How many days of bed rest for acute low back pain? A randomized clinical trial

Evaluation of the success of medical management for presumptive thoracolumbar intervertebral disk herniation in dogs

OBJECTIVE

To determine the success of medical management of presumptive thoracolumbar disk herniation in dogs and the variables associated with treatment outcome.

STUDY DESIGN

Retrospective case series.

ANIMALS

Dogs (n=223) with presumptive thoracolumbar disk herniation.

METHODS

Medical records from 2 clinics were used to identify affected dogs, and owners were mailed a questionnaire about success of therapy, recurrence of clinical signs, and quality of life (QOL) as interpreted by the owner. Signalment, duration and degree of neurologic dysfunction, and medication administration were determined from medical records.

RESULTS

Eighty-three percent of dogs (185/223) were ambulatory at initial evaluation. Successful treatment was reported for 54.7% of dogs, with 30.9% having recurrence of clinical signs and 14.4% classified as therapeutic failures. From bivariable logistic regression, glucocorticoid administration was negatively associated with success (P=.008; odds ratio [OR]=.48) and QOL scores (P=.004; OR=.48). The duration of cage rest was not significantly associated with success or QOL. Nonambulatory dogs were more likely to have lower QOL scores (P=.01; OR=2.34).

CONCLUSIONS

Medical management can lead to an acceptable outcome in many dogs with presumptive thoracolumbar disk herniation. Cage rest duration does not seem to affect outcome and glucocorticoids may negatively impact success and QOL. The conclusions in this report should be interpreted cautiously because of the retrospective data collection and the use of client self-administered questionnaire follow-up.

CLINICAL RELEVANCE

These results provide an insight into the success of medical management for presumptive thoracolumbar disk herniation in dogs and may allow for refinement of treatment protocols.

Do motor control genes contribute to interindividual variability in decreased movement in patients with pain?

Background

Because excessive reduction in activities after back injury may impair recovery, it is important to understand and address the factors contributing to the variability in motor responses to pain. The current dominant theory is the "fear-avoidance model", in which the some patients' heightened fears of further injury cause them to avoid movement. We propose that in addition to psychological factors, neurochemical variants in the circuits controlling movement and their modification by pain may contribute to this variability. A systematic search of the motor research literature and genetic databases yielded a prioritized list of polymorphic motor control candidate genes. We demonstrate an analytic method that we applied to 14 of these genes in 290 patients with acute sciatica, whose reduction in movement was estimated by items from the Roland-Morris Disability Questionnaire.

Results

We genotyped a total of 121 single nucleotide polymorphisms (SNPs) in 14 of these genes, which code for the dopamine D2 receptor, GTP cyclohydrolase I, glycine receptor α1 subunit, GABA-A receptor α2 subunit, GABA-A receptor β1 subunit, α-adrenergic 1C, 2A, and 2C receptors, serotonin 1A and 2A receptors, cannabinoid CB-1 receptor, M1 muscarinic receptor, and the tyrosine hydroxylase, and tachykinin precursor-1 molecules. No SNP showed a significant association with the movement score after a Bonferroni correction for the 14 genes tested. Haplotype analysis of one of the blocks in the GABA-A receptor β1 subunit showed that a haplotype of 11% frequency was associated with less limitation of movement at a nominal significance level value (p = 0.0025) almost strong enough to correct for testing 22 haplotype blocks.

Conclusion

If confirmed, the current results may suggest that a common haplotype in the GABA-A β1 subunit acts like an "endogenous muscle relaxant" in an individual with subacute sciatica. Similar methods might be applied a larger set of genes in animal models and human laboratory and clinical studies to understand the causes and prevention of pain-related reduction in movement.

WITHDRAWN: Advice to stay active as a single treatment for low-back pain and sciatica

BACKGROUND

Low back pain is one of the most common conditions managed in primary care. Restricted activity, rest, and symptomatic analgesics are the most commonly prescribed treatment for low back pain and sciatica.

OBJECTIVES

To assess the effects of advice to stay active as single treatment for patients with low back pain.

SEARCH STRATEGY

Computerised searches in MEDLINE, EMBASE, Sport, The Cochrane Controlled Trials Register, Musculoskeletal Group's Trials Register and Scisearch, and scanning of reference lists from relevant articles were undertaken. Relevant studies were also traced by contacting authors. Date of the most recent searches: December 1998.

SELECTION CRITERIA

We included all randomised trials or quasi-randomised trials where the study population consisted of adult patients with low back pain or sciatica, in which one comparison group was advised to stay active. The main outcomes of interest were pain, functional status, recovery and return to work.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed the validity of included trials and extracted data. Investigators were contacted to collect missing data or for clarification when needed.

MAIN RESULTS

Four trials, with a total of 491 patients, were included. Advice to stay active was compared to advice to rest in bed in all trials. Two trials were assessed to have low risk of bias and two to have moderate to high risk of bias. The results were heterogeneous. Results from one high quality trial of patients with acute simple LBP found small differences in functional status [Weighted Mean Difference (on a 0-100 scale) 6.0 (95% CI: 1.5, 10.5)] and length of sick leave [WMD 3.4 days (95% CI: 1.6, 5.2)] in favour of staying active compared to advice to stay in bed for two days. The other high quality trial compared advice to stay active with advice to rest in bed for 14 days for patients with sciatic syndrome, and found no differences between the groups. One of the high quality trials also compared advice to stay active with exercises for patients with acute simple LBP, and found improvement in functional status and reduction in sick leave in favour of advice to stay active.

AUTHORS' CONCLUSIONS

The best available evidence suggests that advice to stay active alone has small beneficial effects for patients with acute simple low back pain, and little or no effect for patients with sciatica. There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica. If there is no major difference between advice to stay active and advice to rest in bed, and there is potential harmful effects of prolonged bed rest, then it is reasonable to advise people with acute low back pain and sciatica to stay active. These conclusions are based on single trials.

Evaluation of the Success of Medical Management for Presumptive Cervical Intervertebral Disk Herniation in Dogs

OBJECTIVE

To determine the success of medical management of presumptive cervical disk herniation in dogs and variables associated with treatment outcome.

DESIGN

Retrospective case series.

ANIMALS

Dogs (n=88) with presumptive cervical disk herniation.

