Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews

Cough Radiculopathy: Postinfectious Cough-Related Acute Lumbar Radiculopathy

Cough is a protective reflex of airways and lungs. Cough may result in several complications. Postinfectious cough is a cough that begins during an acute respiratory tract infection, usually is self-limited, and is due to airway hyperresponsiveness as a result of airway inflammation. Cough radiculopathy has been once reported by Torrington and Adornato in the form of acute cervical radiculopathy. This is a case of acute lumbar radiculopathy as a result of postinfectious cough. Literature review did not show a similar case.

[The assessment of efficacy and tolerability of the complex therapy of low back pain]

OBJECTIVE

To assess the efficacy of the complex therapy of nonspecific low back pain (LBP) with amelotex, calmirex, kompligamB in comparison with the monotherapy with amelotex.

MATERIAL AND METHODS

This observational study included sixty patients, aged 53.73±11.84 53 years, with nonspecific LBP. Patients were divided into 2 groups: the basic group (n=30) received calmirex (150mg 2 times a day during 10 days), amelotex (7.5 mg 2 times a day, 7 days) and kompligamB (1 ml once a day, 10 days). The control group (n=30) received only amelotex (7.5 mg 2 times a day, 7 days). The dynamics of the condition was assessed on a 10-point numerical rating scale (at rest, walking, palpation), the Oswestry functional status questionnaire (Oswestry Disability Index; ODI), as well as indicators of laboratory markers reflecting the severity of the inflammatory process (erythrocyte sedimentation rate, C-reactive protein (CRP)).

RESULTS

The severity of pain syndrome significantly decreased in both groups, to a greater extent in the basic group, and ODI indicators also significantly improved in the basic group. CRP indicators showed more pronounced changes in the basic group.

CONCLUSION

The complex therapy that affects all links in the formation of pain syndrome should be recommended to patients with LBP.

Predictors of instanteous relief from spinal manipulation for non-specific low back pain: a delphi study

Background

There is some evidence and anecdotal reports that high-velocity low-amplitude (HVLA) spinal manipulation therapy (SMT) for non-specific low back pain (NSLBP) may immediately reduce pain in some patients. The mechanism for such a change remains unclear and the evidence is conflicting. The aim of this study was to seek consensus among a sample of expert manual therapists as to the possible clinical predictors that could help identify patients who are most likely to receive instant relief from NSLBP with SMT intervention.

Methods

Thirty-seven expert chiropractors and manipulative physiotherapists from around the world were invited to participate in a three round online Delphi questionnaire during the second half of 2018. Participants were provided with a list of 55 potential signs and symptoms as well as offering them the option of suggesting other factors in the first round. The variables were rated using a 4-point Likert likelihood scale and a threshold of 75% agreement was required for any item to progress to the next round.

Results

Of these 37 experts, 19 agreed to participate. Agreement as to the proportion of patients who receive instantaneous relief was minimal (range 10–80%). A total of 62 items were ranked over the 3 rounds, with 18 of these retained following the third round. The highest rated of the 18 was ‘A history including a good response to previous spinal manipulation’.

Discussion/conclusion

Five categories; patient factors, practitioner factors, signs and symptoms of NSLBP presentation, an instrument of measurement (FABQ), and the presence of cavitation following SMT best describe the overall characteristics of the factors. The 18 factors identified in this study can potentially be used to create an instrument of measurement for further study to predict those patients with NSLBP who will receive instantaneous relief post-SMT.

Microanatomy of the lumbar vertebral bony endplate of rats using scanning electron microscopy

INTRODUCTION

The bony endplate of a vertebra is a porous structure containing a large number of capillaries. To date, not very much is known regarding the appearance of the bony endplate microstructure, or the distribution of foramina in the bony endplate.

HYPOTHESIS

The purpose of this study was to provide information on this microstructure based on scanning electron microscopy (SEM) images.

MATERIALS AND METHODS

The bony endplates of rats was observed by SEM scanning. The resulting SEM images were used to evaluate the structural characteristics of the bony endplates, such as the shape and the foramen distribution. Quantitative data were analyzed using SPSS software.

