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PubMed2001

[Gender-specific aspects in chronic low back pain rehabilitation].

Gender-specific Aspects in Chronic Low Back Pain Rehabilitation. Little is known about gender differences in utilisation, outcomes and evaluation of orthopaedic rehabilitation for chronic low back pain. The purpose of this article is to review and analyse the literature on rehabilitation and recovery of men and women with chronic back pain. In Western societies, chronic back pain is one of the most common causes for utilising medical rehabilitation services. In general no significant gender differences in the prevalences of back pain are found, but men are more sick-listed and early retired due to musculoskeletal diseases. Also, more men than women participate in medical rehabilitation programmes. National and international studies pinpoint the fact that differences exist between women and men with regard to participating in an orthopaedic rehabilitation programme. Additionally there is some evidence that different physical and psychological therapy services have different effects on health status of women and men. Mixed results are available regarding gender differences concerning the outcomes of rehabilitation programmes. Rehabilitation activities after discharge from in-patient programmes and these being performed within the home setting are primary indicators of recovery. Gender differences have been identified regarding various types of activities, apparently because especially family roles interfere with activity. Further research must be conducted so as to increase the understanding of women's and men's experiences relative to orthopaedic diseases and orthopaedic rehabilitation services.

Adult↗
PubMed1998

Perils and pointers in the evaluation and management of back pain.

This article examines the current treatment of low back pain in light of the recent Agency for Health Care Practice and Research (AHCPR) guidelines on the acute management of low back pain (the AHCPR is an agency of the federal government). The article describes the most important history questions, the most helpful physical signs, and the most practical examination techniques. Considerable emphasis is placed on ruling out the "red flag" diagnoses that require immediate treatment. The article agrees with the AHCPR that if the red flags of cancer, infection, fracture, and neurologic deficit are ruled out, most of the remaining causes of acute back pain are largely self-healing over 4-8 weeks. Emphasis is placed on using the history and physical examination rather than expensive studies to rule out the red flag cases, so that cost-effective management of low back pain is possible. The author also reviews the ten top causes of low back pain and their evaluation and treatment.

Back Pain↗
PubMed1990

A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain.

A number of treatments are widely prescribed for chronic back pain, but few have been rigorously evaluated. We examined the effectiveness of transcutaneous electrical nerve stimulation (TENS), a program of stretching exercises, or a combination of both for low back pain. Patients with chronic low back pain (median duration, 4.1 years) were randomly assigned to receive daily treatment with TENS (n = 36), sham TENS (n = 36), TENS plus a program of exercises (n = 37), or sham TENS plus exercises (n = 36). After one month no clinically or statistically significant treatment effect of TENS was found on any of 11 indicators of outcome measuring pain, function, and back flexion; there was no interactive effect of TENS with exercise. Overall improvement in pain indicators was 47 percent with TENS and 42 percent with sham TENS (P not significant). The 95 percent confidence intervals for group differences excluded a major clinical benefit of TENS for most outcomes. By contrast, after one month patients in the exercise groups had significant improvement in self-rated pain scores, reduction in the frequency of pain, and greater levels of activity as compared with patients in the groups that did not exercise. The mean reported improvement in pain scores was 52 percent in the exercise groups and 37 percent in the nonexercise groups (P = 0.02). Two months after the active intervention, however, most patients had discontinued the exercises, and the initial improvements were gone. We conclude that for patients with chronic low back pain, treatment with TENS is no more effective than treatment with a placebo, and TENS adds no apparent benefit to that of exercise alone.

Back Pain↗
PubMed2000

Do cerebral potentials to magnetic stimulation of paraspinal muscles reflect changes in palpable muscle spasm, low back pain, and activity scores?