METHODS

Dogs with presumptive cervical and thoracolumbar disk herniation were identified from medical records at 2 clinics and clients were mailed a questionnaire related to the success of therapy, clinical recurrence of signs, and quality of life (QOL) as interpreted by the owner. Signalment, duration and degree of neurologic dysfunction, and medication administration were determined from medical records.

RESULTS

Ninety-seven percent of dogs (84/87) with complete information were described as ambulatory at initial evaluation. Successful treatment was reported for 48.9% of dogs with 33% having recurrence of clinical signs and 18.1% having therapeutic failure. Bivariable logistic regression showed that non-steroidal anti-inflammatory drug (NSAID) administration was associated with success (P=.035; odds ratio [OR]=2.52). Duration of cage rest and glucocorticoid administration were not significantly associated with success or QOL. Dogs with less-severe neurologic dysfunction were more likely to have a successful outcome (OR=2.56), but this association was not significant (P=.051).

CONCLUSIONS

Medical management can lead to an acceptable outcome in many dogs with presumptive cervical disk herniation. Based on these data, NSAIDs should be considered as part of the therapeutic regimen. Cage rest duration and glucocorticoid administration do not appear to benefit these dogs, but this should be interpreted cautiously because of the retrospective data collection and use of client self-administered questionnaire follow-up.

CLINICAL RELEVANCE

These results provide insight into the success of medical management for presumptive cervical disk herniation in dogs and may allow for refinement of treatment protocols.

Tai chi and perceived health status in older adults who are transitionally frail: a randomized controlled trial

BACKGROUND AND PURPOSE

Tai chi, a Chinese exercise derived from martial arts, while gaining popularity as an intervention for reducing falls in older adults, also may improve health status. The purpose of this study was to determine whether intense tai chi (TC) exercise could improve perceived health status and self-rated health (SRH) more than wellness education (WE) for older adults who are transitionally frail.

SUBJECTS

Study subjects were 269 women who were >or=70 years of age and who were recruited from 20 congregate independent senior living facilities.

METHODS

Participants took part in a 48-week, single-blind, randomized controlled trial. They were randomly assigned to receive either TC or WE interventions. Participants were interviewed before randomization and at 1 year regarding their perceived health status and SRH. Perceived health status was measured with the Sickness Impact Profile (SIP).

RESULTS

Compared with WE participants, TC participants reported significant improvements in the physical dimension and ambulation categories and borderline significant improvements in the body care and movement category of the SIP. Self-rated health did not change for either group.

DISCUSSION AND CONCLUSION

These findings suggest that older women who are transitionally frail and participate in intensive TC exercise demonstrate perceived health status benefits, most notably in ambulation.

Lumbar disc herniations: surgical versus nonsurgical treatment

Lumbar disc herniation is among the most common causes of lower-back pain and sciatica. The cause(s) of lumbar disc herniation and the relation of lumbar disc herniation to back pain and sciatica have not been fully elucidated, but most likely comprise a complex combination of mechanical and biologic processes. Furthermore, the natural history of lumbar disc herniation seems generally to be favorable, leaving the optimum treatment for lumbar disc herniation a debate in the literature. Various nonoperative and operative treatment strategies have been tried with varying degrees of success. Treatment often involves patient education, physical therapy, alternative medicine options, and pharmaco-therapy. If these fail, surgical intervention is usually recommended. A literature search was conducted to evaluate the currently known effectiveness of traditional and novel non-operative and surgical techniques for the treatment lumbar disc herniation and to determine if there are substantive new advantages in these newer contemporary treatments or combinations thereof. A structured approach to treatment of a patient who may have a symptomatic lumbar disc herniation is presented, based on analysis of the current literature. No one method of nonoperative or operative treatment would seem definitively to be superior to another. Appropriate multidisciplinary treatment including behavioral analysis and support may offer the hope of improved outcomes for patients with lumbar disc herniation.

LEVEL OF EVIDENCE

Level V (expert opinion). See the Guidelines for Authors for a complete description of the levels of evidence.

Outcome of non-invasive treatment modalities on back pain: an evidence-based review

At present, there is an increasing international trend towards evidence-based health care. The field of low back pain (LBP) research in primary care is an excellent example of evidence-based health care because there is a huge body of evidence from randomized trials. These trials have been summarized in a large number of systematic reviews. This paper summarizes the best available evidence from systematic reviews conducted within the framework of the Cochrane Back Review Group on non-invasive treatments for non-specific LBP. Data were gathered from the latest Cochrane Database of Systematic Reviews 2005, Issue 2. The Cochrane reviews were updated with additional trials, if available. Traditional NSAIDs, muscle relaxants, and advice to stay active are effective for short-term pain relief in acute LBP. Advice to stay active is also effective for long-term improvement of function in acute LBP. In chronic LBP, various interventions are effective for short-term pain relief, i.e. antidepressants, COX2 inhibitors, back schools, progressive relaxation, cognitive-respondent treatment, exercise therapy, and intensive multidisciplinary treatment. Several treatments are also effective for short-term improvement of function in chronic LBP, namely COX2 inhibitors, back schools, progressive relaxation, exercise therapy, and multidisciplinary treatment. There is no evidence that any of these interventions provides long-term effects on pain and function. Also, many trials showed methodological weaknesses, effects are compared to placebo, no treatment or waiting list controls, and effect sizes are small. Future trials should meet current quality standards and have adequate sample size.

The insensate foot following severe lower extremity trauma: an indication for amputation?

BACKGROUND

Plantar sensation is considered to be a critical factor in the evaluation of limb-threatening lower extremity trauma. The present study was designed to determine the long-term outcomes following the treatment of severe lower extremity injuries in patients who had had absent plantar sensation at the time of the initial presentation.

METHODS

We examined the outcomes for a subset of fifty-five subjects who had had an insensate extremity at the time of presentation. The patients were divided into two groups on the basis of the treatment in the hospital: an insensate amputation group (twenty-six patients) and an insensate salvage group (twenty-nine patients), the latter of which was the group of primary interest. In addition, a control group was constructed from the parent cohort so that the patients in the study groups could be compared with patients in whom plantar sensation was present and in whom the limb was reconstructed. Patient and injury characteristics as well as functional and health-related quality-of-life outcomes at twelve and twenty-four months after the injury were compared between the subjects in the insensate salvage group and those in the other two groups.