RESULTS

A bony endplate resembled a concave lens and had a unique three-dimensional structure with a large number of surface and interior foramina. The anterior side of the bony endplate had a large number of heterogeneous foramina. The majority of the foramina were seen concentrated toward the center of the bony endplate, as the density decreased further away from the center with few foramina at the margins. The posterior side of the bony endplate had numerous, larger, and more evenly distributed foramina. The integral structure resembled a sponge, and most of the foramina contained capillary structures.

DISCUSSION

The spongy structure of the bony endplate is the structural basis of nutrient transport. Depending on the location of the bony endplate, capillaries can penetrate it and contact to the cartilage endplate, thus supporting nutritional transport. The findings provide a theoretical basis for future studies on intervertebral disc degeneration.

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

BACKGROUND

The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial.

METHODS

After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached.

RESULTS

17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary).

CONCLUSIONS

Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Ozone Therapy and Aquatic Rehabilitation Exercises to Overcome the Lumbar Pain Caused by Facet Joint Syndrome - Case Report

Purpose

Facet joint syndrome (FJS) is an arthritis-like condition of the spine that can be a significant source of low back pain (LBP). Ozone therapy (OT) could be an additional treatment method. We evaluated the therapeutic results of percutaneous injection of ozone to ablate acute LBP caused by FJS.

Methods

A 73-year-old Caucasian woman was treated by OT: one ozone injection (20 µg/mL) per week for 3 weeks under ultrasound guidance. After a break of 1 week, she performed exercises for aquatic rehabilitation (twice a week for 4 weeks).

Results

The outcome measure was pain relief for ≥6 months according to the Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), and Brief Pain Inventory (BPI) test. From baseline to 1 month after OT, a reduction in pain was documented and the result was maintained at 6-month follow-up.

Conclusion

OT followed by aquatic exercises could be efficacious against the LBP caused by FJS.

Emerging Spine Care Trends and Innovations

The spine is an anchoring structure that is the base for mechanical motion of the body and a protector of neuroelements. Spinal disorders continue to plague generations with issues. Management options continue to evolve, allowing for operative and nonoperative pathways to treat underlying causes. Positive patient outcomes and long-term relief are achieved through evidence-based practice and innovative trends. The future of spine care will continue to push boundaries, allowing patients to return to activity at a much faster rate, with decreased restrictions and lower rates of future complications.

Lumbar Axial Rotation Kinematics in an Upright Sitting and With Forward Bending Positions in Men With Nonspecific Chronic Low Back Pain

STUDY DESIGN

A controlled cross-sectional study.

OBJECTIVE

The aim of this study was to compare the kinematics of lumbar axial rotation while sitting in an upright and forward bending position in men suffering with and without nonspecific chronic low back pain (NSCLBP).

SUMMARY OF BACKGROUND DATA

Lumbar rotation while sitting is an important factor in the mechanism of low back pain. Nevertheless, its kinematics has scarcely been investigated.

METHODS

Range of motion (ROM in), average velocity (AV), maximum velocity (MV), and maximal acceleration (MA) of lumbar rotation while sitting in an upright (UP-sitting) and full forward bending position (FFB-sitting) were examined using an industrial lumbar motion monitor in 50 men (25 with NSCLBP and 25 controls). Pain level and the Rolland Morris questionnaire (RMQ) were also included.

RESULTS

All examined kinematical parameters were significantly lower in men with NSCLBP compared with the controls (↓ROM = 16%-29%; ↓AV = 35%-53%; ↓MV = 3%-46%; ↓MA = 7%-44%) and significantly decreased when moving from UP-sitting to FFB-sitting. In the UP-sitting, the ROM and AV in both groups and the right rotation-MV in the NSCLBP group were always greater during the right rotation compared to the left (NSCLBP = ROM: Δ3.92°, AV: Δ2.74°, MV:Δ3.61°; controls = ROM: Δ3.46°, AV: Δ1.72°). The left rotation-MV was significantly greater compared to the right only in FFB-sitting in the controls (Δ3.03°). In all kinematical parameters in the NSCLBP group, no correlations were found in the visual analogue scale (VAS) levels (4.43 ± 1.47) or RMQ total score (12.32 ± 5.44).

CONCLUSION

The kinematic parameters of lumbar rotation were reduced in men with NSCLBP compared with controls both in an UP-sitting and FFB-sitting. In both groups, NSCLBP and controls, asymmetry in lumbar rotation kinematics was indicated as well as a decrease when moving from UP-sitting to FFB-sitting.

