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PubMed2006

Characterizing the course of low back pain: a latent class analysis.

Understanding the course of back pain is important for clinicians and researchers, but analyses of longitudinal data from multiple time points are lacking. A prospective cohort study of consecutive back pain consulters from five general practices in the United Kingdom was carried out between 2001 and 2003 to identify groups defined by their pain pathways. Patients were sent monthly questionnaires for a year. Longitudinal latent class analysis was performed by using pain intensity scores for 342 consulters. Analysis yielded four clusters representing different pathways of back pain. Cluster 1 ("persistent mild"; n = 122) patients had stable, low levels of pain. Patients in cluster 2 ("recovering"; n = 104) started with mild pain, progressing quickly to no pain. Cluster 3 ("severe chronic"; n = 71) patients had permanently high pain. For patients in cluster 4 ("fluctuating"; n = 45), pain varied between mild and high levels. Distinctive patterns for each cluster were maintained throughout follow-up. Clusters showed statistically significant differences in disability, psychological status, and work absence (p < 0.001). This is the first time, to the authors' knowledge, that latent class analysis has been applied to longitudinal data on back pain patients. Identification of four distinct groups of patients improves understanding of the course of back pain and may provide a basis of classification for intervention.

Adult↗
PubMed2006

Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain.

In a randomized controlled trial plus a nonrandomized cohort, the authors investigated the effectiveness and costs of acupuncture in addition to routine care in the treatment of chronic low back pain and assessed whether the effects of acupuncture differed in randomized and nonrandomized patients. In 2001, German patients with chronic low back pain were allocated to an acupuncture group or a no-acupuncture control group. Persons who did not consent to randomization were included in a nonrandomized acupuncture group. All patients were allowed to receive routine medical care in addition to study treatment. Back function (Hannover Functional Ability Questionnaire), pain, and quality of life were assessed at baseline and after 3 and 6 months, and cost-effectiveness was analyzed. Of 11,630 patients (mean age=52.9 years (standard deviation, 13.7); 59% female), 1,549 were randomized to the acupuncture group and 1,544 to the control group; 8,537 were included in the nonrandomized acupuncture group. At 3 months, back function improved by 12.1 (standard error (SE), 0.4) to 74.5 (SE, 0.4) points in the acupuncture group and by 2.7 (SE, 0.4) to 65.1 (SE, 0.4) points among controls (difference=9.4 points (95% confidence interval 8.3, 10.5); p<0.001). Nonrandomized patients had more severe symptoms at baseline and showed improvements in back function similar to those seen in randomized patients. The incremental cost-effectiveness ratio was euro10,526 (euros) per quality-adjusted life year. Acupuncture plus routine care was associated with marked clinical improvements in these patients and was relatively cost-effective.

Acupuncture↗
PubMed2004

Lysis of adhesions and epidural injection of steroid/local anaesthetic during epiduroscopy potentially alleviate low back and leg pain in elderly patients with lumbar spinal stenosis.

BACKGROUND: Lumbar spinal stenosis causes various forms of back or leg pain, and is recognized with increasing frequency in elderly patients whose physical status is not always suitable for surgery. Epiduroscopy, a new, minimally invasive diagnostic and therapeutic technique, may be useful for pain relief in such patients. We investigated the epiduroscopic findings and immediate and long-term changes in back and leg pain after epiduroscopy in elderly patients with spinal stenosis. METHODS: Patients with degenerative lumbar spinal stenosis (n=58, median age 71 yr) were divided into two groups based on presenting symptoms: a monosegmental group (n=34) and a multisegmental group (n=24). Each patient underwent epiduroscopy, and the findings were evaluated using visual analogue scales for low back and leg symptoms. Epiduroscopy included breaking down adhesions in the epidural space by injections of saline, and injection of steroids/local anaesthetic. RESULTS: Epiduroscopy showed that the amount of fatty tissue and the degree of vascularity were greater in the monosegmental group than in the multisegmental group. Relief of low back pain was observed up to 12 months after epiduroscopy in both groups. Relief of leg pain was evident up to 12 months after epiduroscopy in the monosegmental group, and up to 3 months after epiduroscopy in the multisegmental group. None of the patients showed deterioration of motor or sensory deficits during follow-up. One patient was excluded from analysis because of accidental dural puncture during the procedure. CONCLUSIONS: The findings of epiduroscopy corresponded to the symptoms. Epiduroscopy may reduce low back and leg pain in elderly patients with degenerative lumbar spinal stenosis, particularly those with radiculopathy.

