The rising prevalence of chronic low back pain

Cost-effectiveness of minimal interventional procedures for chronic mechanical low back pain: design of four randomised controlled trials with an economic evaluation

BACKGROUND

Minimal interventional procedures are frequently applied in patients with mechanical low back pain which is defined as pain presumably resulting from single sources: facet, disc, sacroiliac joint or a combination of these. Usually, these minimal interventional procedures are an integral part of a multidisciplinary pain programme. A recent systematic review issued by the Dutch Health Insurance Council showed that the effectiveness of these procedures for the total group of patients with chronic low back pain is yet unclear and cost-effectiveness unknown. The aim of the study is to evaluate whether a multidisciplinary pain programme with minimal interventional procedures is cost-effective compared to the multidisciplinary pain programme alone for patients with chronic mechanical low back pain who did not respond to conservative primary care and were referred to a pain clinic.

METHODS

All patients with chronic low back pain who are referred to one of the 13 participating pain clinics will be asked to participate in an observational study. Patients with a suspected diagnosis of facet, disc or sacroiliac joint problems will receive a diagnostic block to confirm this diagnosis. If confirmed, they will be asked to participate in a randomized controlled trial (RCT). For each single source a separate RCT will be conducted. Patients with a combination of facet, disc or sacroiliac joint problems will be invited for participation in a RCT as well. An economic evaluation from a societal perspective will be performed alongside these four RCTs. Patients will complete questionnaires at baseline, 3 and 6 weeks, 3, 6, 9 and 12 months after start of the treatment. Costs will be collected using self-completed cost questionnaires.

DISCUSSION

No trials are yet available which have evaluated the cost-effectiveness of minimal interventional procedures in patients with chronic mechanical low back pain, which emphasizes the importance of this study.

TRIAL REGISTRATION NUMBER

National Trial Register: NTR3531.

The role of fluoroscopic interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: a randomized, double-blind trial

BACKGROUND

There is continued debate on the effectiveness, indications, and medical necessity of epidural injections in managing pain and disability from lumbar disc herniation, despite extensive utilization. There is paucity of literature on interlaminar epidural injections in managing lumbar disc herniation or radiculitis in contemporary interventional pain management settings utilizing fluoroscopy.

METHODS

A randomized, double-blind, active-control trial was undertaken to assess the effectiveness of lumbar interlaminar epidural injections with or without steroids for disc herniation and radiculitis. The primary outcome was defined as pain relief and functional status improvement of ≥ 50%. One hundred twenty patients were randomly assigned to 1 of the 2 groups. Group I patients received lumbar interlaminar injections containing a local anesthetic (lidocaine 0.5%, 6 mL), whereas Group II patients received lumbar interlaminar epidural injections of 0.5% lidocaine, 5 mL, mixed with 1 mL of non-particulate betamethasone.

RESULTS

In the patients who responded with initial 2 procedures with at least 3 weeks of relief, significant improvement was seen in 80% of the patients in the local anesthetic group and 86% of the patients in the local anesthetic and steroid group. The overall average procedures per year were 3.6 in the local anesthetic group and 4.1 in the local anesthetic and steroid group, with an average relief of 33.7 ± 18.1 weeks in the local anesthetic group and 39.1 ± 12.2 weeks in the local anesthetic and steroid group over a period of 52 weeks in the overall population.

CONCLUSIONS

Lumbar interlaminar epidural injections of local anesthetic with or without steroids might be effective in patients with disc herniation or radiculitis, with potential superiority of steroids compared with local anesthetic alone at 1 year follow-up.

Exercise therapy for chronic low back pain: protocol for an individual participant data meta-analysis

BACKGROUND

Low back pain (LBP) is one of the leading causes of disability and has a major socioeconomic impact. Despite a large amount of research in the field, there remains uncertainty about the best treatment approach for chronic LBP, and identification of relevant patient subgroups is an important goal. Exercise therapy is a commonly used strategy to treat chronic low back pain and is one of several interventions that evidence suggests is moderately effective.In parallel with an update of the 2005 Cochrane review, we will undertake an individual participant data (IPD) meta-analysis, which will allow us to standardize analyses across studies and directly derive results, and to examine differential treatment effects across individuals to estimate how patients' characteristics modify treatment benefit.

METHODS/DESIGN

We will use standard systematic review methods advocated by the Cochrane Collaboration to identify relevant trials. We will include trials evaluating exercise therapy compared to any or no other interventions in adult non-specific chronic LBP. Our primary outcomes of interest include pain, functional status, and return-to-work/absenteeism. We will assess potential risk of bias for each study meeting selection criteria, using criteria and methods recommended by the Cochrane BRG.The original individual participant data will be requested from the authors of selected trials having moderate to low risk of bias. We will test original data and compile a master dataset with information about each trial mapped on a pre-specified framework, including reported characteristics of the study sample, exercise therapy characteristics, individual patient characteristics at baseline and all follow-up periods, subgroup and treatment effect modifiers investigated. Our analyses will include descriptive, study-level meta-analysis and meta-regression analyses of the overall treatment effect, and individual-level IPD meta-analyses of treatment effect modification. IPD meta-analyses will be conducted using a one-step approach where the IPD from all studies are modeled simultaneously while accounting for the clustering of participants with studies.

DISCUSSION

We will analyze IPD across a large number of LBP trials. The resulting larger sample size and consistent presentation of data will allow additional analyses to explore patient-level heterogeneity in treatment outcomes and prognosis of chronic LBP.

Multivariate classification of structural MRI data detects chronic low back pain

Chronic low back pain (cLBP) has a tremendous personal and socioeconomic impact, yet the underlying pathology remains a mystery in the majority of cases. An objective measure of this condition, that augments self-report of pain, could have profound implications for diagnostic characterization and therapeutic development. Contemporary research indicates that cLBP is associated with abnormal brain structure and function. Multivariate analyses have shown potential to detect a number of neurological diseases based on structural neuroimaging. Therefore, we aimed to empirically evaluate such an approach in the detection of cLBP, with a goal to also explore the relevant neuroanatomy. We extracted brain gray matter (GM) density from magnetic resonance imaging scans of 47 patients with cLBP and 47 healthy controls. cLBP was classified with an accuracy of 76% by support vector machine analysis. Primary drivers of the classification included areas of the somatosensory, motor, and prefrontal cortices--all areas implicated in the pain experience. Differences in areas of the temporal lobe, including bordering the amygdala, medial orbital gyrus, cerebellum, and visual cortex, were also useful for the classification. Our findings suggest that cLBP is characterized by a pattern of GM changes that can have discriminative power and reflect relevant pathological brain morphology.

Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs

STUDY DESIGN

A retrospective cohort.

OBJECTIVE

To describe physical therapy utilization following primary care consultation for low back pain (LBP) and evaluate associations between the timing and content of physical therapy and subsequent health care utilization and costs.

SUMMARY OF BACKGROUND DATA

Primary care management of LBP is highly variable and the implications for subsequent costs are not well understood. The importance of referring patients from primary care to physical therapy has been debated, and information on how the timing and content of physical therapy impact subsequent costs and utilization is needed.

METHODS

Data were extracted from a national database of employer-sponsored health plans. A total of 32,070 patients with a new primary care LBP consultation were identified and categorized on the basis of the use of physical therapy within 90 days. Patients utilizing physical therapy were further categorized based on timing (early [within 14 d] or delayed)] and content (guideline adherent or nonadherent). LBP-related health care costs and utilization in the 18-months following primary care consultation were examined.

RESULTS

Physical therapy utilization was 7.0% with significant geographic variability. Early physical therapy timing was associated with decreased risk of advanced imaging (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21, 0.32), surgery (OR = 0.45, 95% CI: 0.32, 0.64), injections (OR = 0.42, 95% CI: 0.32, 0.64), and opioid medications (OR = 0.78, 95% CI: 0.66, 0.93) compared with delayed physical therapy. Total medical costs for LBP were $2736.23 lower (95% CI: 1810.67, 3661.78) for patients receiving early physical therapy. Physical therapy content showed weaker associations with subsequent care.

CONCLUSION

Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. Further research is needed to clarify exactly which patients with LBP should be referred to physical therapy; however, if referral is to be made, delaying the initiation of physical therapy may increase risk for additional health care consumption and costs.

A randomized, placebo-controlled study of the impact of the 7-day buprenorphine transdermal system on health-related quality of life in opioid-naïve patients with moderate-to-severe chronic low back pain

This study evaluated the impact of treatment with Buprenorphine Transdermal System (BTDS) on the health-related quality of life for patients with moderate-to-severe chronic low back pain (CLBP), and the correspondence between quality of life and pain. A multicenter, enriched, double-blind (DB), placebo-controlled, randomized trial evaluated BTDS 10 and 20 μg/hour for treatment of opioid-naïve patients with moderate-to-severe CLBP. The SF-36v2 survey, which measures 8 domains of quality of life, was administered at screening and following an open-label run-in period with BTDS and at weeks 4, 8, and 12 of the DB phase. Post hoc analyses compared SF-36v2 scores between BTDS and placebo groups during the DB phase. Condition burden was examined through comparisons with a U.S. general population sample. Correlations examined the correspondence between quality of life and pain measures. BTDS produced larger improvements than placebo at 12 weeks in all quality-of-life domains (Ps < .05). Treatment group differences in both physical and mental quality of life emerged by 4 weeks. Patients' pretreatment quality of life was worse than that in the general population (Ps < .05); only BTDS treatment eliminated deficits in pain, social functioning, and role limitations due to emotional health. Improvements in quality of life were moderately associated with pain reduction. These data suggest that moderate-to-severe CLBP patients receiving BTDS exhibited better quality of life than patients receiving placebo.

PERSPECTIVE

This post hoc analysis suggests that patients with moderate-to-severe CLBP treated with BTDS exhibit better health-related quality of life than those using placebo within 4 weeks of treatment, and were more likely to exhibit clinically meaningful improvements in quality of life following 12 weeks of treatment.

Medical complications, clinical findings, and educational outcomes in adults with Noonan syndrome

Noonan syndrome (NS) is a heterogeneous developmental disorder caused by missense mutations in genes involved in the Ras/MAPK signaling pathway, a major mediator of early and late developmental processes. The diagnosis of NS is made on clinical grounds with molecular confirmation of a mutation found in 63% of cases. Key clinical features include short stature, cardiac defects, developmental delay, lymphatic dysplasias, bleeding tendency, and a constellation of distinctive facial features and physical exam findings. The prevalence of medical issues or the development of new ones in adults with NS is not well-studied. This cross-sectional study reports on the prevalence of clinical conditions and their ages of onset in a cohort of 35 adolescents and adults with NS aged 16-68 years old (mean age 28 years). In this cohort, 34 of 35 subjects (97%) had had full PTPN11 sequencing; 37% were PTPN11 positive, 23% were SOS1 positive, and 3% were BRAF positive. Mean adult height in both men and women was at the 3rd-10th centile. The most prevalent clinical findings in this cohort included pulmonary valve stenosis (71%), easy bruising (63%), GERD (60%), constipation (51%), scoliosis (54%), chronic joint pain (54%), lymphedema (49%), depression (49%), anxiety (49%), Chiari malformation (20%), and osteopenia/osteoporosis (14%). In summary, adults with NS are affected by multi-organ morbidity and require special medical management aimed towards the most prevalent and serious known medical complications. Larger studies characterizing the clinical conditions found in NS adults are needed to provide potential genotype-phenotype correlations that may aid in clinical management.

Heterogeneity of chronic pain

Chronic pain is a widespread public health issue that has many effects on physical, emotional and cognitive functions. An estimated 10-55% of all adults are thought to have chronic pain. Chronic pain is a multifactorial condition, caused by the complex interplay of nociceptive, neuropathic or mixed pathogenic mechanisms. Chronic pain is associated with specific and non-specific medical conditions such as cancer, HIV/AIDS, rheumatoid arthritis, fibromyalgia, osteoarthritis, low back pain or spinal stenosis and is broadly categorized as cancer pain and non-cancer pain. Evaluation of chronic pain requires a clear understanding of the nature of the pain and its underlying pathophysiology. Adequate assessment of pain, using validated tools, is an essential prerequisite of successful pain management. Unidimensional scales are useful for the measurement of pain intensity, while multidimensional scales measure both pain intensity and the extent to which pain interferes with life activity and emotional functioning. Patients should be reassessed and followed up in order to monitor progress and measure improvements in pain.