LEVEL OF EVIDENCE

3.

Identifying Acute Low Back Pain Episodes in Primary Care Practice From Clinical Notes: Observational Study

BACKGROUND

Acute and chronic low back pain (LBP) are different conditions with different treatments. However, they are coded in electronic health records with the same International Classification of Diseases, 10th revision (ICD-10) code (M54.5) and can be differentiated only by retrospective chart reviews. This prevents an efficient definition of data-driven guidelines for billing and therapy recommendations, such as return-to-work options.

OBJECTIVE

The objective of this study was to evaluate the feasibility of automatically distinguishing acute LBP episodes by analyzing free-text clinical notes.

METHODS

We used a dataset of 17,409 clinical notes from different primary care practices; of these, 891 documents were manually annotated as acute LBP and 2973 were generally associated with LBP via the recorded ICD-10 code. We compared different supervised and unsupervised strategies for automated identification: keyword search, topic modeling, logistic regression with bag of n-grams and manual features, and deep learning (a convolutional neural network-based architecture [ConvNet]). We trained the supervised models using either manual annotations or ICD-10 codes as positive labels.

RESULTS

ConvNet trained using manual annotations obtained the best results with an area under the receiver operating characteristic curve of 0.98 and an F score of 0.70. ConvNet's results were also robust to reduction of the number of manually annotated documents. In the absence of manual annotations, topic models performed better than methods trained using ICD-10 codes, which were unsatisfactory for identifying LBP acuity.

CONCLUSIONS

This study uses clinical notes to delineate a potential path toward systematic learning of therapeutic strategies, billing guidelines, and management options for acute LBP at the point of care.

Development of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process

OBJECTIVE

The purpose of this study was to develop a clinical decision aid for chiropractic management of common conditions causing low back pain (LBP) in veterans receiving treatment in US Veterans Affairs (VA) health care facilities.

METHODS

A consensus study using an online, modified Delphi technique and Research Electronic Data Capture web application was conducted among VA doctors of chiropractic. Investigators reviewed the scientific literature pertaining to diagnosis and treatment of nonsurgical, neuromusculoskeletal LBP. Thirty seed statements summarizing evidence for chiropractic management, a graphical stepped management tool outlining diagnosis-informed treatment approaches, and support materials were then reviewed by an expert advisory committee. Email notifications invited 113 VA chiropractic clinicians to participate as Delphi panelists. Panelists rated the appropriateness of the seed statements and the stepped process on a 1-to-9 scale using the RAND/University of California, Los Angeles methodology. Statements were accepted when both the median rating and 80% of all ratings occurred within the highly appropriate range.

RESULTS

Thirty-nine panelists (74% male) with a mean (standard deviation) age of 46 (11) years and clinical experience of 17 (11) years participated in the study. Accepted statements addressed included (1) essential components of chiropractic care, (2) treatments for conditions causing or contributing to LBP, (3) spinal manipulation mechanisms, (4) descriptions and mechanisms of commonly used chiropractic interventions, and (5) a graphical stepped clinical management tool.

CONCLUSION

This study group produced a chiropractic clinical decision aid for LBP management, which can be used to support evidence-based care decisions for veterans with LBP.

Does the awareness of having a lumbar spondylolisthesis influence self-efficacy and kinesiophobia? A retrospective analysis

BACKGROUND

High pain self-efficacy and low kinesiophobia seem related to a better prognosis in patients complaining of low back pain (LBP). The literature stresses the potential negative effects of anatomical defect diagnosis (e.g. lumbar spondylolisthesis) on the psychological profile. The aim of this study is to investigate the relationships between awareness of having a spondylolisthesis, pain self-efficacy and kinesiophobia.

METHODS

A secondary retrospective analysis was done. Ninety-eight subjects with subacute and chronic LBP were included: 49 subjects with diagnosed symptomatic lumbar spondylolisthesis and 49 subjects with diagnosed non-specific LBP. The pain self-efficacy measured with the Pain Self-Efficacy Questionnaire and the fear of movement measured with the Tampa Scale of Kinesiophobia were considered variables to investigate, whereas diagnosis and demographic/clinical variables were considered predictors or potential confounders.