Aged↗
PubMed1999

Guidelines for low back pain: changes in GP management.

BACKGROUND: Management guidelines are aimed at reducing inappropriate practice and improving efficiency; however, the effectiveness of many guidelines has yet to be confirmed. This study targets GPs' management of back pain and its relationship with the recent management guidelines. OBJECTIVES: We aimed to investigate changes in GP management of low back pain, low back pain episode duration and time before consultation, over a 5-year period. METHOD: A case series report of 574 patient notes was collected from a large practice in North Yorkshire (January 1992-March 1997). In addition, 713 referral notes from 26 practices across North Yorkshire were collected. The patients were potential subjects for a larger randomized controlled trial evaluating the effectiveness of an exercise programme. Both groups of data were analysed by identifying trends over time and using log linear regression. RESULTS: Recommendation of activity or exercise was found to be a trend increasing over time. In contrast, recommendation to rest was found to be a trend decreasing over time. Activity or exercise was more frequently recommended to younger patients. There was evidence that individuals are seeking a GP consultation more quickly. CONCLUSIONS: The gap between GP practice and the recent guidelines appears to be reducing. However, many variations in practice still exist. Evidence of decreasing time before consultations may indicate that the level of self-care by low back pain patients is decreasing. Although management guidelines may have some effect, there is some way to go before back pain management is optimized.

Adolescent↗
PubMed1997

Oral contraceptives and back pain in women in a Swedish community.

BACKGROUND: Female back pain is a clinical problem-especially low back pain with symptoms from the pelvic posterior region-that is often aggravated in connection with pregnancy and childbirth. Hormones have been suggested as an aetiologic factor. This study is aimed to determine whether additional hormone preparations, i.e. oral contraceptives (OC), may contribute to the increased frequency of such pain. METHODS: A register study was conducted to investigate the use of drugs and health care use in a female population with known OC consumption. Specifically, we registered the number of primary health care visits for low back pain, comparing OC users with non-OC using age-matched women with otherwise equal circumstances. RESULTS: OC users recorded a significantly higher incidence of low back symptoms during the study period compared to non-users. Pregnancy was not found to be a confounding factor. CONCLUSIONS: The intriguing association between OC use and a higher incidence of low back pain, does not enable us to conclude that there is a causal connection, but it should lead to further studies.

Adolescent↗
PubMed1995

Incidence and risk factors of low-back pain in middle-aged farmers.

A 12-year follow-up study was carried out to evaluate the risk factors for unspecified low-back pain and sciatic pain. Middle-aged farmers who did not report any low-back or neck-shoulder pain during the previous year in a postal questionnaire in 1979 were included in the follow-up study in 1992 (n = 537). In total, 366 (68%) of these farmers were interviewed by telephone. In 1992, the one-year prevalence rates of unspecified low-back pain (13.3%) and sciatic pain (9.6%) were low. Full-time farmers had a significantly higher prevalence of sciatic pain than did part-time or retired farmers. In the logistic regression modelling of sciatic pain in men, the odds ratio was 9.6 (95% CI: 2.7-65.2) for current smokers and 13.1 (95% CI: 1.7-53.0) for ex-smokers as compared to never smokers. Mental stress, body height, body mass index and production factors did not predict unspecified low-back pain or sciatic pain. Farmers who are free of back problems in middle age seem to stay well in the long run despite the heavy work. The close association between smoking and the prevalence of sciatic pain found in men is in line with the hypothesis that smoking is a causal risk factor for lumbar disc disease.