OBJECTIVE: Previous studies have shown that cortical-evoked potentials on magnetic stimulation of muscles are influenced by muscle contraction, vibration, and muscle spasm. This study was carried out to determine whether these potentials correlate with palpatory muscle spasm, patient symptoms, and disability in patients with low back pain. METHODS: A prospective observational study was performed on 13 subjects with a history of low back pain visiting an orthopedic hospital-based clinic. Patients were screened for serious pathologic conditions by an orthopedic surgeon. The patients were then evaluated for the presence of muscle spasm by one of the investigators who was blinded to the results of the evoked potential studies. Patients were asked to complete a low back pain visual analogue scale (VAS) and a Roland-Morris Activity Scale (RMAS). Cortical-evoked potentials were recorded with a magnetic stimulator placed over the lumbar paraspinal muscles with the patient in the prone position. The palpatory examination, VAS, RMAS, and the cortical potentials were repeated after 2 weeks of therapy commonly used to reduce muscle spasm. RESULTS: The patients demonstrated a significant decrease in low back pain VAS and RMAS scores after treatment compared with before treatment. There was a reduction in the amount of palpatory muscle spasm in 11 of 13 cases. The cortical potentials before treatment were attenuated compared with previously reported controls and showed a significant increase before and after treatment in the amplitude of these potentials with multivariate analysis of variance. There was significant correlation between the changes in cortical potentials after treatment and the changes noted in paraspinal muscle spasm and VAS and RMAS scores. CONCLUSIONS: This study confirms the previous report that the amplitude of cerebral-evoked potentials on magnetic stimulation of paraspinal muscles is depressed in the presence of palpable muscle spasm. The close correlation among these potentials, paraspinal muscle spasm, and clinical symptoms suggests that the measurement of muscle activity may be more important in the assessment of low back pain than is commonly accepted.

Adult↗
PubMed2001

Recovery pattern of patients treated with chiropractic spinal manipulative therapy for long-lasting or recurrent low back pain.

OBJECTIVE: To investigate the recovery pattern in chiropractic patients being treated for long-lasting or recurrent low back pain; in particular, to identify the minimum number of required treatments and the minimum number of days from the beginning of treatment to the occurrence of improvement. DESIGN: Prospective, uncontrolled multicenter study. SETTING: Private practice. PARTICIPANTS: Each of 19 selected Norwegian chiropractors provided 10 consecutive patients; each of the latter fulfilled a set of criteria (low back pain, a present episode longer than 2 weeks in duration, a total of more than 4 weeks of low back pain in the preceding year, no chiropractic treatment during the preceding 6 months, and suitability for manipulation). Response Rate: Data were collected on 164 patients (86% of the optimal study sample), 6 of whom were excluded. This left 158 patients for the analyses. MAIN OUTCOME MEASURES: Information on low back pain status was collected on each visit (maximum, 12 visits) through use of both a 10-point numeric pain rating scale and a global improvement scale (for the question "Do you feel that you have improved since you began receiving chiropractic treatment?," 5 answers were possible, ranging from "Yes, definite improvement" to "No, I am worse now than when the treatment started"). With respect to the numeric pain rating scale, "improvement" was defined as the point at which the score reached 2 for the first time or, if the initial score was 2, the point at which the score reached 1 for the first time. With respect to the global improvement scale, "improvement" was defined as the point at which the patient first answered "Yes, definite improvement." RESULTS: Approximately 50% of patients reported that they had "improved" at the 4th visit and within 2 weeks. After this time, fewer new cases of "improvement" occurred for every visit or day since the first treatment. At the 12th visit (earlier if treatment was concluded before the 12th visit), approximately 75% of the patients reported that "improvement" had occurred. CONCLUSION: There is a large group of chiropractic patients with relatively long-lasting or recurrent low back pain who report "improvement" early in the course of treatment.

Humans↗
PubMed2001

Stiffness and neuromuscular reflex response of the human spine to posteroanterior manipulative thrusts in patients with low back pain.

