history of easy bruisability, had a large ecchymosis, and had worsening back pain with bedrest. An abdominal aortic aneurysm was ruled out and the patient was discovered to have a large retroperitoneal hemorrhage. He was diagnosed with acquired hemophilia secondary to factor VIII inhibitors. This has implications for physicians who treat patients with acute low back pain. They must be alert to potentially life-threatening causes of low back pain.

Aged↗
PubMed2004

Determination of the usage of body mechanics in clinical settings and the occurrence of low back pain in nurses.

This explorative study was designed to identify the usage of body mechanics in clinical settings and the occurrence of low back pain in nurses. The sample was composed of 56 nurses who work on the medical, surgical, emergency and intensive care units of a state hospital in Bolu, Turkey. Data collected through observation and interviews were evaluated using percentages, Chi-square and Mann-Whitney U tests. Results of the study showed that the majority of the nurses (87.5%) experienced low back pain at some time in their lives. Among the contributing factors for back pain, the relationship between wearing high heels, heavy lifting and back pain was significant statistically. According to the observations, the majority of the nurses used body mechanics correctly while sitting (53.6%), standing (58.7%), carrying (64.3%), pulling or pushing (79.4%), moving the patient to the side of the bed without an assistant (53.4%), moving the patient to a sitting position in bed (71.4%) and assisting the patient to a standing position (66.6%). However 57.1% of the nurses lifted and 82% extended incorrectly. The conclusion from this research was that some of the nurses do not use body mechanics correctly and the majority have low back pain.

Adult↗
PubMed2001

Underestimation of object mass in lifting does not increase the load on the low back.

Sudden, unexpected loading on the low back is associated with a high incidence of low back pain. Experiments in which sudden loading was applied during standing revealed increased compression forces on the spine and increased trunk angle, which may cause injury to the spine and hence explain this association. During a more dynamic daily activity, i.e. lifting, this could not be demonstrated, which may be due to experimental constraints. We therefore reinvestigated the loading of the low back when subjects were lifting an unexpectedly heavy object. Ten males lifted boxes, weighing 1.6 or 6.6 kg, at a self-selected lifting velocity. In some trials the mass of these boxes was unexpectedly increased by 10 kg. The ground reaction forces, body movements and trunk muscle activity were measured and from these, the L5/S1 torques and compression forces were estimated. Underestimation of the mass did not lead to an increase in low back loading. This finding was independent of the mass the subjects were expecting to lift. In conclusion, no evidence was found to support inference regarding causality of the association between sudden loading and low back pain during whole body lifting movements.

Adult↗
PubMed2003

The mechanics of back-extensor torque production about the lumbar spine.

The purpose of this study was to develop and evaluate a biomechanical model of lumbar back extension over a wide range of positions for the lumbar spine, incorporating the latest information on muscle geometry and intra-abdominal pressure (IAP). Analysis of the Visible Human data was utilised in order to obtain anatomical information unavailable from the literature and magnetic resonance imaging was used to generate subject-specific anatomical descriptions. The model was evaluated by comparisons with measured maximal voluntary static back-extension torques. Predicted maximal specific muscle tensions agreed well with in vitro measurements from the literature. When modelling the maximal static back-extension torque production, it was possible to come fairly close to simultaneous equilibrium about all the lumbar discs simply by a uniform muscle activation of all back-extensor muscles (the caudal part showed, however, less agreement). This indicates that equilibrium in the lumbar spine is mainly regulated by passive mechanical properties, e.g. muscle length changes due to postural changes, rather than due to complex muscle coordination, as earlier proposed. The model showed that IAP (measured during torque exertions) contributes about 10% of the total maximal voluntary back-extensor torque and that it can unload the spine from compression. The spinal unloading effect from the IAP was greatest with the spine held in a flexed position. This is in opposition to the effects of changed muscle lever arm lengths, which for a given load would give the largest spinal unloading in the extended position. These findings have implications for the evaluation of optimal lifting techniques.

Abdomen↗
PubMed1986

Relationship between bone mineral density of spine and strength of back extensors in healthy postmenopausal women.

We determined the bone mineral density of the lumbar spine and the strength of back extensors in 68 healthy postmenopausal Caucasian women. Bone mineral density of the second to fourth lumbar vertebrae was measured by dual-photon absorptiometry, and back extensor strength was determined with use of a strain-gauge dynamometer. The bone mineral density percentile ranged from 2 to 99%, and back extensor strength ranged from 37 to 145 lb. Statistical analysis demonstrated a significant positive correlation (P = 0.004) between bone mineral density and back extensor strength, even when bone mineral density was corrected for age. Bone mineral density was also significantly positively correlated with body weight (P = 0.003), height (P = 0.001), and arm span (P = 0.008). These data suggest that the strength of back muscles may contribute to the bone mineral density of vertebral bodies.

Aged↗
PubMed1999

Low back pain. Evaluation and management in the primary care setting.