Agriculture↗
PubMed1995

Early intervention for back-injured nurses at a large Canadian tertiary care hospital: an evaluation of the effectiveness and cost benefits of a two-year pilot project.

This study evaluated a two-year multidisciplinary early intervention pilot programme for back-injured nurses employed at a large teaching hospital, using a pre- versus post-programme analysis. The purpose was to ascertain whether this programme could reduce the incidence, morbidity, time lost and cost due to back injuries in the 250 nurses employed on ten targeted high-risk wards. Injuries in the remaining 1395 nurses employed on the other 45 wards were monitored concurrently for comparison. The programme consisted of prompt assessment, treatment and rehabilitation through modified work. Evaluative data were gathered by one research nurse on standardized forms at the time of injury, weekly until return to work, and at a six-month follow-up. Time lost and cost data for up to one-year post-injury were derived from workers' compensation statements. Compared to the two years prior to introduction of the programme, the rates of back injuries and lost-time back injuries decreased by 23% and 43%, respectively, on the targeted wards, while these increased on the control wards. Combined expenditure was 32% lower per injury and 34% lower per lost-time injury for those in the targeted group who consented to take part in the programme compared to their counterparts on the control wards, as the increased assessment and treatment costs per case attributable to the programme were more than offset by the savings in lower compensation (wage loss) costs. This programme thus reduced the incidence and time lost due to back injuries and was cost-beneficial.

Back Injuries↗
PubMed1999

Cross-sectional associations of asthma, hay fever, and other allergies with major depression and low-back pain among adults aged 20-39 years in the United States.

Although low-back pain and depression are common comorbidities, the mechanisms responsible for their association remain unclear. The effects of proinflammatory cytokines on the hypothalamic-pituitary-adrenal (HPA) axis lead to the hypothesis that allergic reactions, as markers for inflammation-associated activation of the HPA axis, result in aberrant responses to subsequent stressors. Data from 6,836 US adults 20-39 years old from the Third National Health and Nutrition Examination Survey (1988-1994) were used. Subjects responded to questions regarding low-back pain in the past 12 months and history of asthma, hay fever, and other allergies. The history and onset of major depression were obtained from the Diagnostic Interview Schedule. Logistic regression modeling was used to estimate the associations between allergies and depression and low-back pain. Subjects with a history of any allergy were more likely to report low-back pain (odds ratio = 1.51; 95% confidence interval: 1.16, 1.96), to be diagnosed with major depression (odds ratio = 1.58; 95% confidence interval: 1.13, 2.21), and much more likely to have both major depression and low-back pain (odds ratio = 3.03; 95% confidence interval: 1.32, 6.92). Hypersensitivity reactions may prime the HPA axis to respond aberrantly to stressors, resulting in physical and behavioral consequences.

Adult↗
PubMed1991

Effects of an exercise program on sick leave due to back pain.

The purposes of this study were to evaluate the effect of a weekly exercise program on short-term sick leave (less than 50 days) attributable to back pain and to determine whether changes in absenteeism were related to changes in cardiovascular fitness. Subjects were randomly assigned to an exercise group (n = 58) and a control group (n = 53). Sick leave attributable to back pain was determined in the intervention period of 1 1/2 years and a comparable 1 1/2-year period prior to the study. In the exercise group, the number of episodes of back pain and the number of sick-leave days attributable to back pain in the intervention period decreased by over 50%. Absenteeism attributable to back pain increased in the control group. The decrease in sick leave in the exercise group was not accompanied by any change in cardiovascular fitness. Suggestions for establishing exercise programs are given.

Absenteeism↗
PubMed1994

Managing low back pain: attitudes and treatment preferences of physical therapists.