BACKGROUND: Studies investigating posteroanterior (PA) forces in spinal stiffness assessment have shown relationships to spinal level, body type, and lumbar extensor muscle activity. Such measures may be important determinants in discriminating between patients who are asymptomatic and those who have low back pain. However, little objective evidence is available concerning variations in PA stiffness and their clinical significance. Moreover, although several studies have assessed only load input in relation to stiffness, a more complete assessment based on dynamic stiffness measurements (force/velocity) and concomitant neuromuscular response may offer more information concerning mechanical properties of the low back. OBJECTIVE: To determine the stiffness and neuromuscular characteristics of the symptomatic low back. STUDY DESIGN: This study is a prospective clinical study investigating the in vivo mechanical and muscular behavior of human lumbar spinal segments to high loading rate PA manipulative thrusts in research subjects with low back pain (LBP). METHODS: Twelve men and 10 women, aged 15 to 73 years (mean age of 42.8 +/- 17.5 years) underwent physical examination and completed outcome assessment instruments, including Visual Analog Scale, Oswestry Low Back Disability Index, and SF-36 health status questionnaires. Clinical categorization was made on the basis of symptom frequency and LBP history. A hand-held spinal manipulation device, equipped with a preload control frame and impedance head, was used to deliver high-rate (<0.1 millisecond) PA manipulative thrusts (190 N) to several common spinal landmarks, including the ilium, sacral base, and L5, L4, L2, T12, and T8 spinous and transverse processes. Surface, linear-enveloped, electromyographic (sEMG) recordings were obtained from electrodes (8 leads) located over the L3 and L5 paraspinal musculature to monitor the bilateral neuromuscular activity of the erector spinae group during the PA thrusts. Maximal-effort isometric trunk extensions were performed by the research subjects before and immediately after the testing protocol to normalize sEMG data. The accelerance or stiffness index (peak acceleration/peak force, kg-1) and composite sEMG neuromuscular reflex response were calculated for each of the thrusts. RESULTS: Posteroanterior stiffness obtained at the sacroiliac joints, transverse processes, or spinous processes was not different for subjects grouped according to LBP chronicity. However, in those with frequent or constant LBP symptoms, there was a significantly increased spinous process (SP) stiffness index (7.0 kg-1) (P <.05) in comparison with SP stiffness index (6.5 kg-1) of subjects with only occasional or no LBP symptoms. Subjects with frequent or constant LBP symptoms also reported significantly greater scores on the visual analog scale (P =.001), Oswestry (P =.001), and perceived health status (P =.03) assessments. The average SP stiffness index was 6.6% greater (P <.05) and 19.1% greater (P <.001) than the average sacroiliac stiffness index and average transverse process stiffness index, respectively. CONCLUSIONS: This study is the first to assess erector spinae neuromuscular reflex responses simultaneously during spinal stiffness examination. This study demonstrated increased spinal stiffness index and positive neuromuscular reflex responses in subjects with frequent or constant LBP as compared with those reporting intermittent or no LBP.

Adolescent↗
PubMed2002

Long-term effectiveness of bone-setting, light exercise therapy, and physiotherapy for prolonged back pain: a randomized controlled trial.

BACKGROUND: Chiropractic manipulation and strenuous exercise therapy have been shown effective in the treatment of nonspecific back pain. Bone-setting, the predecessor of modern manual therapies, still survives in some parts of Finland and was compared with a light exercise therapy and non-manipulative, pragmatic physiotherapy in a year-long randomized controlled trial on patients with long-term back pain. METHODS: One hundred fourteen ambulatory patients of working age with back pain for 7 weeks or more were randomly assigned to the therapies, which were offered in up to 10 sessions during a 6-week treatment period. The outcome was measured by the Oswestry Disability Questionnaire. Sick-leaves and visits to health centers were recorded for 1 year before and after the therapy. RESULTS: The Oswestry disability scores improved most in the bone-setting group (P =.02, Kruskall-Wallis test). Visits to health centers for back pain were reduced only in the physiotherapy group (P =.01, Wilcoxon test). Sick-leaves were not significantly different between groups. A secondary analysis based on the use of additional therapies after the intervention showed a possible subgroup with an enhanced effect from bone-setting. CONCLUSIONS: Traditional bone-setting seemed more effective than exercise or physiotherapy on back pain and disability, even 1 year after therapy.

Adult↗
PubMed1989

A preliminary comparison of front and back squat exercises.