RESULTS

By comparing the two groups, the awareness of having a spondylolisthesis did not significantly influence neither pain self-efficacy (p = 0.82), nor kinesiophobia (p = 0.75). Higher perceived pain reduces pain self-efficacy and increases kinesiophobia in both groups (p = 0.002 and p = 0,031 respectively).

CONCLUSIONS

It seems that the awareness of an anatomical defect as spondylolisthesis does not significantly affect the beliefs of carry out activities and movements despite the pain. Other studies with wider samples are required, to confirm these preliminary results.

CHANGES IN PELVIC TILT DURING THREE DIFFERENT RECIPROCAL STANCE POSITIONS IN PATIENTS WITH SACROILIAC JOINT REGIONAL PAIN

PURPOSE

Essential to the successful management of patients with sacroiliac joint pain (SIJP) is understanding how these joints move. The innominates tilt together in the same direction with symmetrical activities (i.e. forward-bending) but move opposite of one another when performing asymmetrical activities (i.e. walking). How they move in patients with SIJP is unknown. The purpose of this study was to examine inter-innominate movement (tilt) when assuming three different stance positions to describe how the innominate bones move in those with and without SIJP.

STUDY TYPE

Observational Cohort Study.

METHODS

Twenty-eight participants were classified into two groups; SIJP with low back pain (LBP), and no SIJP or LBP. SIJP participants were further classified into groups with left or right pelvic tilt. Pelvic tilt was measured during neutral standing and in both left-sided and right-sided reciprocal stance, with a full-stride (one hip fully flexed the other fully extended) and in a half-stride position, which mimic the double-stance phase of gait. A repeated measure ANOVA assessed for differences between Groups (Level, Left or Right Pelvic Tilt), stance side position (left/right), and stride length (full/half).

RESULTS

The was a significant Group main effect (F [2, 25] = 130.2, p < 0.0001), and a significant Side main effect (F [1, 25] = 429.7, p < 0.0001), qualified by a significant Side x Group interaction (F [2, 25] = 19.9 p < .0001). Follow-up comparisons showed that pelvic tilts for right and left stance were significantly different (p < 0.05) for each group (Level, left and right pelvic tilt). For the right stance condition, all groups were significantly different from each other (p < 0.05). For the left stance position, the right pelvic tilt and level pelvic tilt means were not different from each other (p > 0.05), but each was different from the mean for the left pelvic tilt group (p < 0.05).

CONCLUSIONS

When assuming an asymmetrical stance position, the innominates tilt opposite of each other in those without SIJP. In patients with SIJP they behave in the normal fashion in one asymmetrical stance position but not the other. Instead of tilting opposite, as expected, the innominates remain symmetrical, dependent on the side of the presenting pelvic tilt.

LEVEL OF EVIDENCE

2b.

LincRNA-SLC20A1 (SLC20A1) promotes extracellular matrix degradation in nucleus pulposus cells in human intervertebral disc degeneration by targeting the miR-31-5p/MMP3 axis

Long non-coding RNAs (lncRNAs) are novel players in intervertebral disc degeneration (IDD) and show multiple functions. LncRNA lincRNA-SLC20A1 (SLC20A1) is aberrantly expressed in IDD. However, the role of SLC20A1 in degenerative nucleus pulposus (NP) cells and its underlying mechanism are unclear. The expressions of SLC20A1, miR-31-5p, and MMP3 were determined using RT-qPCR and western blotting. Extracellular matrix (ECM) degradation was evaluated by ECM-related genes collagen II, aggrecan, and ADAMTS4 using western blotting and an enzyme-linked immunosorbent assay (ELISA). The target binding between miR-31-5p and SLC20A1 or matrix metalloproteinase (MMP3) was predicted based on the miRcode or starBase websites and confirmed using a luciferase reporter assay and an RNA pull-down assay. SLC20A1 expression is upregulated in NP tissues from IDD patients, and this expression promotes ADAMTS5 expression and represses collagen II and aggrecan expression in degenerative NP cells derived from IDD patients. Mechanically, SLC20A1 acts as a competing endogenous RNA (ceRNA) to negatively regulate miRNA-31-5p (miR-31-5p) expression. Moreover, MMP3 is a downstream target for miR-31-5p and is positively modulated by SLC20A1 in degenerative NP cells. Similar to the SLC20A1 effect in human NP cells, the downregulation of miR-31-5p facilitates ECM degradation as well. On the contrary, miR-31-5p upregulation abolishes the promoting role of SLC20A1 in degenerative NP cells, the effect of which is then blocked by the ectopic expression of MMP3. The upregulation of SLC20A1 aggravates ECM degradation in degenerative human NP cells by targeting the miR-31-5p/MMP3 axis, suggesting that the SLC20A1/miR-31-5p/MMP3 pathway can contribute to IDD progression.