BACKGROUND AND PURPOSE: We surveyed physical therapists about their attitudes, beliefs, and treatment preferences in caring for patients with different types of low back pain problems. SUBJECTS AND METHODS: Questionnaires were mailed to all 71 therapists employed by a large health maintenance organization in western Washington and to a random sample of 331 other therapists licensed in the state of Washington. RESULTS: Responses were received from 293 (74%) of the therapists surveyed, and 186 of these claimed to be practicing in settings in which they treat patients who have back pain. Back pain was estimated to account for 45% of patient visits. The McKenzie method was deemed the most useful approach for managing patients with back pain, and education in body mechanics, stretching, strengthening exercises, and aerobic exercises were among the most common treatment preferences. There were significant variations among therapists in private practice, hospital-operated, and health maintenance organization settings with respect to treatment preferences, willingness to take advantage of the placebo effect, and mean number of visits for patients with back pain. CONCLUSIONS AND DISCUSSION: These variations emphasize the need for more outcomes research to identify the most effective treatment approaches and to guide clinical practice.

Adult↗
PubMed1996

Physician referral to physical therapy in a cohort of workers compensated for low back pain.

BACKGROUND AND PURPOSE: This study described the physical therapy referral of workers compensated for back injury; characterized physical therapy by duration and choice of therapeutic techniques; and compared workers who were and were not referred for physical therapy in terms of age, gender, diagnosis, and absence from work. SUBJECT: A cohort of 2,147 subjects were randomly selected from 54,401 workers compensated for back injuries in 1988. METHODS: Each subject was followed for 2 years from date of entry into the study. Data were obtained from the Quebec Worker's Compensation Board computerized files, medical files, and initial reports completed by physical therapists. RESULTS: Of the cohort, 389 subjects (18%) had received physical therapy after referral by their physician. Exercise, heat, ultrasound, back education, manipulation, and transcutaneous electrical nerve stimulation were the most frequently selected treatments. Implementation of physical therapy within 1 month of back injury had a strong protective effect on return to work within 60 days. Female gender and presence of a specific diagnosis were predictors for greater than 60 days' absence. CONCLUSION AND DISCUSSION: This study demonstrated that physicians request physical therapy services based on certain patient characteristics. Patients who were referred earlier tended to return to work sooner than those who were referred later, which indicates that timing of physical therapy is an important factor in the rehabilitation of workers with low back pain.

Absenteeism↗
PubMed2002

A comparison of five low back disability questionnaires: reliability and responsiveness.

BACKGROUND AND PURPOSE: The aim of this study was to examine 5 commonly used questionnaires for assessing disability in people with low back pain. The modified Oswestry Disability Questionnaire, the Quebec Back Pain Disability Scale, the Roland-Morris Disability Questionnaire, the Waddell Disability Index, and the physical health scales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) were compared in patients undergoing physical therapy for low back pain. SUBJECTS AND METHODS: Patients with low back pain completed the questionnaires during initial consultation with a physical therapist and again 6 weeks later (n=106). Test-retest reliability was examined for a group of 47 subjects who were classified as "unchanged" and a subgroup of 16 subjects who were self-rated as "about the same." Responsiveness was compared using standardized response means, receiver operating characteristic curves, and the proportions of subjects who changed by at least as much as the minimum detectable change (MDC) (90% confidence interval [CI] of the standard error for repeated measures). Scale width was judged as adequate if no more than 15% of the subjects had initial scores at the upper or lower end of the scale that were insufficient to allow change to be reliably detected. RESULTS: Intraclass correlation coefficients (2,1) calculated to measure reliability for the subjects who were classified as "unchanged" and those who were self-rated as "about the same" were greater than.80 for the Oswestry and Quebec questionnaires and the SF-36 Physical Functioning scale and less than.80 for the Waddell and Roland-Morris questionnaires and the SF-36 Role Limitations-Physical and Bodily Pain scales. None of the scales were more responsive than any other. DISCUSSION AND CONCLUSION: Measurements obtained with the modified Oswestry Disability Questionnaire, the SF-36 Physical Functioning scale, and the Quebec Back Pain Disability Scale were the most reliable and had sufficient width scale to reliably detect improvement or worsening in most subjects. The reliability of measurements obtained with the Waddell Disability Index was moderate, but the scale appeared to be insufficient to recommend it for clinical application. The Roland-Morris Disability Questionnaire and the Role Limitations-Physical and Bodily Pain scales of the SF-36 appeared to lack sufficient reliability and scale width for clinical application.