A review of pharmacotherapy for chronic low back pain with considerations for sports medicine

Up to 30% of athletes experience low back pain (LBP) depending on sport type, sex, training intensity and frequency, and technique. United States clinical guidelines define back pain as chronic if it persists for ≥ 12 weeks, and subacute if it persists 4 to < 12 weeks. Certain sports injuries are likely to lead to chronic pain. Persistent or chronic symptoms are frequently associated with degenerative lumbar disc disease or spondylolytic stress lesions. Exercise therapy is widely used and is the most conservative form of treatment for chronic LBP (cLBP). Pharmacotherapies for cLBP include acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids. Acetaminophen is a well-tolerated first-line pharmacotherapy, but high-dose, long-term use is associated with hepatic toxicity. Nonsteroidal anti-inflammatory drugs can be an effective second-line option if acetaminophen proves inadequate but they have well-known risks of gastrointestinal, cardiovascular, and other systemic adverse effects that increase with patient age, dose amount, and duration of use. The serotonin-norepinephrine reuptake inhibitor, duloxetine, has demonstrated modest efficacy and is associated with systematic adverse events, including serotonin syndrome, which can be dose related or result from interaction with other analgesics. Opioids may be an effective choice for moderate to severe pain but also have significant risks of adverse events and carry a substantial risk of addiction and abuse. Because the course of cLBP may be protracted, patients may require treatment over years or decades, and it is critical that the risk/benefit profiles of pharmacotherapies are closely evaluated to ensure that short- and long-term treatments are optimized for each patient. This article reviews the clinical evidence and the guideline recommendations for pharmacotherapy of cLBP.

Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain

Purpose

The aim of this study is to provide a narrative review of the current state of knowledge of the role of cognitive behavioral therapy (CBT) in the management of chronic nonspecific back pain.

Methods

A literature search on all studies published up until July 2012 (PubMed and PsycINFO) was performed. The search string consisted of 4 steps: cognitive behavioral therapy/treatment/management/modification/intervention, chronic, back pain (MeSH term) or low back pain (MeSH term), and randomized controlled trial (MeSH term). The conclusions are based on the results from randomized controlled trials (RCTs) and reviews of RCTs. Interventions were not required to be pure CBT interventions, but were required to include both cognitive and behavioral components.

Results

The search yielded 108 studies, with 46 included in the analysis. Eligible intervention studies were categorized as CBT compared to wait-list controls/treatment as usual, physical treatments/exercise, information/education, biofeedback, operant behavioral treatment, lumbar spinal fusion surgery, and relaxation training. The results showed that CBT is a beneficial treatment for chronic back pain on a wide range of relevant variables, especially when compared to wait-list controls/treatment as usual. With regards to the other comparison treatments, results were mixed and inconclusive.

Conclusion

The results of this review suggest that CBT is a beneficial treatment for chronic nonspecific back pain, leading to improvements in a wide range of relevant cognitive, behavioral and physical variables. This is especially evident when CBT is compared to treatment as usual or wait-list controls, but mixed and inconclusive when compared with various other treatments. Multidisciplinary and transdisciplinary interventions that integrate CBT with other approaches may represent the future direction of management of chronic back pain, with treatments modified for specific circumstances and stakeholders. There is a need for future intervention studies to be specific in their use of cognitive behavioral elements, in order for results to be comparable.

Spine osteoarthritis

Osteoarthritis of the spine develops as a consequence of the natural aging process and is associated with significant morbidity and health care expenditures. Effective diagnosis and treatment of the resultant pathologic conditions can be clinically challenging. Recent evidence has emerged to aid the investigating clinician in formulating an accurate diagnosis and in implementing a successful treatment algorithm. This article details the degenerative cascade that results in the osteoarthritic spine, reviews prevalence data for common painful spinal disorders, and discusses evidence-based treatment options for management of zygapophysial and sacroiliac joint arthrosis.

Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series

STUDY DESIGN

A case series of consecutive patients with chronic low back pain.

BACKGROUND AND PURPOSE

In patients with chronic low back pain (CLBP), the importance of impairments at the hip joints is unclear. However, it has been postulated that impairments at the hip joints may contribute to CLBP. The purpose of this case series was to investigate the short-term outcomes in patients with CLBP managed with impairment-based manual therapy and exercise directed at the hip joints.

METHODS

EIGHT CONSECUTIVE PATIENTS (MEAN AGE: 43·9 years) with a primary report of CLBP (>6 months) without radiculopathy were treated with a standardized approach of manual physical therapy and exercise directed at bilateral hip impairments for a total of three sessions over approximately 1 week. At initial examination, all patients completed a numeric rating pain scale (NPRS), Oswestry disability index (ODI), fear-avoidance beliefs questionnaire (FABQ), and patient-specific functional scale (PSFS). At the second and third treatment sessions, each patient completed all outcome measures as well as the Global Rating of Change (GROC).

RESULTS

Five of the eight (62·5%) patients reported 'moderately better' or higher (>+4) on the GROC at the third session, indicating a moderate improvement in self-reported symptoms. These five individuals also experienced a 24·4% reduction in ODI scores.

DISCUSSION

This case series suggests that an impairment-based approach directed at the hip joints may lead to improvements in pain, function, and disability in patients with CLBP. A neurophysiologic mechanism may be a plausible explanation regarding the clinical outcomes of this study. A larger, well-controlled trial is needed to determine the potential effectiveness of this approach with patients with CLBP.

Cost effectiveness of epidural steroid injections to manage chronic lower back pain

BACKGROUND

The efficacy of epidural steroid injections in the management of chronic low back pain is disputed, yet the technique remains popular amongst physicians and patients alike. This study assesses the cost effectiveness of injections administered in a routine outpatient setting in England.

METHODS

Patients attending the Nottingham University Hospitals' Pain Clinic received two injections of methylprednisolone plus levobupivacaine at different dosages, separated by at least 12 weeks. Prior to each injection, and every week thereafter for 12 weeks, participants completed the EQ-5D health-related quality of life instrument. For each patient for each injection, total health state utility gain relative to baseline was calculated. The cost of the procedure was modelled from observed clinical practice. Cost effectiveness was calculated as procedure cost relative to utility gain.

RESULTS

39 patients provided records. Over a 13-week period commencing with injection, mean quality adjusted life year (QALY) gains per patient for the two dosages were 0.028 (SD 0.063) and 0.021 (SD 0.057). The difference in QALYs gained by dosage was insignificant (paired t-test, CIs -0.019 - 0.033). Based on modelled resource use and data from other studies, the mean cost of an injection was estimated at £219 (SD 83). The cost utility ratio of the two injections amounted to £8,975 per QALY gained (CIs 5,480 - 22,915). However, at costs equivalent to the tariff price typically paid to providers by health care purchasers, the ratio increased to £27,459 (CIs 16,779 - 70,091).