The primary care physician plays a major role in the identification of low back pain and the entry of the patient into the health care system. Acute low back pain remits within a short period of time in most patients, and major diagnostic studies are not required. If the pain persists beyond the treatment parameters of the primary care physician, consultation is necessary. A basic component of the initial evaluation is the identification of myofascial syndromes that mimic so-called root syndromes. Further, low back pain in the population at large is not usually a surgical problem, and the chances of there being significant pathology requiring surgical or other forms of intervention may be less than 1% of those affected. When the initial attempts at treatment fail, the patient should be referred to a multidisciplinary comprehensive pain center so as to avoid or limit chronicity, the earlier, the better. Practitioners should feel comfortable in asking the centers to which they make a referral for outcome data. If these are not available, the choice should be made elsewhere. Low back pain per se is in the majority not a neurologic problem, an orthopedic problem, or a neurosurgical problem, so that consultation with these groups, unless there are strong suspicions otherwise, has limited value. The criteria for selection and referral of patients to multidisciplinary pain centers have been presented, including specific considerations for the geriatric age group. The overwhelming cost of low back pain to the economy can be decreased along with suffering and the adverse impact that pain has on all social strata.

Chronic Disease↗
PubMed1995

Low back pain.

Low back pain is a common reason for physician visits and is associated with enormous costs to health care and industry. Radiographic abnormalities of the lumbar spine, including disk protrusion, are common in asymptomatic subjects and only loosely associated with symptoms and neurologic examination. Therefore, highly selective evaluation is required to avoid subjecting patients with back pain to unnecessary tests and surgical procedures. Reassurance about the favorable prognosis of low back pain is an important component of therapy. Most patients with simple back pain recover with symptomatic treatment. Plain radiographs are indicated for evaluation of patients with radiculopathy and those with risk factors for underlying medical conditions. The majority of patients with back pain, even those with radiculopathy, improve with conservative management and surgery is unnecessary. Surgical consultation and CT or MR imaging scans are indicated for patients with persistent or progressive neurologic deficits or persistent sciatica with nerve root tension signs. Acute radiculopathy with bilateral neurologic deficits, saddle anesthesia, or urinary symptoms is suggestive of cord compression or cauda equina syndrome and requires urgent surgical referral.

Ambulatory Care↗
PubMed2003

Indications, techniques, and outcomes of posterior surgery for chronic low back pain.

This article summarizes a number of issues surrounding the diagnosis, indications, and techniques of posterior lumbar spine surgery for chronic low back pain. It would not be entirely unjustified for a spine surgeon to adhere to a totally avoidant approach to chronic low back pain, rationalized by a reasonably legitimate nihilism regarding the presently available means of diagnosing and surgically managing low back pain [64]. Judging by the number of lumbar fusions performed in North America and the tremendous intellectual and financial investment currently being made in technologies to enhance spinal fusion, such an approach is evidently not achieving wide-spread acceptance on this continent. A rationale approach is therefore required for the many low back pain sufferers with degenerative disk disease who arrive in the office having exhausted almost every imaginable form of nonoperative therapy. Every effort should be made to establish a pathoanatomic etiology of the back pain with a combination of diagnostic modalities. Surgical intervention should be approached cautiously and only after extensive dialog with the patient to establish realistic goals and expectations. Posteriorly performed interbody fusion procedures may provide a high fusion rate and satisfactory clinical outcomes for this challenging problem, although further research is necessary to determine more conclusively the role of surgery and the relative effectiveness of the various arthrodesis techniques.

Chronic Disease↗
PubMed1983

Low back pain.

Low back pain probably always will be a problem because of the anatomic arrangement of the lower spine and posture in standing and walking. However, during recent years, new attempts at diagnosis and treatment of this difficult problem have occurred, and it is now possible, in most cases, with a good history, physical examination, and diagnostic work-up to determine the cause of the problem. The injuries are still difficult to treat in many cases, but often with a thorough explanation to the patient about the underlying problem and mechanism of pain, and with use of the "back school" and conservative measures, most of the patients can continue on with daily activities. Formal surgery is playing less of a role in the treatment of back problems, with the development of various injections and percutaneous techniques. Still to be addressed, and where considerable effort and energy should be spent, is in the prevention of back problems with changes in daily habits and in increased awareness of ways to avoid back injuries.

Acute Disease↗
PubMed2000

Work-related low back pain.

Low back pain is a common problem among working adults in the United States. Occupational risk factors for low back pain include forceful lifting, bending and twisting of the trunk, whole body vibration and heavy manual labor. The initial assessment of the patient with low back pain requires obtaining an occupational history to identify risk factors in the workplace in addition to the usual inquiries and physical assessment. For those with uncomplicated low back pain, minimal use of medical tests and rapid return to limited activity are indicated. Long-term prevention of low back pain requires modification of occupational or other risk factors.

Adult↗