Adult↗
PubMed1989

Diffuse idiopathic skeletal hyperostosis (DISH) of the spine: a cause of back pain? A controlled study.

This is the first controlled study of the frequency of back pain in a European caucasian population with diffuse idiopathic skeletal hyperostosis (DISH). Elderly patients admitted to hospital for reasons other than back pain were assessed for the presence of spinal DISH using the routine lateral chest radiograph films. A total of 106 probands (82 males, 24 females) with a mean age of 70 years fulfilled the criteria for DISH as defined previously. One hundred and seventy-eight patients (117 males, 61 females) not meeting these criteria were used as controls. The prevalence of back pain was assessed by a blinded interviewer using a structured questionnaire. Our primary hypothesis was that spinal DISH positive probands had not had back pain more often than controls. This controlled study showed no statistically significant difference in pain frequency between spinal DISH positive probands and controls at any spinal level. We conclude that back pain does not occur more often in radiographically defined DISH positive probands than in controls. The radiological finding of spinal DISH, as far as it does not lead to stenosis of the spinal canal or dysphagia, thus seems to be a finding without clinical relevance.

Aged↗
PubMed1990

The influence of prophylactic orthoses on abdominal strength and low back injury in the workplace.

This study was designed to determine the effect of multimodal intervention and the prevention of back injury, and to evaluate the adverse side effects of using a lumbosacral corset in the workplace. Subjects were 90 male warehouse workers randomly selected from over 800 employees at a grocery distribution center. Subjects were assigned to three groups: true controls, no back school, no brace orthoses; back school only; and back school plus wearing a custom molded lumbosacral orthosis. Comparisons of pre-testing and 6-month follow-up post-testing for abdominal strength, cognitive data, work injury incidence and productivity and use of health care services were evaluated. Controls and training-only group showed no changes in strength productivity or lost time. Orthoses and training-group showed no changes in strength productivity or accident rate; however, they showed substantially less lost time. This study supports the concept of using education and prophylactic bracing to prevent back injury and reduce time loss. It appears that the use of intermittent prophylactic bracing has no adverse affects on abdominal muscle strength and may contribute to decreased lost time from work injuries.

Abdomen↗
PubMed2002

Back pain, physical function, and estimates of aerobic capacity: what are the relationships among methods and measures?

OBJECTIVES: To establish the correlations of measures of self-reported disability, self-efficacy, physical performance, level of pain, and estimates of aerobic capacity (PvO2 ) in subjects with low back pain. DESIGN: Fifty-one low back pain subjects, ranging in age from 26 to 65 yr, entered the study. Participants completed the Roland-Morris Disability Questionnaire and the self-efficacy questionnaire. Physical performance was evaluated by the loaded-reach test, sit/stand test, 5-min walk test, 50-foot walking test, and time to roll from right to left. Pain intensity and pain affect were measured using two visual analog scales. PvO2 was predicted from an equation. RESULTS: The correlation coefficient among the physical performance outcomes ranged from 0.47 to 0.78. Pain measures had low correlations with measures of function but stronger correlations with other self-report measures. The disability measure correlated moderately with physical performance. Correlations between PvO2 and all other measurements were minimal, except for the 5-min walk test. CONCLUSION: Performance and disability were more consistent in evaluating low back pain. PvO2 failed to correlate with most other aspects of low back pain. This study suggests that aerobic capacity might not be a primary concern for patients with low back pain.

Adult↗
PubMed1993

Multivariate cluster analysis of the MMPI-2 in chronic low-back pain patients.