CONCLUSIONS

When provided in an outpatient setting, epidural steroid injections are a short term, but nevertheless cost effective, means of managing chronic low back pain. However, designation of the procedure as a day case requires the National Health Service to reimburse providers at a price which pushes the procedure to the margin of cost effectiveness.

TRIAL REGISTRATION

ISRCTN 43299460.

What is the prevalence of musculoskeletal problems in the elderly population in developed countries? A systematic critical literature review

BACKGROUND

The proportion of older people will be tripled by the year 2050. In addition, the incidence of chronic musculoskeletal (MSK) conditions will also increase among the elderly people. Thus, in order to prepare for future health care demands, the magnitude and impact of MSK conditions from this growing population is needed. The objective of this literature review is to determine the current prevalence of MSK disorders in the elderly population.

METHODS

A systematic literature search was conducted in Pubmed on articles in English, published between January 2000 and July 2011. Studies from developed countries with prevalence estimates on elderly people (60+) on the following MSK conditions were included: Non-specific extremity pain, rheumatoid arthritis, osteoarthritis, osteoporosis, and back pain. The included articles were extracted for information and assessed for risk of bias.

RESULTS

A total of 85 articles were included with 173 different prevalence estimates. Musculoskeletal disorders are common in the elderly population, but due to heterogeneity of the studies, no general estimate on the prevalence of MSK can be determined. Women report more often MSK pain than men. Overall, prevalence estimates either remain fairly constant or increase slightly with increasing age, but with a tendency to decrease in the oldest (80+) people.

CONCLUSIONS

Musculoskeletal disorders remain prevalent in the elderly population. Given the increasing proportion of elderly population in the world population and the burden of MSK diseases among the elderly people, efforts must be made to maintain their functional capacity for as long as possible through optimal primary and secondary health care.

Medical and psychological risks and consequences of long-term opioid therapy in women

BACKGROUND

Long-term opioid use has increased substantially over the past decade for U.S. women. Women are more likely than men to have a chronic pain condition, to be treated with opioids, and may receive higher doses. Prescribing trends persist despite limited evidence to support the long-term benefit of this pain treatment approach.

PURPOSE

To review the medical and psychological risks and consequences of long-term opioid therapy in women.

METHOD

Scientific literature containing relevant keywords and content were reviewed.

RESULTS AND CONCLUSIONS

Long-term opioid use exposes women to unique risks, including endocrinopathy, reduced fertility, neonatal risks, as well as greater risk for polypharmacy, cardiac risks, poisoning and unintentional overdose, among other risks. Risks for women appear to vary by age and psychosocial factors may be bidirectionally related to opioid use. Gaps in understanding and priorities for future research are highlighted.

Appropriate use of lumbar imaging for evaluation of low back pain

Use of lumbar spine imaging, particularly advanced imaging, continues to grow rapidly in the United States. Many lumbar spine imaging tests are obtained in patients who have no clinical symptoms or risk factors suggesting a serious underlying condition, yet evidence shows that this routine imaging is not associated with benefits, exposes patients to unnecessary harms, and increases costs. This article reviews current trends and practice patterns in lumbar spine imaging, direct and downstream costs, benefits and harms, current recommendations, and potential strategies for reducing imaging overuse.

Does back and neck pain become more common as you get older? A systematic literature review

BACKGROUND

It is generally believed that the prevalence of back pain increases with age and as the proportion of elderly will keep rising we may be facing serious public health concerns in the future.

AIM

The aim of this systematic literature review is to establish whether back pain (i.e. neck, mid-back and/or low back pain) becomes increasingly common in the older population, specifically to study 1) whether there is a significant increase in the prevalence of back pain after middle age, and 2) whether there is a significant gradually increasing prevalence of back pain with continued old age.

METHODS

A systematic literature search was conducted in Pubmed on articles in English, published between January 2000 and July 2011. Non-clinical studies from the developed countries with prevalence estimates on elderly people (60+) on any type of self-reported back pain and on different age groups with adequate sample sizes were included in the review. The included articles were extracted for information by two independent reviewers.

RESULTS

A total of 12 articles were included covering the entire spine. Neck pain was studied nine times, low back pain eight times, back pain three times, upper back two times and neck/shoulders once. All studies showed no significant increase of back pain with age, neither when passing from middle age (i.e. 45+ years of age) into the sixties, nor later in life. In contrast, most studies reported a decline for the oldest group.

CONCLUSIONS

Back pain is no more common in the elderly population (>60 years) when compared to the middle age population. Back pain does not increase with increasing age, but seems to decline in the oldest people.

Subgroups of musculoskeletal pain patients and their psychobiological patterns - the LOGIN study protocol

BACKGROUND

Pain conditions of the musculoskeletal system are very common and have tremendous socioeconomic impact. Despite its high prevalence, musculoskeletal pain remains poorly understood and predominantly non-specifically and insufficiently treated.The group of chronic musculoskeletal pain patients is supposed to be heterogeneous, due to a multitude of mechanisms involved in chronic pain. Psychological variables, psychophysiological processes, and neuroendocrine alterations are expected to be involved. Thus far, studies on musculoskeletal pain have predominantly focused on the general aspects of pain processing, thus neglecting the heterogeneity of patients with musculoskeletal pain. Consequently, there is a need for studies that comprise a multitude of mechanisms that are potentially involved in the chronicity and spread of pain. This need might foster research and facilitate a better pathophysiological understanding of the condition, thereby promoting the development of specific mechanism-based treatments for chronic pain. Therefore, the objectives of this study are as follows: 1) identify and describe subgroups of patients with musculoskeletal pain with regard to clinical manifestations (including mental co-morbidity) and 2) investigate whether distinct sensory profiles or 3) distinct plasma levels of pain-related parameters due to different underlying mechanisms can be distinguished in various subgroups of pain patients.

METHODS/DESIGN

We will examine a population-based chronic pain sample (n = 100), a clinical tertiary care sample (n = 100) and pain-free patients with depression or post-traumatic stress disorder and pain-free healthy controls (each n = 30, respectively). The samples will be pain localisation matched by sex and age to the population-based sample. Patients will undergo physical examination and thorough assessments of mental co-morbidity (including psychological trauma), perceptual and central sensitisation (quantitative sensory testing), descending inhibition (conditioned pain modulation, the diffuse noxious inhibitory control-like effect), as well as measurement of the plasma levels of nerve growth factor and endocannabinoids.