Ginsenoside Rd inhibits IL-1β-induced inflammation and degradation of intervertebral disc chondrocytes by increasing IL1RAP ubiquitination

Many compounds of ginsenosides show anti-inflammatory properties. However, their anti-inflammatory effects in intervertebral chondrocytes in the presence of inflammatory factors have never been shown. Increased levels of pro-inflammatory cytokines are generally associated with the degradation and death of chondrocytes; therefore, finding an effective and nontoxic substance that attenuates the inflammation is worthwhile. In this study, chondrocytes were isolated from the nucleus pulposus tissues, and the cells were treated with ginsenoside compounds and IL-1β, alone and in combination. Cell viability and death rate were assessed by CCK-8 and flow cytometry methods, respectively. PCR, western blot, and immunoprecipitation assays were performed to determine the mRNA and protein expression, and the interactions between proteins, respectively. Monomeric component of ginsenoside Rd had no toxicity at the tested range of concentrations. Furthermore, Rd suppressed the inflammatory response of chondrocytes to interleukin (IL)-1β by suppressing the increase in IL-1β, tumor necrosis factor (TNF)-α, IL-6, COX-2, and inducible nitric oxide synthase (iNOS) expression, and retarding IL-1β-induced degradation of chondrocytes by improving cell proliferation characteristics and expression of aggrecan and COL2A1. These protective effects of Rd were associated with ubiquitination of IL-1 receptor accessory protein (IL1RAP), blocking the stimulation of IL-1β to NF-κB. Bioinformatics analysis showed that NEDD4, CBL, CBLB, CBLC, and ITCH most likely target IL1RAP. Rd increased intracellular ITCH level and the amount of ITCH attaching to IL1RAP. Thus, IL1RAP ubiquitination promoted by Rd is likely to occur by up-regulation of ITCH. In summary, Rd inhibited IL-1β-induced inflammation and degradation of intervertebral disc chondrocytes by increasing IL1RAP ubiquitination.

Optimizing the Management and Outcomes of Failed Back Surgery Syndrome: A Proposal of a Standardized Multidisciplinary Team Care Pathway

Failed back surgery syndrome (FBSS) is a major, worldwide health problem that generates considerable expense for healthcare systems. A number of controversial issues concerning the management of FBSS are regularly debated, but no clear consensus has been reached. This pitfall is the result of lack of a standardized care pathway due to insufficient characterization of underlying pathophysiological mechanisms, which are essential to identify in order to offer appropriate treatment, and the paucity of evidence of treatment outcomes. In an attempt to address the challenges and barriers in the clinical management of FBSS, an international panel of physicians with a special interest in FBSS established the Chronic Back and Leg Pain (CBLP) Network with the primary intention to provide recommendations through consensus on how to optimize outcomes. In the first of a series of two papers, a definition of FBSS was delineated with specification of criteria for patient assessment and identification of appropriate evaluation tools in order to choose the right treatment options. In this second paper, we present a proposal of a standardized care pathway aiming to guide clinicians in their decision-making on how to optimize their management of FBSS patients. The utilization of a multidisciplinary approach is emphasized to ensure that care is provided in a uniform manner to reduce variation in practice and improve patient outcomes.

Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP)

Examination of a patient with chronic low back pain (LBP) is aimed at eliminating its specific cause and assessing the social and psychological factors of chronic pain. The diagnosis of chronic nonspecific (musculoskeletal) LBP is based on the exclusion of a specific cause of pain, discogenic radiculopathy, and lumbar stenosis. It is advisable to identify possible pain sources: pathology of intervertebral disc pathology, facet joints, and sacroiliac joint and myofascial syndrome.