RESULTS

The patients in the insensate salvage group did not report or demonstrate significantly worse outcomes at twelve or twenty-four months after the injury compared with subjects in the insensate amputation or sensate control groups. Among the patients in whom the limb was salvaged (that is, those in the insensate salvage and sensate control groups), an equal proportion (approximately 55%) had normal plantar sensation at two years after the injury, regardless of whether plantar sensation had been reported to be intact at the time of admission. No significant differences were noted among the three groups with regard to the overall, physical, or psychosocial scores. At two years after the injury, only one patient in the insensate salvage group had absent plantar sensation.

CONCLUSIONS

Outcome was not adversely affected by limb salvage, despite the presence of an insensate foot at the time of presentation. More than one-half of the patients who had presented with an insensate foot that was treated with limb reconstruction ultimately regained sensation at two years. Initial plantar sensation is not prognostic of long-term plantar sensory status or functional outcomes and should not be a component of a limb-salvage decision algorithm.

A Randomized Clinical Trial of Continuous Low-Level Heat Therapy for Acute Muscular Low Back Pain in the Workplace

OBJECTIVES

We sought to compare the therapeutic benefits of ThermaCare Heat Wrap combined with an education program to an education-only program on reducing pain and disability from acute work-related low back pain.

METHODS

Forty-three eligible patients, aged 20 to 62 years who presented to an occupational injury clinic, were randomized into one of two intervention arms: 1) education regarding back therapy and pain management alone or 2) education regarding back therapy and pain management combined with three consecutive days of topical heat therapy (104 degrees F or 40 degrees C for 8 hours). The primary endpoints in this trial were measures of pain intensity and pain relief levels obtained approximately four times per day for the three consecutive working days of treatment, followed by measures of pain intensity and pain relief levels obtained in three follow-up visits at day 4 and 14 from treatment initiation. The secondary measures were overall impairment due to injury and disability caused by low back pain assessed at Intake, Visit 2 (day 4), 3 (day 7), and 4 (day 14).

RESULTS AND CONCLUSION

A total of 18 individuals enrolled in the education-only group and 25 in the treatment group completed the intervention and all follow-up visits. The general linear model adjusting for age, sex, baseline pain intensity, and pain medication indicated that the topical heat therapy had significantly reduced pain intensity, increased pain relief, and improved disability scores during and after treatment.

Evidence-Based Medicine and the Challenge of Low Back Pain: Where Are We Now?

Low back pain has long been described as a challenge for both primary care physicians and specialists. Management of low back pain has also been criticized as frequently arbitrary, inappropriate, or ineffective. Contributing factors have been an inadequate evidence base and a need for more rigorous appraisals of the available literature. Evidence-based medicine, an approach to clinical problem solving, is predicated on the premise that high-quality health care will result from practices consistent with the best evidence. In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion, authority, and unsystematic clinical observations, evidence-based medicine emphasizes the need for rigorous critical appraisals of the scientific literature to inform medical decision making. Evidence-based medicine places strong weight on the requirement for valid studies, particularly randomized controlled trials, to appropriately evaluate the effectiveness of health care interventions. Because of the rapidly increasing volume of medical literature, however, most clinicians are unable to keep up-to-date with all the new data. Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic reviews and evidence-based clinical practice guidelines. Like primary studies, systematic reviews and clinical practice guidelines must adhere to high methodologic standards to reduce error and bias. As in other areas of medicine, the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings. In addition to more rigorous primary studies, an increasing number of high-quality systematic reviews and evidence-based clinical practice guidelines for low back pain are also available. Although some research gaps and methodologic shortcomings persist, the richer evidence base has greatly improved our understanding of what does and does not work for low back pain. Despite these advances, the best available evidence often does not inform everyday clinical decisions for low back pain. Nonetheless, there is widespread agreement that adherence to evidence-based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care. This article reviews basic principles of evidence-based medicine, discusses evidence-based medicine in the context of low back pain management, and summarizes some useful evidence-based medicine resources.

What Is the Perceived Quality of Life of Adults With Congenital Heart Disease and Does It Differ by Anomaly?

Adults with congenital heart disease (CHD) represent a growing population of patients thanks to the medical and surgical advances which enable at least 85% of children to survive to adulthood. These advances may create quality-of-life (QoL) issues not previously considered. The purpose of this cross-sectional study of 124 adults with CHD was to describe their QoL as a basis for providing appropriate information, counseling, and anticipatory guidance. Thirteen patients had single ventricle physiology (SVP), 43 had cyanotic lesions with 2 ventricle repairs, and 68 had acyanotic CHD. On the basis of Sickness Impact Profile (SIP) scores, individuals with SVP had worse QoL than did those with cyanotic lesions (with 2 ventricle repairs) and acyanotic anomalies (SIP = 9.98 vs 4.61 and 3.76). SIP scores were statistically significantly different between those with SVP and those with acyanotic anomalies (P = .02). For all groups, the areas of life most affected were work and sleep and rest. Participants with SVP saw themselves as having the poorest QoL.

Acute low back pain: diagnostic and therapeutic practices reported by Brazilian rheumatologists

STUDY DESIGN

A cross-sectional study.

OBJECTIVES

To assess resource utilization in the diagnosis, management, and hospitalization of patients with low back pain (LBP) as prescribed by Brazilian rheumatologists.

SUMMARY OF BACKGROUND DATA

LBP is an important cause of disability, suffering, and social costs. Two to five percent of patients miss workdays because of LBP; it is the second highest cause of physician visits and absenteeism.

METHODS

Rheumatologists taking part in a national rheumatology medical congress answered a questionnaire to assess management of patients with LBP. It consisted of two hypothetical scenarios describing patients with acute LBP (scenario 1) and sciatica (scenario 2). There were 29 questions mainly related to education, protective measures, rest, and medication.

RESULTS

A total of 207 questionnaires were returned. In scenario 1, 70% of the participants ordered some diagnostic test at first visit; lumbar radiograph was the most ordered (92%), while more than 80% prescribed rest and 100% at least one drug. Nonsteroidal anti-inflammatory drugs were prescribed by 69% of the participants. In scenario 2, 93% of the physicians ordered diagnostic tests at first visit, with computed tomography being the most ordered test (69%). Rest was prescribed by 90% (average 18 days) of the participants and physical therapy was counseled by 84%.

CONCLUSIONS

Considering the hypothetical scenarios, participants overused diagnostic and therapeutic procedures. A dissemination of guidelines for optimizing resource use in LBP diagnosis and management is needed.