The purpose of this study was to compare the knee extensor demands and low back injury risks of the front and back squat exercises. Highly strength-trained college-aged males (n = 8), who performed each type of squat (Load = 75% of front squat one repetition maximum), were filmed (50 fps) from the sagittal view. The body was modeled as a five link system. Film data were digitized and reduced through Newtonian mechanics to obtain joint forces and muscle moments. Mean and individual subject data results were examined. The maximum knee extensor moment comparison indicated similar knee extensor demands, so either squat exercise could be used to develop knee extensor strength. Both exercises had similar low back injury risks for four subjects, but sizable maximum trunk extensor moment and maximum lumbar compressive and shear force differences existed between the squat types for the other subjects. The latter data revealed that with the influence of trunk inclination either exercise had the greatest low back injury risk (i.e., with greater trunk inclination: greater trunk extensor demands and lumbar shear forces, but smaller lumbar compressive forces). For these four subjects low back injury risk was influenced more by trunk inclination than squat exercise type.

Adult↗
PubMed2004

Low back pain: diagnosis, treatment, and prognosis.

Low back pain seems to be an integral part of most human lives and cause different degrees of suffering and disability. The exact cause of the pain cannot be identified in most instances. The making of the diagnosis rests mainly on the patient's history, location, and duration of the pain. Different diagnostic tests have not been proven to add much information and even advanced imaging seems not to be able to identify where the pain comes from in the majority of cases. In establishing a working relationship between the patient and the health care provider the physical examination may be valuable. If the specific cause for the pain cannot be found, there cannot be any specific treatment applied. The multitude of different treatments offered to patients must be regarded as pain modulating modalities and not as cures for low back pain. There is no treatment that has been proven to be highly effective. The natural history of low back pain seems in general to be favourable, but of concern is the consequence of long term or permanent disability. Fear avoidance behaviour has been shown to be part of the disabling pathway in chronic low back pain. Cognitive interventions, designed to remove fear and uncertainty, and to give the patient the confidence that the back is robust even if it hurts, seem promising.

Diagnosis, Differential↗
PubMed1999

Reproducibility of a survey questionnaire for the investigation of low back problems in adolescents.

A test-retest design was used to investigate the reproducibility of the results obtained using a survey questionnaire for low back problems in adolescents. A 1-wk interval between test and retest was chosen. Participants were recruited from four schools. Selection of schools was based on geographic location, size of the school and educational level. Sixty-seven adolescents (mean age = 16.62 y; SD = 0.57; range = 16-18) suffering from low back problems agreed to participate. A questionnaire on perceived characteristics of back problems and functional limitations was designed. Item completion rate and the reproducibility of results were investigated by means of percentage agreement and (weighted) kappa. High levels of reproducibility were found for items that evaluated perceived characteristics of back problems and functional limitations (Kw = 0.70-0.93). Results suggest that the questionnaire used in the present study provided reproducible information. Detailed information on low back problems in adolescents could be obtained using this questionnaire.

Adolescent↗
PubMed2005

A randomized trial comparing a group exercise programme for back pain patients with individual physiotherapy in a severely deprived area.

PURPOSE: To compare a group exercise programme known as the Back to Fitness programme with individual physiotherapy for patients with non-specific low back pain from a materially deprived area. METHOD: This was a randomized controlled trial including 237 physiotherapy patients with back pain lasting more than six weeks. Participants were allocated to either the Back to Fitness programme or to individual physiotherapy, and followed up at three months and 12 months after randomization. The main outcome measure was the Roland Disability Questionnaire. Secondary measures were: SF12, EQ5D, Pain Self-Efficacy Scale. Health care diaries recording patients' use of health care resources were also collected over a 12-month period. RESULTS: There were no statistically significant differences in change scores between groups on the primary outcome measure at three months (CI - 2.24 to 0.49) and at 12 months (CI - 1.68 to 1.39). Only minor improvements in disability scores were observed in the Back to Fitness group at three months and 12 months respectively (mean change scores; - 0.89, - 0.77) and in the individual physiotherapy arm (mean change scores; - 0.02, - 0.63). Further analysis showed that patients from the most severely deprived areas were marginally worse at three month follow-up whereas those from more affluent areas tended to improve (CI 0.43 to 3.15).

Adult↗
PubMed2004

Effects on sick-leave of a multidisciplinary rehabilitation programme for chronic low back, neck or shoulder pain: comparison with usual treatment.