An integrated multidisciplinary approach (a high level of evidence), including therapeutic exercises, physical activity optimization, psychological treatments (cognitive behavioral therapy), an educational program (back pain school for patients), and manual therapy, is effective in treating chronic musculoskeletal LBP. For pain relief, one may use nonsteroidal anti-inflammatory drugs in minimally effective doses and in a short cycle, muscle relaxants, and a capsaicin patch, and, if there is depressive disorder, antidepressants (a medium level of evidence). Radiofrequency denervation or therapeutic blockages with anesthetics and glucocorticoids (damage to the facet joints, sacroiliac joint), back massage, and acupuncture (a low level of evidence) may be used in some patients.

Therapeutic exercises and an educational program (the prevention of excessive loads and prolonged static and uncomfortable postures and the use of correct methods for lifting weights, etc.) are recommended for preventive purposes. 

Optimizing the Management and Outcomes of Failed Back Surgery Syndrome: A Consensus Statement on Definition and Outlines for Patient Assessment

Failed back surgery syndrome (FBSS) is a controversial term for identifying patients affected by new, recurrent, or persistent pain in the low back and/or legs following spinal surgery. The lack of a comprehensive standardized care pathway compromises the appropriate management of FBSS patients, which is associated with a heavy financial burden. An international panel of spine surgeons, neurosurgeons, and pain specialists with a particular interest in FBSS established the chronic back and leg pain (CBLP) network with the aim of addressing the challenges and barriers in the clinical management of FBSS patients by building a common transdisciplinary vision. Based on literature reviews, additional input from clinical expertise of multiple professional disciplines, and consensus among its members, the network attempted to provide recommendations on the management of patients with FBSS utilizing a multidisciplinary team (MDT) approach. The presentation of this work has been divided in two separate parts to enhance its clarity. This first paper, in favour of selecting appropriate validated tools to improve the FBSS patient assessment, focuses on FBSS taxonomy and its clinical implications for evaluation. Concise recommendations for assessment, treatment, and outcome evaluation using a MDT approach would be an important resource for specialists and nonspecialist clinicians who manage patients with FBSS, to improve decision-making, reduce variation in practice, and optimize treatment outcomes in this difficult-to-treat population.

Clinical utility of flexion-extension ratio measured by surface electromyography for patients with nonspecific chronic low-back pain

BACKGROUND

Patients with chronic nonspecific low-back pain (CNSLBP) lack the flexion-relaxation phenomenon in full-trunk bending. This can be quantified by surface electromyography (SEMG) measurement of lumbar erector muscle. The study objective is to explore the clinical utility of the SEMG flexion-extension ratio (FER) in distinguishing patients with CNSLBP from painfree persons.

METHODS

This was a comparative cross-sectional study. We adopted a balanced study design by recruiting 130 participants each for the CNSLBP and control arms. Each participant underwent dynamic SEMG measurement in full-trunk bending, which consisted of standing, flexion, relaxation, and extension. The FER ratio was the ratio of the maximum SEMG in flexion to the maximum SEMG during extension. Receiver-operating characteristic (ROC) analysis was conducted to identify optimal values of the FER and associated sensitivity, specificity, and diagnostic accuracy.

RESULTS

The CNSLBP group and control group were generally comparable in terms of demographics and clinical profile. The CNSLBP group had higher SEMG amplitudes during flexion but lower SEMG during extension. The mean (SD) FER of the CNSLBP group was 0.90 (0.26), which was almost double that of controls 0.47 (0.14). The ROC curve identified an optimal FER cutoff of ≥ 0.692, for which sensitivity and specificity were 76.15% (95%confidence interval [CI], 68.14-82.66) and 98.46% (95%CI, 94.56-99.58). The diagnostic accuracy was 92.1% (95%CI, 88.70-95.54).

CONCLUSION

The FER derived by lumbar muscle SEMG is able to distinguish patients with CNSLBP from pain-free people with excellent accuracy. This provides good evidence that a customized FER can be used in various clinical scenarios.

Current concepts for lumbar disc herniation

PURPOSE

To present the pathophysiology, biology, clinical presentation, diagnosis, and current treatment options for lumbar disc herniation.

METHODS

A thorough literature search was undertaken in PubMed and Google Scholar to summarize the current knowledge and future perspectives on lumbar disc herniation.