Bed rest for acute low-back pain and sciatica

BACKGROUND

Low-back pain (LBP) is a common reason for consulting a general practitioner, and advice on daily activities is an important part of the primary care management of low-back pain.

OBJECTIVES

To assess the effects of advice to rest in bed for patients with acute LBP or sciatica.

SEARCH STRATEGY

We searched the Cochrane Back Group Specialized Registry, CENTRAL, MEDLINE, EMBASE, Sport, and SCISEARCH to March 2003, reference lists of relevant articles, and contacted authors of relevant articles.

SELECTION CRITERIA

Randomised or controlled clinical trials with quasi-randomisation (alternate allocation, case record numbers, dates of birth, etc.), in any language, where the effectiveness of advice to rest in bed was evaluated. The main outcomes of interest were pain, functional status, recovery and return to work.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed the internal validity of included trials and extracted data. Investigators were contacted to obtain missing information.

MAIN RESULTS

Eleven trials (1963 patients) were included in this updated version. There is high quality evidence that people with acute LBP who are advised to rest in bed have a little more pain [Standardised Mean Difference (SMD) 0.22 (95% Confidence Interval (CI): 0.02, 0.41)] and a little less functional recovery [SMD 0.29 (95% CI: 0.05, 0.45)] than those advised to stay active. For patients with sciatica, there is moderate quality evidence of little or no difference in pain [SMD -0.03 (95% CI: -0.24, 0.18)] or functional status [SMD 0.19 (95% CI: -0.02, 0.41)] between bed rest and staying active. For patients with acute LBP, there is moderate quality evidence of little or no difference in pain intensity or functional status between bed rest and exercises. For patients with sciatica, there is moderate quality evidence of little or no difference in pain intensity between bed rest and physiotherapy, but small improvements in functional status [Weighted Mean Difference 6.9 (on a 0-100 scale) (95% CI: 1.09, 12.74)] with physiotherapy. There is moderate quality evidence of little or no difference in pain intensity or functional status between two to three days and seven days of bed rest.

REVIEWERS' CONCLUSIONS

For people with acute LBP, advice to rest in bed is less effective than advice to stay active. For patients with sciatica, there is little or no difference between advice to rest in bed and advice to stay active. There is little or no difference in the effect of bed rest compared to exercises or physiotherapy, or seven days of bed rest compared with two to three.

Factors affecting recovery from work-related, low back disorders in autoworkers

OBJECTIVE

To simultaneously evaluate personal, medical, and job factors that could affect recovery from work-related, low back disorders, specifically focusing on an active working sample.

DESIGN

Observational, longitudinal study.

SETTING

Two US automotive plants.

PARTICIPANTS

Employees (N=352; 289 men, 63 women; mean age +/- standard deviation, 45.1+/-7.5 y) who were active hourly autoworkers, diagnosed with work-related, low back disorder by the plant's medical department.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Oswestry Disability Questionnaire for back pain was used to evaluate recovery.

RESULTS

Factors associated with better recovery were lower stress levels (P<.001) and exercise or physical activity outside work (P<.001); factors associated with higher disability levels over time were current cigarette smoking (P<.01) and bedrest (P<.001).

CONCLUSIONS

Personal modifiable factors are major influences in the recovery from work-related, low back disorders, even in active working populations. Interventions aimed at increasing exercise and decreasing stress should also be considered as a part of rehabilitation in employed persons with low levels of disability.

Prognosis and quality of life in patients with acute low back pain: Insights from a comprehensive inception cohort study

OBJECTIVE

To investigate the respective contribution of various biologic and psychosocial factors, especially initial health-related quality of life (HRQOL), in the natural history of acute low back pain (LBP) and to evaluate the impact of this condition on HRQOL.

METHODS

For 3 months, we assessed 113 patients consulting for nonspecific acute LBP of <72 hours duration at inclusion and treated with acetaminophen. Endpoints included pain, disability assessed by the Roland Disability Questionnaire, and HRQOL assessed by the Short Form 36 health survey (SF-36).

RESULTS

Seventy-three percent of patients recovered within 2 weeks and 5% of patients developed chronic LBP. Prior low back surgery, higher initial disability questionnaire score, lower SF-36 score, and temporary compensation status were independently associated with delayed recovery. The impact of the acute LBP episode on HRQOL was brief and moderate, except for patients with comorbidity, psychiatric disorders, those of foreign origin, unemployed, or with job dissatisfaction. The impact of compensation status, sick leave, and bed rest was more profound and lasting.

CONCLUSIONS

This study highlights the large contribution of work-related factors, but also initial HRQOL, to the prognosis of LBP. It also suggests that LBP impairs HRQOL mainly through compensation and inappropriate medical care, and that, in turn, impaired HRQOL favors the condition becoming chronic. These findings have implications for future research into the management of LBP.

Compliance in Pain Rehabilitation: Patient and Provider Perspectives

OBJECTIVE

To identify potential predictors and correlates of compliance and to examine differences between patient and provider perspectives on compliance.

PATIENTS

One hundred eighty-four patients (84 men and 96 women) were recruited from a chronic pain treatment program for this telephone follow-up study.

RESULTS

Health care providers (HCPs) reported making more recommendations than patients reported hearing. Patients rated themselves as more compliant than did HCPs. Overall compliance rates at a >6-month follow-up were 89% from the patients' perspective and 70% from the HCPs' perspective. HCPs rated compliance specific to psychological care as more related to positive outcomes than did patients. Participants' pain and anxiety ratings at a >6-month follow-up and satisfaction with treatment were significantly associated with patients' compliance ratings. For HCP-rated compliance, only HCPs' perceived benefit and interference from compliance were associated.

CONCLUSION

Results suggest important disparities between HCPs and patients on remembered recommendations, levels of compliance, and health-related importance of complying with recommendations.

Low back pain: an economic assessment in the United States

Although it is clear that LBP imposes a grave economic cost on society, the lack of consensus on causes and appropriate treatments makes it difficult to develop explicit guidelines and best practices. To gain a greater understanding of the economic impact of the condition and to reduce the unnecessary procedures that patients undergo, a series of cost-effectiveness analyses on established treatment options and on proposed integrated programs of prevention, treatment, and counseling, would be not only informative but integral to the progress of LBP disease management.