OBJECTIVE: To test the outcome of active multidisciplinary treatment in an outpatient setting upon sick-leave status among patients with neck, shoulder and low back pain. DESIGN: Multidisciplinary treatment was administered to 121 patients (intervention group) over 4 weeks of structured intervention, followed by 8 weeks of less structured consultations. Effects of treatment were compared with usual treatment (control group: n = 97). PATIENTS: All patients were in the chronic stage of pain (average sick-leave: 6 months) with different diagnoses: neck-shoulder pain, low back pain or low back pain with radiating extremity pain. METHOD: The intervention group programme included posture corrections, pain perception, skills to cope with pain, aerobic and fitness-promoting activities and relaxation techniques administered to groups of 8-10 patients. The Local National Insurance Office referred the patients who were diagnosed by general practitioners. A 12-month follow-up by the Local National Insurance Office provided feedback about sick-leave status of all 218 patients. RESULTS: There was a significant treatment difference in proportion taken off the sick list after 12 months (intervention group: 78.5%; control group: 50.5%; p < 0.001). The difference was greater among low back pain (p < 0.001) than among neck-shoulder (p < 0.053) and low back pain with radiating extremity pain (p < 0.031) patients. CONCLUSION: Long-term effects of active multidisciplinary treatment were superior to treatment as usual in all diagnostic groups.

Adult↗
PubMedDate not supplied

The role of rehabilitation in juvenile low back disorders.

Both children and adolescents are frequently affected by low back pain--mainly when they are involved in sporting activities--but they rarely ask for medical help, because their symptoms are often mild and self-resolving. However, in the young patients who seek orthopaedic evaluation, especially in referral centres, there is a high incidence of organic causes of their back pain. Mechanical, developmental, inflammatory and tumoural or tumour-like disorders are the most frequent aetiologic factors. A diagnosis of psychosomatic back pain should be made only when all the other possible organic causes have been excluded. Rehabilitation is part of the treatment of low back disorders in children and adolescents. Postural low back pain is likely to be resolved by physical therapy alone. In other disorders that initially require medical, orthotic or surgical treatment, rehabilitation plays an important role either in combination with them or as a subsequent treatment.

Adolescent↗
PubMedDate not supplied

Short-term efficacy of back injury intervention project for patient care providers at one hospital.

A one-year Back Injury Prevention Program was initiated at a 440-bed acute care hospital in 1996 in response to concerns over high incidence and severity of back injuries among nursing staff and others. The program included an ergonomic evaluation of patient handling, pilot testing and purchase of new equipment, a train-the-trainer program, and training of 374 nurses and other patient handling staff (approximately one-half of the nursing staff). An impact evaluation, measured by comparing self-reported knowledge, work practices, and back pain among a subset of trainees and controls revealed an increase in knowledge of risk factors, a marginal increase in the use of mechanical devices to transfer patients, and a significant decrease in repositioning of patients in bed among trained versus control subjects (p = .017). Over the course of the program, the number of back injuries was 30% below the average of the prior 3 years, with the number of reported injuries in the final quarter (immediately following the training program) approximately one-seventh of the three prior quarters. It is concluded that back injury training may increase knowledge of risk factors and controls and may impact behaviors over which individuals have control (e.g., how often they move patients). However, training effectiveness is limited when engineering controls such as patient transfer devices are unavailable.

Back Injuries↗
PubMed1987

Manual materials handling and the biomechanical basis for prevention of low-back pain in industry--an overview.

Two different but dependent strategies must be developed to prevent low-back pain in industry. One is of an administrative nature and is concerned with whether the worker who performs activities that stress back tissues is appropriately evaluated and trained for such work. The second strategy is of an engineering type, dealing with methods to assure that the workplace and work tasks are specified in ways that minimize injurious stresses to the low back. Both of these strategies rely on knowledge of the biomechanical requirements of a job. These must be carefully evaluated by informed observers using prescribed measurement and analysis procedures. The fundamental biomechanics of heavy lifting and observational procedures developed by an expert panel for NIOSH are described. The procedure rates the difficulty of a lifting task and then recommends whether administrative or engineering controls are warranted to reduce low-back stresses. Some suggestions for preventing excessive low-back stress by redesigning the workplace are presented also.

Back Pain↗
PubMed2005

Predictors of return to work in patients sick listed for sub-acute low back pain: a 12-month follow-up study.