OBJECTIVE: The purpose of our study was to investigate whether Minnesota Multiphasic Personality Inventory-2 cluster solutions of chronic low-back pain patients would replicate those found in previous research with the Minnesota Multiphasic Personality Inventory. SETTING: A multidisciplinary pain clinic in the southeastern United States. PATIENTS: The subjects were 201 chronic low-back pain patients who had suffered a work-related back injury. OUTCOME MEASURES: The Minnesota Multiphasic Personality Inventory-2. RESULTS: We found four relatively homogeneous subgroups of chronic low-back pain patients that were similar to those identified by previous researchers using data collected with the Minnesota Multiphasic Personality Inventory. CONCLUSION: These findings indicate that interpretations of the Minnesota Multiphasic Personality Inventory-2 should parallel those of the Minnesota Multiphasic Personality Inventory for chronic low-back pain patients. They further suggest that the results of Minnesota Multiphasic Personality Inventory-based studies are also applicable to Minnesota Multiphasic Personality Inventory-2.

Adult↗
PubMed1995

Health care providers' attitudes and beliefs about functional impairments and chronic back pain.

OBJECTIVE: This study validated a measure entitled the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) for assessing the attitudes and beliefs of health care providers about functional expectation for chronic low back pain patients. HC-PAIRS was developed by modifying the Pain and Impairment Relationship Scale (PAIRS) used to assess the attitudes and beliefs of chronic pain patients. DESIGN: This study surveyed 150 community health care providers and 66 functional restoration providers using HC-PAIRS. HC-PAIRS consists of 15 items attributing back pain patients' impairment and disability to pain, followed by a seven-point Likert scale anchored with degrees of agreement and disagreement. Reliability of HC-PAIRS was determined using Cronbach's alpha. Factor analysis was performed to explore the dimensions of attitudes and beliefs. Validity was determined by HC-PAIRS accurately measuring the pain attitudes and beliefs of functional restoration providers, who have a stated philosophy concerning this notion. RESULTS: For the 150 community health care providers, HC-PAIRS revealed a Cronbach's alpha of 0.78. Factor analysis showed four dimensions of attitudes and beliefs measures by HC-PAIRS, which were entitled "functional expectations," "social expectations," "need for cure," and "projected cognition." Community providers showed a mean score of 52 (S.D. = 10). Most respondents were neutral or disagreed somewhat with the notion that chronic back pain should limit functional performance, but a wide range of responses were noted (range 33-80), indicating that diverse pain attitudes and beliefs are held. The 66 functional restoration providers had a mean HC-PAIRS score of 38 (S.D. = 7), and a range of scores from 26 to 52 was found. As expected, these scores corresponded to disagreement with the notion that chronic low back pain justifies impairments and disability. This was accurately measured by HC-PAIRS and is evidence of HC-PAIRS validity. Comparison of HC-PAIRS between community and functional restoration providers revealed a significantly lower score for function restoration providers (t = 12.14, p < 0.000). CONCLUSION: These results suggested that HC-PAIRS can be used to measure health care providers' attitudes and beliefs about the degree to which chronic low back pain justifies impairments and disability. HC-PAIRS may be useful to health care providers interested in examining this notion.

Attitude of Health Personnel↗
PubMed1998

Comparison of the effects of perceived self-efficacy on coping with chronic cancer pain and coping with chronic low back pain.

OBJECTIVE: The purposes of this study were to explore the differences between chronic cancer pain and chronic low back pain with respect to (a) the use of coping strategies to manage pain and (b) the relationship between self-efficacy for attenuating pain and pain outcomes. DESIGN: Descriptive correlational design. PATIENTS: Eighty-five patients experiencing chronic low back pain (n = 85) and 88 patients with chronic cancer pain (n = 88) were recruited for this study. OUTCOME MEASURES: Modified Coping Strategies Questionnaire, self-efficacy expectancies, and the Brief Pain Inventory. RESULTS AND CONCLUSIONS: The major findings of this study were that (a) patients with chronic cancer pain reported significantly lower pain intensity and pain interference than did patients with chronic low back pain; (b) the most frequently used coping strategies were almost the same between the low back pain group and the cancer pain group; (c) for both chronic cancer pain and chronic low back pain groups, patients' perceived self-efficacy was significantly inversely correlated with pain intensity and pain interference with daily life; and (d) patients' use of coping strategies was positively correlated with pain intensity and pain interference with daily life. These findings were discussed in terms of implications for clinical practice and future research.

Activities of Daily Living↗