Compliance among general practitioners in France with recommendations not to prescribe bed rest for acute low back pain

Acute low back pain is a very common reason for general practitioner visits.

OBJECTIVE

To evaluate practices among French general practitioners regarding the prescription of bed rest in patients with low back pain.

METHODS

2000 general practitioners were to include the first three patients presenting within the first 3 d of onset of acute low back pain without nerve root pain. The characteristics of the pain, social and demographic characteristics of the patients, and treatments prescribed by the physicians were recorded.

RESULTS

5355 patients were included, of whom more than half had a history of one or more episodes of low back pain. The mean pain severity score on a 100-mm visual analog scale was 57.2 +/- 22.7 mm. Bed rest was recommended to 27.6% of the patients, for a mean duration of 4.4 d. Patients to whom bed rest was recommended were significantly more likely than the other patients to have chronic low back pain (32.1% vs. 26.5%) and received a greater number of medications. Bed rest was associated with significantly poorer outcomes in the multivariable analysis adjusting for confounding factors.

CONCLUSION

Recommendations to avoid bed rest in patients with acute low back pain are widely followed in France. Furthermore, our results confirm that bed rest is associated with poorer outcomes.

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

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

Cyclobenzaprine with ibuprofen versus ibuprofen alone in acute myofascial strain: a randomized, double-blind clinical trial

STUDY OBJECTIVE

We evaluate the analgesic and side effects of adding cyclobenzaprine to ibuprofen in emergency department patients with acute myofascial strain.

METHODS

A randomized, prospective, double-blind study was conducted at an urban teaching ED with an annual census of 44,000. One hundred two patients aged 18 to 70 years with acute myofascial strain caused by minor trauma within the prior 48 hours were included, and 77 patients completed the protocol. Each patient received a single dose of 800 mg of ibuprofen in the ED and a vial of 6 capsules containing 800 mg of ibuprofen to take every 8 hours as needed after discharge from the ED. In addition, 51 patients received a single dose of 10 mg of cyclobenzaprine and a vial of 6 capsules containing 10 mg of cyclobenzaprine to take every 8 hours as needed after discharge from the ED; the remaining 51 patients received an identically labeled placebo capsule and vial of placebo capsules to take every 8 hours as needed after discharge from the ED. Patients rated the intensity of their pain on a 100-mm visual analog scale (VAS) at baseline; 30, 60, 90, 120, and 180 minutes; and 24 and 48 hours after treatment. Telephone follow-up was obtained at 24 and 48 hours, and side effects were elicited at 24 and 48 hours by means of open-ended questioning.

RESULTS

The patients in each group were similar with regard to diagnosis and baseline pain score. The number of patients who did not complete the protocol and the number of those who required additional analgesia were similar in both groups. Over the 48 hours of the protocol, the mean VAS score for the combination group decreased from 60.4 to 35.6, and the mean VAS score for the ibuprofen alone group decreased from 62.2 to 35.4. The mean VAS scores between groups across time was not statistically significant (P =.962, repeated-measures analysis of variance). At both 24 and 48 hours, central nervous system side effects were reported more frequently in the patients receiving cyclobenzaprine (16 [42%] versus 7 [18%] at 24 hours and 15 [39%] versus 5 [13%] at 48 hours, respectively).

CONCLUSION

In ED patients with acute myofascial strain, the addition of cyclobenzaprine to ibuprofen does not improve analgesia but is associated with a greater prevalence of central nervous system side effects.

Work restrictions and outcome of nonspecific low back pain

STUDY DESIGN

Retrospective cohort study was conducted.

OBJECTIVE

To evaluate the association of prescribed work restrictions with work absenteeism and recurrence in cases of nonspecific low back pain.

SUMMARY OF BACKGROUND DATA

The efficacy of commonly prescribed work restrictions in limiting sickness-related absence because of back pain has not been evaluated.

METHODS

Employees who had back pain-related sickness absence were identified from medical records of a utility company. The workers were grouped into those who had received a work restriction for their back pain and those who had not. The duration of work disability was compared between the two groups. Employees who returned back to regular, full duty within 1 year of onset were followed for one additional year to determine rates of recurrence. The Cox Proportional Hazards model was used to generate hazard ratios adjusted for age, gender, and job category.

RESULTS

Restrictions were given to 43% of the workers. Sickness absence duration did not differ between those who had received restrictions and those who had not (adjusted hazard ratio, 1.12; P = 0.41). The median duration of restricted duty was 32.5 days. For 22% of the workers, restricted duty was never lifted. Recurrence appeared less likely to occur among those who had work restrictions in their initial episode. However, this difference was not statistically significant (adjusted hazard ratio, 0.77; P = 0.48).

CONCLUSIONS

No evidence of an association between a prescription of work restriction and early return to work was found. More research is needed to clarify the utility of restricted duty in promoting a positive outcome for work-related low back pain.

Evaluation and treatment of low back pain: an evidence-based approach to clinical care

Low back pain is a common reason for patient visits to a health care provider. For most patients, low back symptoms are nonspecific, meaning that the pain is localized to the back or buttocks and is due to a presumed musculoligamentous process. For patients with radicular leg symptoms, a precise etiology is more commonly identified. The history and physical examination usually provide clues to the uncommon but potentially serious causes of low back pain, as well as to those patients at risk for prolonged recovery. Diagnostic testing should not be a routine part of the initial evaluation, but used selectively based upon the history, examination, and initial treatment response. For patients without significant neurological impairment, initial treatments should include activity modification, nonnarcotic analgesics, and education. For patients whose symptoms are not improving over 2 to 4 weeks, referral for physical treatments is appropriate. A variety of therapeutic options of limited or unproven benefit are available for patients with radicular leg symptoms or chronic low back pain. Patients with radicular pain and little or no neurological findings should receive conservative treatment, but elective surgery is appropriate for those with nerve root compression who are unresponsive to conservative therapy.