OBJECTIVE: To investigate whether personal and work-related factors, physical performance and back-specific questionnaires predict return to work. A prospective study identifying prognostic factors for return to work. SUBJECTS: Ninety-three patients sick-listed for 8-12 weeks for non-specific sub-acute low back pain included in a randomized controlled trial. METHODS: Patients were examined with regard to demographic variables, a battery of back-specific questionnaires and physical tests before entering a randomized controlled trial. A stepwise backward Cox regression model was established to identify the most powerful predictors. RESULTS: During follow-up 78.5% of the patients have returned to full-time work. Fear-avoidance beliefs for work (relative risk (RR) for 1 SD change 0.49; 95% confidence interval (CI) 0.38-0.64), disability (RR 1.39, 95% CI 1.02-1.88) and cardiovascular fitness (RR 1.42, 95% CI 1.12-1.79) were identified as the best predictors for return to work. The prevalence of correct predictions was 69.3%. CONCLUSION: The predictors identified in the present study may reflect personal risk factors in a patient who gets acute low back pain. On the other hand, they may support that fear of pain and injury may be more disabling than pain itself, and that deconditioning is a result of altered behaviour reflecting attitudes towards low back pain in society, and information and advice given in primary healthcare.

Acute Disease↗
PubMed2006

Functioning description according to the icf model in chronic back pain: disablement appears even more complex with decreasing symptom-specificity.

OBJECTIVE: To determine the significance of degree of symptom-specificity in the disablement condition in chronic back pain. DESIGN: Cross-sectional design. SUBJECTS: All inhabitants of a restricted geographical area of Norway, who had had 8 weeks of sick-leave due to back pain during a 2-year period, were included in this study. Following examination they were diagnosed as having "specific back pain" (n=34), "non-specific back pain" (n=113) or "widespread pain" (n=49). METHODS: Functioning of the 3 diagnostic subgroups was described and compared. Functioning assessment was guided by the concepts of the International Classification of Functioning, Disability and Health (ICF): health condition, body function and structure, activity, participation and contextual factors. RESULTS: Pain components and final participation restriction did not differ among the diagnostic subgroups. However, with increasing symptom-specificity, loss of physical body functions and structures and subsequent activity limitation tended to increase. On the other hand, with decreasing symptom-specificity, mental distress, unfavourable contextual factors and dissatisfaction with various factors of life tend to increase, which may raise the impact of pain on restricting participation in activities. CONCLUSION: Functioning description according to the components of the ICF model indicated that the disablement condition in patients with back pain who had been on sick-leave for 8 weeks may appear more complex with decreasing symptom-specificity.

Adolescent↗
PubMed1999

Pregnancy-related back and pelvic pain and changes in bone density.

OBJECTIVE: To elucidate whether there is an association between pregnancy-related back and pelvic pain and changes in bone density. METHODS: In this prospective cohort study, bone density was measured in the distal and ultra-distal forearm at 12 and 35 weeks of pregnancy and at 5 months post partum. The location and degree of any back or pelvic pain was registered. The patients were classified into four subgroups on the basis of presence or absence of disabling pain in late pregnancy and presence or absence of pain at 5 months' follow-up. Forty-nine women participated. RESULTS: Bone density decreases during pregnancy and lactation. Trabecular bone is mainly lost during pregnancy and cortical bone during lactation. No association between back or pelvic pain during pregnancy and bone loss was found. Between 35 weeks of pregnancy and 5 months post partum, bone loss in all the women was estimated as 1.1% of cortical bone (p < 0.001) and 0.6% of trabecular bone (n.s.). During the same period five women with mild pain during pregnancy and pain at follow-up lost 3.9% of cortical bone (p=0.043) and 5.3% of trabecular bone (p=0.043). Although this bone loss was significant compared to the other subgroups, the small study size does not permit general conclusions to be drawn from this finding. CONCLUSION: The results indicate that bone density decreases during pregnancy and lactation. The decrease in bone density was not associated with back or pelvic pain during pregnancy. It remains unclear whether bone loss is associated with back and pelvic pain during lactation.

Absorptiometry, Photon↗