DISCUSSION

The identification of the underlying pathophysiologic mechanisms in different subgroups of chronic musculoskeletal pain patients will contribute to a mechanism-based subgroup classification. This will foster the development of mechanism-based treatments and holds promise to treat patients more sufficient.

The history of lower back pain: a look "back" through the centuries

The diagnosis and treatment of low back pain must be standardized, based on evidence and solid research. The cost to individuals and society is great and only those diagnostic tests or treatments that can improve the quality and cost of care should be advocated.

Understanding inhibitory mechanisms of lumbar spinal manipulation using H-reflex and F-wave responses: a methodological approach

The purpose of this research was to characterize unique neurophysiologic events following a high velocity, low amplitude (HVLA) spinal manipulation (SM) procedure. Descriptive time series analysis techniques of time plots, outlier detection and autocorrelation functions were applied to time series of tibial nerve H-reflexes that were evoked at 10-s intervals from 100 s before the event until 100 s after three distinct events L5-S1 HVLA SM, or a L5-S1 joint pre-loading procedure, or the control condition. Sixty-six subjects were randomly assigned to three procedures, i.e., 22 time series per group. If the detection of outliers and correlograms revealed a pattern of non-randomness that was only time-locked to a single, specific event in the normalized time series, then an experimental effect would be inferred beyond the inherent variability of H-reflex responses. Tibial nerve F-wave responses were included to determine if any new information about central nervous function following a HVLA SM procedure could be ascertained. Time series analyses of H(max)/M(max) ratios, pre-post L5-S1 HVLA SM, substantiated the hypothesis that the specific aspects of the manipulative thrust lead to a greater attenuation of the H(max)/M(max) ratio as compared to the non-specific aspects related to the postural perturbation and joint pre-loading. The attenuation of the H(max)/M(max) ratio following the HVLA SM procedure was reliable and may hold promise as a translational tool to measure the consistency and accuracy of protocol implementation involving SM in clinical trials research. F-wave responses were not sensitive to mechanical perturbations of the lumbar spine.

Intensive interdisciplinary outpatient pain management program for chronic back pain: a pilot study

BACKGROUND

Chronic back pain is relatively resistant to unimodal therapy regimes. The aim of this study was to introduce and evaluate the short-term outcome of a three-week intensive multidisciplinary outpatient program for patients with back pain and sciatica, measured according to decrease of functional impairment and pain.

METHODS

The program was designed for patients suffering from chronic back pain to provide intensive interdisciplinary therapy in an outpatient setting, consisting of interventional injection techniques, medication, exercise therapy, back education, ergotherapy, traction, massage therapy, medical training, transcutaneous electrical nerve stimulation, aquatraining, and relaxation.

RESULTS

Based on Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) scores, a significant improvement in pain intensity and functionality of 66.83% NRS and an ODI of 33.33% were achieved by our pain program within 3 weeks.

CONCLUSION

This paper describes the organization and short-term outcome of an intensive multidisciplinary program for chronic back pain on an outpatient basis provided by our orthopedic department, with clinically significant results.

Auricular point acupressure for chronic low back pain: a feasibility study for 1-week treatment

Objectives. The objective of this one-group, repeated-measures design was to explore the acceptance of auricular point acupressure (APA) to reduce chronic low back pain (CLBP) and estimate minimum clinically important differences (MCIDs) for pain intensity change. Methods. Subjects received 7-day APA treatment. After appropriate acupoints were identified, vaccaria seeds were carefully taped onto each selected auricular point for 7-day. The Brief Pain Inventory Short Form (BPI) was used to collect outcome data. Results. A total of 74 subjects participated in the study. Ten subjects dropped out and the retention rate was 87%. Subjects reported a 46% reduction in BPI worst pain, and over 50% reduction in BPI average pain, overall pain severity and pain interference by the end of study, and 62.5% subjects also reported less pain medication use. The MCIDs for the subscale of BPI ranged from .70 to 1.86 points. The percentage improvement of MCIDs from baseline was between 14.5-24.9%. Discussion. APA appears to be highly acceptable to patients with CLBP. A sham group is needed in order to differentiate the true effects of APA from the possible psychological effects of more frequent visits by the auricular therapist and patients' expectation of the APA treatment.

[Identifying and prioritising adverse episodes and failures related to patient safety in Pain Treatment Units]

OBJECTIVES

An expert group coordinated by the Andalusian School of Public Health identified the most serious and frequent adverse events in Pain Treatment Units (PTU), as well the failures and underlying causes, as a prior step to preparing preventive actions. The aims of the project were to identify potential adverse events in Pain Treatment Units, identify failures and their underlying causes, and prioritise these failures according to a failure modes and effects analysis (FMEA) tool.

MATERIAL AND METHODS

The method employed consisted of a literature search, the selection of an expert group with experience in PTU, creating a catalogue of adverse events using the generation of ideas technique, and putting the FMEA and Risk Priority Index tools into practice.

RESULTS

Up to 66 types of adverse events were identified associated with; medication (30), invasive techniques (15), care process (10), patient information and education (6), and clinical practice (5). It was found that up to 101 failures could be triggered by these adverse events, and that 242 causes could lead to these failures.

CONCLUSIONS

The results indicated the need to work principally in two directions, improving the care process in the PTU (the health care organisation), and the professional work, this latter having two aspects, improving the clinical practice, and increase professional skills by means of specific training. Communication, whether inter-professional or inter-department, or with the patient and their family, is identified as a key aspect for improvement.

A physician-driven solution--the Association for Medical Ethics, the Physician Payment Sunshine Act, and ethical challenges in pain medicine

The practice of contemporary pain medicine is laced with a number of significant ethical challenges. Considerable difficulties include the overutilization of interventional procedures, the application of under-evidenced treatment modalities, and potentially superfluous opioid prescribing. As with many other fields in medicine, including orthopedic surgery, relationships with industry are both common and pervasive, and influence our medical practice through education, publications, and research. This article highlights these ethical challenges and broaches several physician-driven solutions: The Association for Medical Ethics, the Physicians Payment Sunshine inspired by it, and other non-legislative reforms are discussed.