Quality of life experienced by adults with congenital heart disease

Adults with congenital heart disease (CHD) represent a growing population of patients. Medical and surgical advances have increased the number of CHD adult survivors, which may create quality-of-life (QOL) issues not previously considered. Quality-of-life issues pertinent to this patient population involve health and life insurance acquisition, birth control, genetic counseling, pregnancy concerns, employment, and independent living arrangements. The purpose of this study was to describe the QOL of adults with CHD. The study used a prospective cross-sectional case-control design to examine QOL using the Sickness Impact Profile (SIP). The study participants were a sample of 124 adults with CHD from an outpatient cardiology clinic in a metropolitan university-affiliated teaching hospital in the Northeast and 124 matched healthy control subjects. Between the participants and the matched control subjects, there was a significant difference in the total mean SIP score, the physical and psychosocial dimension scores, and all the category scores (P < 0.05). The areas of life the adults with CHD reported as lacking in quality involved the categories of work (SIP of 11.1, moderate disability) and sleep and rest (SIP of 9.03, mild disability). The results of this study indicate that the SIP can be used for quantitative and subjective QOL assessment of adults with CHD. It is suggested that cardiac advanced practice nurses use the results of this study to develop appropriate information, counseling, and anticipatory guidance for this patient population.

Kryorhizotomy: an alternative technique for lumbar medial branch rhizotomy in lumbar facet syndrome

OBJECT

The authors conducted a prospective study to investigate the efficacy of kryorhizotomy, an alternative procedure for lumbar medial branch neurotomy, in the treatment of lumbar facet syndrome (LFS).

METHOD

Fifty patients with chronic low-back pain, in whom pain was relieved by controlled diagnostic medial branch blocks of the lumbar zygapophyseal (facet) joints, underwent lumbar medial branch kryorhizotomy. Outcome was evaluated using the Visual Analog Pain Scales and assessment of work capacity. All outcome measures were repeated at 6 weeks, 6 months, and 1 year after surgery. At 1-year follow-up examination, 31 (62%) of 50 patients experienced a good response to lumbar facet kryorhizotomy. Good results with pain relief of 50% or more were obtained in 85% of patients without previous spinal surgery but only in 46% who had undergone previous spinal surgery. This difference was statistically significant. In five patients (16%) in whom a good initial benefit was observed but who experienced increased pain within 6 weeks after kryorhizotomy, the beneficial result was regained after an early repeated procedure. There were no side effects. Overall, 19 (38%) of 50 procedures were not considered successful. In six of these 19 cases a rigid stabilization of the involved segment provided permanent pain relief.

CONCLUSIONS

Based on this study, patients with LFS who have not undergone previous spinal surgery benefit significantly from percutaneous lumbar kryorhizotomy. Kryorhizotomy, which has virtually no risk, seems to be a valuable alternative technique to lumbar medial branch neurotomy.

Low back pain

Low back pain is a very common condition, with about 80% of people suffering from it at some point in their lives. It is usually self-limited, resolving in 4 to 8 weeks in more than 50% of patients, yet the recurrence rate is high, about 85%. Because of the complexity of the bony, muscular ligamentous, and neural elements of the back, a specific anatomic diagnosis often cannot be made. Evaluation should include a careful history and physical examination, paying particular attention to alarm symptoms or "red flags" mentioned in the text. Imaging procedures are usually not necessary because of the lack of specificity and the high rate of early, spontaneous remission. Exceptions to this include history of recent trauma, presence of red flags or chronic unremitting course. Many treatment modalities, including physical therapy, ultrasound, thermal therapy, and local injection have been tried, but most studies are inconclusive as to their effectiveness. Prolonged bed rest is not indicated. Nonsteroidal anti-inflammation agents, judicious use of muscle relaxers, and patient education about the cause and prognosis are justified.

Cervical radiculopathies: conservative approaches to management

It is now well recognized that the natural course of cervical radiculopathy is generally favorable. Comprehensive, aggressive, nonsurgical management often is successful with respect to functional outcomes, pain reduction, and patient satisfaction. Surgery is avoidable for most patients. The focus of this article is a review of the most recent and classic literature related to the nonsurgical management of cervical radiculopathies.

Bed rest or normal activity for patients with acute low back pain: a randomized controlled trial

BACKGROUND

The management of common low back pain has two principal objectives: to relieve acute pain and to attempt prevention of transition to chronicity. Several studies have shown the ineffectiveness of prolonged periods of bed rest.

OBJECTIVE

To compare 4 days of bed rest with continued normal daily activity in acute low back pain, taking into account the type of work (physical or sedentary labor).

METHODS

This open, comparative multicenter study enrolled 281 ambulatory patients, ages 18 to 65 years, with low back pain (onset < 72 hours). The subjects did not have pain radiating below the buttocks and did not have work-related injuries. They were randomized into two treatment groups: one instructed to continue normal activity (insofar as the pain allowed), and the other prescribed 4 days of bed rest. After inclusion, patients were seen at three visits: on day 6 or 7, after 1 month, and after 3 months.

RESULTS

On day 6 or 7, pain intensity was similar for both groups, as was the overall judgment of the treatment by patients and physicians. At 1 and 3 months, the groups again had equivalent intensity of back pain, functional disability, and vertebral stiffness. A higher proportion of patients in the bed rest group than in the normal activity group had an initial sick leave (86% vs 52%; P < 0.0001). This difference was greater for the patients whose work was sedentary.

CONCLUSIONS

For patients with acute low back pain, normal activity is at least equivalent to bed rest. The findings of this study indicate that prescriptions for bed rest, and thus for sick leaves, should be limited when the physical demands of the job are similar to those for daily life activities.

Continuous low-level heat wrap therapy provides more efficacy than Ibuprofen and acetaminophen for acute low back pain

STUDY DESIGN

A prospective, randomized, single (investigator) blind, comparative efficacy trial was conducted.

OBJECTIVE

To compare the efficacy of continuous low-level heat wrap therapy (40 C, 8 hours/day) with that of ibuprofen (1200 mg/day) and acetaminophen (4000 mg/day) in subjects with acute nonspecific low back pain.

SUMMARY OF BACKGROUND DATA

The efficacy of topical heat methods, as compared with oral analgesic treatment of low back pain, has not been established.

METHODS

Subjects (n = 371) were randomly assigned to heat wrap (n = 113), acetaminophen (n = 113), or ibuprofen (n = 106) for efficacy evaluation, or to oral placebo (n = 20) or unheated back wrap (n = 19) for blinding. Outcome measures included pain relief, muscle stiffness, lateral trunk flexibility, and disability. Efficacy was measured over two treatment days and two follow-up days.