Multi-factorial causative model for back pain management; relating causative factors and mechanisms to injury presentations and designing time- and cost effective treatment thereof

Back pain resolution has not statistically improved over many years with some literature suggesting chronic back pain to be increasing. From a search of literature on causes, events, mechanisms, factors and treatment for back pain, a model is developed that relates causes of back injury to factors that result in pain through two primary mechanisms; muscle fatigue and muscle/tendon/connective tissue strain or sprain with other main mechanisms being diminished reactivity and strength, changes in tendon/tissue mechanical properties and fear of back pain recurrence/fear of movement following a back pain episode. The model highlights the fact that back pain/injury is multi-factorial with numerous circular relationships. Therefore treatment should also be multi-factorial; a combination of physical and psychological therapy with attention to mechanisms at work or in daily living that exacerbate the injury and delay recovery thereof. Exercise is one method that can reduce muscle imbalance, improve resilience to muscle fatigue, and address reactivity and strength. More importantly, eccentric exercise can rectify musculotendinous or connective tissue injury which plays a role in prolonging the back injury cycle. Posture is identified as a causative factor for back pain with the time exposure for posture representing the largest portion of daily activities. From literature and from clinical observation, treatment methods can be improved and incorporated into integrated multi-modal programs. An integrated exercise program that commences with motor control exercise and progresses into functional movement is suggested. Furthermore a modification of the McKenzie extension movement may benefit back injury rehabilitation for a majority of lower back pain patients. Otherwise the sit-to-stand movement is a regular and frequent exacerbating mechanism of back pain and likely continuously tears connective tissue during the movement thus prolonging the cycle of back pain and can be addressed instantly with a modification in sit-to-stand technique.

BMP-2 and TGF-β3 do not prevent spontaneous degeneration in rabbit disc explants but induce ossification of the annulus fibrosus

INTRODUCTION

Different approaches for disc regeneration are currently under investigation. Beside gene therapy and tissue engineering techniques, the application of growth and differentiation factors own promising potential. Studies using reduced intervertebral disc models, such as cell or tissue fragment cultures, have limited validity and show controversial results depending on the employed experimental model. Therefore, the goal of the current study was to investigate the effect of BMP-2 and TGF-β3 on intervertebral disc degeneration using an in vitro full-organ disc/endplate culture system.

MATERIALS AND METHODS

Intervertebral rabbit disc explants were cultured in the presence of 1 μg/ml BMP-2 or TGF-β3 for 21 days in DMEM/F12 media. Nucleus and annulus were analyzed for gene expression of collagen type I and II (Col I/II), aggrecan, collagenases (MMP-1/MMP-13) with RT-qPCR, histological changes with bone and proteoglycan-specific staining (von Kossa, toluidine blue) and differences in cellularity (DNA) and proteoglycan content (alcian blue binding assay).

RESULTS

The results demonstrate that disc proteoglycan concentration decreased with time in the TGF-β3 and BMP-2 groups. In the annulus fibrosus (AF), TGF-β3 and BMP-2 resulted in an up-regulation of Col I and type II, and of aggrecan gene expression. In contrast, MMP genes were inhibited. In the nucleus, the growth factors decreased gene expression of aggrecan and spontaneous Col I up-regulation was inhibited by TGF-β3, whereas expression of Col II was decreased with BMP-2. There was no effect on expression of MMP-1 and MMP-13 for most sampling points. However, TGF-β3 and BMP-2 induced ossification of the AF was demonstrated by histology.

CONCLUSION

It can be concluded that both growth factors, at the tested concentrations, may not be suitable to regenerate the whole intervertebral disc organ but they are interesting candidates for being injected alone or in combination into a painful intervertebral disc to induce osseous fusion (spondylodesis).

Physical and psychosocial predictors of functional trunk capacity in older adults with and without low back pain

OBJECTIVE

The purpose of this study was to determine the physical and psychosocial predictors of functional trunk capacity in a group of healthy elderly individuals and a group of elderly patients with chronic low back pain (LBP).

METHODS

The study was done in Canada and included 61 community-dwelling elderly individuals (29 patients with nonspecific chronic LBP and 32 healthy participants) who performed maximal trunk endurance and force tasks. Participants completed various psychologic and functional questionnaires. Sequential linear regression analyses were performed with functional capacity results (endurance and force) as dependent variables and questionnaire scores as independent variables.

RESULTS

Endurance time and peak force were significantly lower in patients compared with healthy elderly individuals (all P values < .001), whereas pain-related fear of movement, pain catastrophizing, and depression levels were higher in patients than their healthy counterpart (all P values < .001). After adjusting for physical activity and disability levels (R(2) = 33.7%-50.5% in patients; R(2) = 0.1%-5.7% in healthy individuals), none of the psychologic questionnaire could explain variations observed in functional capacity in patients (R(2) changes, 4.8%-6.7%) and in healthy participants (R(2) changes, 5.2%-10.6%).

CONCLUSION

Patients showed diminished functional capacity compared with healthy participants. Moreover, physical activity levels represent the most important predictors of functional capacity in elderly patients with LBP.

A combined nurse-pharmacist managed pain clinic: joint venture of public and private sectors

Chronic pain has become one of the most prevalent problems in primary care. The management of chronic pain is complex and often requires a multidisciplinary approach. The limited capacity of general practitioners to manage chronic pain and long waiting time for secondary care referrals further add to the complexity of chronic pain management. Restricted financial and skilled human capital make it hard for healthcare systems across the world to establish and maintain multidisciplinary pain clinics, in spite of their documented effectiveness. Affordability and accessibility to such multidisciplinary pain clinics is often problematic for patients. The purpose of this paper is to share our experience and relevant research evidence of a community based combined nurse-pharmacist managed pain clinic. The pain clinic serves as an example of public-private partnership in healthcare.

Trends in prescriptions and costs of drugs for mental disorders in England, 1998-2010

BACKGROUND

Increasing rates of prescriptions for antidepressants, antipsychotics and stimulants have been reported from various countries.

AIMS

To examine trends in prescriptions and the costs of all classes of psychiatric medication in England.

METHOD

Data from the Prescription Cost Analysis 1998-2010 was examined, using linear regression analysis to examine trends.

RESULTS

Prescriptions of drugs used for mental disorders increased by 6.8% (95% CI 6.3-7.4) per year on average, in line with other drugs, but made up an increasing proportion of all prescription drug costs (P = 0.001). There were rising trends in prescriptions of all classes of psychiatric drugs, except anxiolytics and hypnotics (which did not change). Antidepressant prescriptions increased by 10% (95% CI 9.0-11) per year on average, and antipsychotics by 5.1% (95% CI 4.3-5.9). Antipsychotics overtook antidepressants as the most costly class of psychiatric medication, with costs rising 22% (95% CI 17-27) per year.