RESULTS

Day 1 pain relief for the heat wrap (mean, 2) was higher than for ibuprofen (mean, 1.51; P = 0.0007) or acetaminophen (mean, 1.32; P = 0.0001). Extended mean pain relief (Days 3 to 4) for the heat wrap (mean, 2.61) also was higher than for ibuprofen (mean, 1.68; P = 0.0001) or acetaminophen (mean, 1.95; P = 0.0009). Lateral trunk flexibility was improved with the heat wrap (mean change, 4.28 cm) during treatment (P </= 0.009 vs acetaminophen [mean change, 2.93 cm], P </= 0.001 vs ibuprofen [mean change, 2.51 cm]). The results were similar on Day 4. Day 1 reduction in muscle stiffness with the heat wrap (mean, 16.3) was greater than with acetaminophen (mean, 10.5; P = 0.001). Disability was reduced with the heat wrap (mean, 4.9), as compared with ibuprofen (mean, 2.7; P = 0.01) and acetaminophen (mean, 2.9; P = 0.0007), on Day 4. None of the adverse events were serious. The highest rate (10.4%) was reported in the ibuprofen group.

CONCLUSION

Continuous low-level heat wrap therapy was superior to both acetaminophen and ibuprofen for treating low back pain.

Industrial medicine and acute musculoskeletal rehabilitation. 1. Diagnosing and managing the injured worker with low back pain

This self-directed learning module highlights the evaluation and management of the injured worker with low back pain (LBP). This chapter reviews the importance of recognizing the physiologic implications of a lifting injury and evaluating its structural etiology in a worker with LBP. A review of the steps required to make an accurate diagnosis is included. Justifying restrictions and prescribing therapeutic intervention is summarized.

OVERALL ARTICLE OBJECTIVE

To be able to provide a step-by-step plan for evaluating, treating, and safely returning to work the injured worker with LBP.

Early intervention for acute back injury: can we finally develop an evidence-based approach?

OBJECTIVE

Several reviews of the treatment of acute low back pain have been published in the past and have formed the basis of clinical guidelines. However, these lack consistency in some areas and valid data in others. As the literature in this field has continued to expand, the present review was undertaken to establish whether the guidelines in current use are supported by more recently published, scientifically rigorous research, and whether additional consensus regarding treatment of acute low back injury has been forthcoming in recent years.

DESIGN

A review, and critical analysis, of literature relating to the treatment of acute low back pain that has been published since the production of the currently used clinical guidelines. The guidelines have been reviewed to assess whether their recommendations remain supportable.

CONCLUSIONS

Recent research appears to support current clinical guidelines, i.e. exercise may have a positive effect while bed rest is ineffective and may be harmful, simple analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) have short-term benefits, and spinal manipulation may be effective in the first four weeks; no evidence was found for traction or back schools. However, we need more randomized controlled trials of treatments shown to be successful with the chronic population, e.g. focused on understanding psychological determinants, and using a multidisciplinary biopsychosocial approach. In the future this may help us to prevent acute low back progressing to the chronic state.

An analysis of the respective risks of hematoma formation in 361 consecutive morphological and functional stereotactic procedures

OBJECTIVE

The risk of hematoma formation in stereotactic procedures is generally considered to range between 1 and 4%, and it has been speculated that morphological procedures may have a higher risk of bleeding than functional procedures.

METHODS

Between 1989 and 1999, all patients who underwent a stereotactic procedure performed by the same surgeon were enrolled sequentially onto the study. All patients had normal preoperative prothrombin time, partial thromboplastin time, and platelet count. High-resolution computed tomography or magnetic resonance imaging with a 1.5-T machine were used for the target definition. None of the patients had an angiogram before surgery.

RESULTS

A total of 361 procedures was performed comprising 175 morphological procedures (139 biopsies, 18 lesion evacuations [cysts, abscesses, and hematomas], and 18 drain implantations) and 186 functional procedures (137 lesions [thalamotomy or pallidotomy], 47 deep brain electrode implantations, and two physiological explorations without lesions or implantations). There were no infections or seizures in either group. Three hematomas (1.7%) occurred in the morphological group, two of them in inflammatory lesions in immunocompromised patients (one death) and one in a pineal tumor. Three hematomas (1.6%) occurred in the functional group (no mortality). There was no statistically significant difference (P > 0.05; Fisher's exact test) in the risk of hematoma formation between morphological and functional stereotactic procedures. The morbidity and mortality related to bleeding also were not statistically different (P > 0.05; Fisher's exact test) between these two groups.

CONCLUSION

In this series, the risk of bleeding was not higher for morphological procedures than for functional procedures. This suggests that the risk of bleeding for stereotactic procedures is related more to the patient than to the type of procedure performed. Our study confirms an overall risk of bleeding of 1.7% for any type of stereotactic procedure, resulting in a mortality of 0.3% and a morbidity of 1.4%.

How epidemiology contributes to the management of spinal disorders

Back pain constitutes a nearly universal experience, Point, one-year period and lifetime prevalence reach or exceed, in some European countries, 40%, 70% and 80%, respectively. No health care system is able to cope with the entire quantity and spectrum of cases. Clinically useful distinctions are urgently required. A basic classification distinguishes specific from non-specific cases. Non-specific back pain may then be graded on its actual severity in terms of pain intensity and disability. This already implies limited prognostic information. Staging assumes a more or less unidirectional course with definable phases and transition periods and definitely adds to prognosis (cf. the TNM-system in oncology). So far there seems to be no generally accepted staging system for chronic back pain, although some promising proposals can be presented. The disorder, once it has become chronic, has a rather unfavourable prognosis, although single episodes still have a high probability of completely resolving within a few weeks. An underestimated risk factor for a chronic-disabling course of current back pain is (besides its acute grade and stage) its previous history.

Advice to stay active as a single treatment for low back pain and sciatica

BACKGROUND

Low back pain is one of the most common conditions managed in primary care. Restricted activity, rest, and symptomatic analgesics are the most commonly prescribed treatment for low back pain and sciatica.

OBJECTIVES

To assess the effects of advice to stay active as single treatment for patients with low back pain.

SEARCH STRATEGY

Computerised searches in MEDLINE, EMBASE, Sport, The Cochrane Controlled Trials Register, Musculoskeletal Group's Trials Register and Scisearch, and scanning of reference lists from relevant articles were undertaken. Relevant studies were also traced by contacting authors. Date of the most recent searches: December 1998.