CONCLUSIONS

Rising prescriptions may be partly explained by longer-term treatment and increasing population. Nevertheless, it appears that psychiatric drugs make an increasing contribution to total prescription drug costs, with antipsychotics becoming the most costly. Low-dose prescribing of some antipsychotics is consistent with other evidence that their use may not be restricted to those with severe mental illness.

Identifying neck and back pain in administrative data: defining the right cohort

STUDY DESIGN

We reviewed existing methods for identifying patients with neck and back pain in administrative data. We compared these methods using data from the Department of Veterans Affairs.

OBJECTIVE

To answer the following questions: (1) what diagnosis codes should be used to identify patients with neck pain and back pain in administrative data; (2) because the majority of complaints are characterized as nonspecific or mechanical, what diagnosis codes should be used to identify patients with nonspecific or mechanical problems in administrative data; and (3) what procedure and surgical codes should be used to identify patients who have undergone a surgical procedure on the neck or back.

SUMMARY OF BACKGROUND DATA

Musculoskeletal neck and back pain are pervasive problems, associated with chronic pain, disability, and high rates of health care utilization. Administrative data have been widely used in formative research, which has largely relied on the original work of Volinn, Cherkin, Deyo, and Einstadter and the Back Pain Patient Outcomes Assessment Team first published in 1992. Significant variation in reports of incidence, prevalence, and morbidity associated with these problems may be due to nonstandard or conflicting methods to define study cohorts.

METHODS

A literature review produced 7 methods for identifying neck and back pain in administrative data. These code lists were used to search Veterans Health Administration data for patients with back and neck problems, and to further categorize each case by spinal segment involved, as nonspecific/mechanical and as surgical or not.

RESULTS

There is considerable overlap in most algorithms. However, gaps persist.

CONCLUSION

Gaps are evident in existing methods and a new framework to identify patients with neck pain and back pain in administrative data is proposed.

Stem cell therapy for degenerative disc disease

Low back pain is widely recognized as one of the most prevalent pathologies in the developed world. In the United States, low back pain is the most common health problem for adults under the age of 50, resulting in significant societal and personal costs. While the causes of low back pain are myriad, it has been significantly associated with intervertebral disc (IVD) degeneration. Current first-line therapies for IVD degeneration such as physical therapy and spinal fusion address symptoms, but do not treat the underlying degeneration. The use of tissue engineering to treat IVD degeneration provides an opportunity to correct the pathological process. Novel techniques are currently being investigated and have shown mixed results. One major avenue of investigation has been stem cell injections. Mesenchymal stem cells (MSCs) have shown promise in small animal models, but results in larger vertebrates have been mixed.

Multifidus atrophy is localized and bilateral in active persons with chronic unilateral low back pain

OBJECTIVE

To compare the lumbar multifidi muscle volume devoid of fat local to the site of pain in persons with and without chronic unilateral lower lumbar pain.

DESIGN

Prospective cross-sectional design.

SETTING

University biokinesiology laboratory.

PARTICIPANTS

Active individuals (n=14) with chronic unilateral lower lumbar pain (>1 y) were matched for age, height, weight, and activity level with healthy individuals (n=14). Individuals with back pain had minimal disability (Oswestry Disability Index [mean ± SD], 14.9%±6.3%) at the time of testing.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Multifidus and erector spinae muscle volumes at the L5-S1 levels, multifidus muscle volumes at the L4 and S2-3 levels.

RESULTS

Average multifidus volume was diminished by 18.1% between groups (P=.026) only at the L5-S1 levels. There was no difference between painful and pain-free sides. There were no volume differences between groups above L5, below S1, or in erector spinae at the L5-S1 levels.

CONCLUSIONS

The results of this study indicate that despite a low level of disability and an activity level similar to that of matched control subjects, considerable localized, bilateral multifidus atrophy is present. Such impaired size of the multifidus will likely reduce its capacity to control intersegmental motion, thus increasing the susceptibility to further injury. Unlike acute unilateral low back pain (LBP), muscle size is reduced bilaterally in persons with chronic unilateral LBP.

Low back pain

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.

The effect of remodeling on the kinematics of the malpositioned disc allograft transplantation

STUDY DESIGN

A postoperative biomechanical study.

OBJECTIVE

This study aimed to assess whether the mal-alignment of the intervertebral disc (IVD) allograft during transplantation would negatively affect the biomechanics of the spinal segment.

SUMMARY OF BACKGROUND DATA

Studies of human IVD allograft transplantation have observed remodeling of the allograft implant, suggesting that the remodeling of the allograft may be able to restore the natural mechanics of the IVD.

METHODS

Eighteen male goats (age: 6-12 months; weight: 25-30 kg) were randomly assigned into control (n = 5), aligned (n = 5), or malpositioned (n = 5) groups. Transplantation of a size-matched cryopreserved IVD allograft was performed in the lumbar region (L4-L5) after disc excision. In the aligned group, the IVD allografts were placed aligned and flush with the anterior vertebral margin. In the malpositioned group, the allografts were placed proud anteriorly by 25% of the anterior-posterior diameter of the allograft. The lumbar spines were harvested at 6 months after transplantation. Three-dimensional kinematic assessment of the lumbar spines was performed using an MTS testing machine and an optoelectronic camera system. The range of motion, neutral zone, and instantaneous axis of rotation were calculated.

RESULTS

No significant difference in range of motion was noted between the groups in flexion, axial rotation, and lateral bending. Significance was noted with extension range of motion as detected in both the aligned (17.51 ± 1.97 degrees; P = 0.019) and malpositioned groups (16.61 ± 2.35 degrees; P = 0.027) compared with the control (10.11 ± 1.03 degrees). No significant difference was detected in the neutral zone between the groups. Significant difference in the instantaneous axis of rotation orientation between the malpositioned and control groups was detected in the sagittal plane during lateral bending motion (P = 0.036).

CONCLUSION

Kinematic parameters in both the aligned and malpositioned allograft were similar to those of the intact spine. This suggests that precise positioning of the IVD allograft may not be an essential factor affecting the biomechanics of the spinal segment after transplantation.

Population aging and hospitalization for chronic disease in Germany

BACKGROUND

The population of Germany is aging, i.e., the elderly currently make up an increasing percentage of the population from year to year. Furthermore, many common chronic diseases mainly affect the elderly. For these two reasons, the overall cost of health care in Germany is expected to increase. We studied the effect that population aging has had on the number of hospitalizations for major types of chronic disease in Germany since the year 2000.

METHODS

This study is based on nationwide hospitalization statistics, classified by diagnosis, that were published by the German Federal Statistical Office. We analyzed data for three classes of diagnoses--malignant neoplasia, cardiovascular diseases, and diseases of the musculoskeletal system and connective tissue--which were further broken down into nine diagnostic subgroups. Changes in inpatient case numbers might be due either to population aging or to changing rates of hospitalization for individual diagnoses. We used index decomposition analysis to determine the relative influence of these two factors on changing case numbers.

RESULTS

The author found that the aging of the population increased the number of hospitalizations for all of the diagnoses studied. This was particularly evident with respect to the large birth cohorts born in the 1920s (with the diagnosis of congestive heart failure) and in the period 1934-1944 (with the diagnoses ischemic heart disease, lung cancer, colorectal cancer, and osteoarthritis). On the other hand, changing rates of hospitalization for individual diagnoses increased the number of hospitalizations for some diagnoses (congestive heart failure, diseases of the spine and back) and decreased it for others (ischemic heart disease, cerebrovascular diseases, colorectal cancer, breast cancer).

CONCLUSION

The aging of the population and the changing rates of hospitalization for various diagnoses are exerting separate effects on the number of hospitalizations for chronic diseases in Germany. Predictions of hospital case numbers in the future must take both factors into account.

Spinal cord stimulation use in patients with failed back surgery syndrome

SUMMARY The increase in failed back surgery syndrome (FBSS) cases in the USA has been paralleled by an increase in the number of spinal cord stimulation (SCS) treatments performed. Over the last 40 years, SCS technique has improved drastically and has been shown to be efficacious in FBSS patients with radiculopathy and neuropathic pain. This article will focus on the current patient selection process of SCS in the setting of FBSS, with a review of pertinent clinical trials and current evidence-based guidelines. The current working mechanism of SCS, complications surrounding SCS and the definition of FBSS will also be briefly discussed.

Interventional pain medicine: retreat from the biopsychosocial model of pain

The field of pain medicine has shifted from multidisciplinary rehabilitation to procedure-focused interventional pain medicine (IPM). Considerable controversy exists regarding the efficacy of IPM and its more narrow focus on nociception as an exclusive target of pain treatment. This topical review aims to examine pain research and treatment outcome studies that support a biopsychosocial model of pain, and to critique the clinical practice of IPM given its departure from the premises of a biopsychosocial model. A modern definition of pain and findings from clinical and basic science studies indicate that pain-related psychological factors are integral to pain perception. The clinical viability of IPM is challenged based upon its biomedical view of peripheral nociception as a primary source of pain and the potential of this viewpoint to foster maladaptive pain attributions and discourage the use of pain coping strategies among chronic pain patients. IPM should adopt a biopsychosocial perspective on pain and operate within a framework of multidisciplinary pain rehabilitation to improve its effectiveness.

Positive effects of a musculoskeletal pain rehabilitation program regardless of pain duration or diagnosis

OBJECTIVES

To investigate how sociodemographic and clinical factors are associated with psychosocial functioning and disability at admission to a musculoskeletal pain rehabilitation program and at 1-year follow-up.

DESIGN

A cohort pre-post study.

SETTING

A University hospital specialized pain rehabilitation unit.

PARTICIPANTS

Five hundred nine participants with musculoskeletal pain (neck disorders, 29%; fibromyalgia, 24%; low back pain, 24%; myalgia, 14%; and other pain diagnoses, 8%).

INTERVENTION

A 5-week outpatient, group-based, and goal-oriented comprehensive musculoskeletal interdisciplinary pain rehabilitation program based on cognitive behavioral principles.

MAIN OUTCOME MEASURES

The Multidimensional Pain Inventory (MPI), the Disability Rating Index (DRI), and forms including sociodemographic factors (gender, age, ethnicity, marital status, educational level, and vocational situation) and clinical factors (pain duration and pain diagnoses). Data were analyzed with multivariate logistic regression.

RESULTS

At admission, factors associated with more positive scores on the MPI were being older than 40 years, being at work, being Nordic born, attainment of a higher educational level, and a diagnosis of fibromyalgia (compared with a neck disorder) (P < .05). Being at work and a diagnosis of fibromyalgia (compared with low back pain) were associated with more positive scores on the DRI (P < .05). On the basis of cut points for clinically important change on the MPI, participants rated themselves as most improved on the Affective Distress (52%), Life Control (49%), and Pain Severity (43%) subscales, and on the DRI index, the improvement rate was 22%. At the 1-year follow-up, neither sociodemographic nor clinical factors were associated with clinically important improvements of the MPI and the DRI, but younger age was related to deteriorations in pain severity.

CONCLUSIONS

The lack of an association between sociodemographic and clinical factors and psychosocial functioning and disability at a 1-year follow-up after a musculoskeletal pain rehabilitation program suggests that the program was effective regardless of the participants' initial characteristics, except for age. The changes at the 1-year follow-up indicate that the program influenced the participants' psychosocial functioning more than their perception of disability.

Prevalence of chronic head, neck and low back pain and associated factors in women residing in the Autonomous Region of Madrid (Spain)

OBJECTIVE

To compare the prevalence of chronic headache (CH), chronic neck pain (CNP) and chronic low back pain (CLBP) in the autonomous region of Madrid by analyzing gender differences and to determine the factors associated with each pain location in women in 2007.

METHODS

We analyzed data obtained from adults aged 16 years or older (n = 12,190) who participated in the 2007 Madrid Regional Health Survey. This survey includes data from personal interviews conducted in a representative population residing in family dwellings in Madrid. The presence CH, CNP, and CLBP was analyzed. Sociodemographic features, self-perceived health status, lifestyle habits, psychological distress, drug consumption, use of healthcare services, the search for alternative solutions, and comorbid diseases were analyzed by using logistic regression models.

RESULTS

The prevalence of CH, CNP and CLBP was significantly higher (P<0.001) in women (7.3%, 8.4%, 14.1%, respectively) than in men (2.2%, 3.2%, 7.8%, respectively). In women, CH, CNP and CBLP were significantly associated with having ≥3 chronic diseases (OR 7.1, 8.5, 5.8, respectively), and with the use of analgesics and drugs for inflammation (OR: 3.5, 1.95, 2.5, respectively). In the bivariate analysis, the factors associated with pain in distinct body locations differed between men and women.

CONCLUSIONS

This study found that CH, CNP and CLBP are a major public health problem in women in central Spain. Women have a higher overall prevalence of chronic pain than men. Chronic pain was associated with a higher use of analgesics and healthcare services.