SELECTION CRITERIA

We included all randomised trials or quasi-randomised trials where the study population consisted of adult patients with low back pain or sciatica, in which one comparison group was advised to stay active. The main outcomes of interest were pain, functional status, recovery and return to work.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed the validity of included trials and extracted data. Investigators were contacted to collect missing data or for clarification when needed.

MAIN RESULTS

Four trials, with a total of 491 patients, were included. Advice to stay active was compared to advice to rest in bed in all trials. Two trials were assessed to have low risk of bias and two to have moderate to high risk of bias. The results were heterogeneous. Results from one high quality trial of patients with acute simple LBP found small differences in functional status [Weighted Mean Difference (on a 0-100 scale) 6.0 (95% CI: 1.5, 10.5)] and length of sick leave [WMD 3.4 days (95% CI: 1.6, 5.2)] in favour of staying active compared to advice to stay in bed for two days. The other high quality trial compared advice to stay active with advice to rest in bed for 14 days for patients with sciatic syndrome, and found no differences between the groups. One of the high quality trials also compared advice to stay active with exercises for patients with acute simple LBP, and found improvement in functional status and reduction in sick leave in favour of advice to stay active.

REVIEWER'S CONCLUSIONS

The best available evidence suggests that advice to stay active alone has small beneficial effects for patients with acute simple low back pain, and little or no effect for patients with sciatica. There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica. If there is no major difference between advice to stay active and advice to rest in bed, and there is potential harmful effects of prolonged bed rest, then it is reasonable to advise people with acute low back pain and sciatica to stay active. These conclusions are based on single trials.

Prescription of activity for low back pain: What works?

This paper provides evidence-based guidelines for the prescription of activity in the management of non-specific low back pain (NSLBP). The 62 clinical trials published between 1966 and 1997, identified by a search of the Medline and Cinahl databases, were reviewed to provide the basis for the guidelines. The available evidence suggests that physiotherapists should advise patients with acute and sub-acute NSLBP to avoid bed rest and to return to normal activity using time rather than pain as the guide to activity resumption. While structured exercise programs have not been shown to provide a benefit for acute NSLBP, there is strong evidence to support their use for patients with sub-acute and chronic NSLBP and in the prevention of NSLBP.

Should we give detailed advice and information booklets to patients with back pain? A randomized controlled factorial trial of a self-management booklet and doctor advice to take exercise for back pain

STUDY DESIGN

Randomized controlled factorial trial.

OBJECTIVE

To assess the effectiveness of a booklet and of physician advice to take regular exercise.

SUMMARY OF BACKGROUND DATA

Educational booklets are one of the simplest interventions for back pain but have not been shown to alter pain and function. Although there is evidence that advice to mobilize is effective, doctors have also been advised to encourage regular exercise-but there is no evidence that such advice alone improves outcomes.

METHOD

Eight doctors from six practices randomized 311 patients with a new episode of back pain using sealed numbered opaque envelopes to receive a detailed self-management booklet, advice to take regular exercise, both, or neither. All groups were advised to mobilize and to use simple analgesia. Patients were telephoned during the first week after entry into the study, and after 3 weeks to assess a validated numerical pain/function score (0 = no pain normal activities to 100 = extreme pain no normal activities). Patients also returned a postal questionnaire in the first week with the Aberdeen pain and function scale, a knowledge score, and a reliable satisfaction scale (mean score of 4 items: 0 = not satisfied to 100 = extremely satisfied).

RESULTS

Pain/function scores were obtained in 239 (77%) patients. There were interactions between exercise and booklet groups for both pain/function scores and the Aberdeen scale, which are unlikely to have been chance findings (P = 0.009 and P = 0.012, respectively). In comparison with the control group, there were reductions in the pain/function score in the first week with a booklet (-8.7, 95% CI -17.4 to -0.03) or advice to exercise (-7.9; -16.7 to 0.8) but much less effect with both together (-0.08, -9.0 to 8.9). Similarly, the Aberdeen scale was lower in the booklet group (-3.8, -7.7 to 0.07) and in the exercise advice group (-5.3; -9.3 to -1.38) but much less with both combined (-1.9, -5.8 to 2.1). There was no significant difference between groups in pain/function scores by week 3, when 58% reported being back to normal. Satisfaction was increased in booklet (7.9, 1.3 to 14.4) and exercise groups (7.4, 0.8 to 13.9)), and a booklet also increased knowledge (Kruskal-Wallis chi2 27.2, P = 0.001).

CONCLUSION

Doctors can increase satisfaction and moderately improve functional outcomes in the period immediately after the consultation when back pain is worst, by using very simple interventions: either by endorsing a self-management booklet or by giving advice to take exercise. Previous studies suggest that simple advice and the same written information provide reinforcement. This study supports evidence that it may not be helpful to provide a detailed information booklet and advice together, where the amounts or formats of information differ.

Presurgical psychological screening in back pain patients: a review

OBJECTIVE

The objective of this article is to provide a brief overview of the major psychosocial risk factors impacting recovery from spine surgery.

RESULTS

Numerous personality, cognitive, behavioral and historical factors affecting surgical recovery are reviewed. Among the most significant issues that have been found to have an adverse influence on outcome are Minnesota Multiphasic Personality Inventory scale elevations associated with pain sensitivity, depression, anger and anxiety. Maladaptive pain coping strategies, litigation, workers' compensation and reinforcement of pain behavior by the spouse also have been found to reduce spine surgery results. A number of other factors are reviewed, including pre-existing psychological problems, sexual and physical abuse, marital distress and substance abuse.

CONCLUSIONS

Presurgical psychological screening should be included in the medical diagnostic process of spine surgery candidates, especially when the major goal is pain reduction, or when the surgeon recognizes the existence of psychosocial risk factors. Suggestions for future directions in the development of presurgical psychological screening procedures are also given.

Managing low-back pain: steps to optimize function and hasten return to activity

Low-back pain in active patients is common and often recurs. Comprehensive treatment includes control of pain and inflammation, limited bed rest, early therapeutic exercises within a pain-free range, lumbar stabilization exercises, strengthening of the muscles of the trunk and kinetic chain, aerobic conditioning, and correction of faulty biomechanics. The goal of rehabilitation is to restore normal lumbar spine function and promote independent return to activity. Normal lumbar spine function and the absence of symptoms following sport-specific skills ensure successful return to competition. A patient handout is included.