RESULTS

Several changes in the biology of the intervertebral disc are thought to contribute to disc herniation; nevertheless, the exact inciting event leading to disc herniation is yet to be discovered. Non-operative treatments have stood the test of time as the first-line treatment for most patients with lumbar disc herniation; however, operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function.

CONCLUSIONS

The exact event leading to disc herniation remains unclear. Non-operative treatments should be the first-line treatment for most patients with lumbar disc herniation. Operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. Regenerative medicine is promising.

High frequency of lumbar fusion in patients denied surgical treatment of the sacroiliac joint

PURPOSE

Effective treatment of medical conditions relies on proper diagnosis. Clinical trials show the safety and effectiveness of sacroiliac joint (SIJ) fusion in patients with chronic SI joint dysfunction. To what extent is the condition under recognised?

OBJECTIVE

To determine whether under recognition of SIJ pain affects healthcare trajectories in Spanish patients with low back pain.

METHODS

Retrospective study of characteristics and consequences of 189 patients with persistent SIJ pain seen in an outpatient neurosurgery clinic.

RESULTS

Patients with SIJ pain who were denied surgical treatment had a longer pain duration, higher likelihood of prior lumbar fusion, and a high rate (63%) of lumbar fusion within 2 years prior to SIJ pain diagnosis, which, in most cases, provided little benefit.

CONCLUSIONS

Lack of knowledge of the role of the SIJ in chronic low back pain probably results in diagnostic confusion and may lead to misdirected treatment.

Sacroiliac joint fusion health care cost comparison prior to and following surgery: an administrative claims analysis

Purpose

To assess real-world expenditures on surgical and non-surgical treatment for sacroiliac joint (SIJ) pain by comparing direct health care costs before and after surgery in patients who underwent an SIJ fusion (SIJF) procedure.

Materials and methods

This retrospective observational study examined administrative claims data (January 1, 2010 to February 28, 2017) for adult commercial health plan members with a medical claim for SIJF. Identified patients were included if they had continuous enrollment in the health plan for 12 months pre-SIJF (baseline period) and 12 months post-SIJF (follow-up period). The outcomes of interest were low back pain-related health care costs in the first three quarters of the baseline period (pre-surgery period; excludes the quarter immediately preceding surgery) and last three quarters of the follow-up period (post-surgery period; excludes the quarter in which SIJF was performed).

Results

Some 302 patients met inclusion criteria: 159 patients had the index SIJF in an inpatient hospital setting, 122 in an outpatient hospital setting, 18 in a surgery center, and three in other settings. Mean and median costs in the pre-surgery period were US$16,803 and US$5,849, respectively, and US$13,297 and US$2,269 in the post-surgery period. Median costs were significantly different in the pre- and post-surgery periods (P<0.001), while mean costs were not. Median health care costs in the pre-surgery and post-surgery periods were lower than the corresponding means due to the highly skewed nature of the cost data.

Conclusion

This health care claims data analysis shows the potential for lower post-operative health care costs compared to pre-operative costs in patients undergoing SIJF. Median low back pain-related costs in the post-surgery period were approximately US$400 per quarter overall and US$250 per quarter for those undergoing SIJF in the non-inpatient setting. Future studies with larger sample sizes and longer follow-up will improve the precision of the cost data.

Diagnostics, treatment, rehabilitation and prevention of vertebral syndromes caused by traumatic elements

Vertebral pain occurs due to many reasons, thus complicates diagnostics, treatment, rehabilitation. The spectrum of pathomorphological changes in vertebral segments that can lead to lesions of the segmental nervous and vascular structures should be considered. We propose to define and classify these pathoanatomical changes. Traumatic elements are pathomorphological changes in vertebral segments, due to an injury or vertebral diseases and may cause irritation, partial or total compression of segmental nervous and/or vascular structures due to their size and direction. We also suggested algorithm for the diagnostics, treatment, rehabilitation and prevention of pain and other disorders in the spine. Diagnostic algorithm mentioned in the article allows to choose the right methods of treatment, rehabilitation and prevention. We can conclude that pathoanatomical changes directed towards the segmental nervous and vascular structures may act as traumatic elements. Severity of clinical manifestation of spine pathology more depends on the severity of traumatization of segmental nervous or vascular structures. It’s impossible to differentiate traumatic elements as irritating or compressing ones by changes on X-ray and MRI.

Interrater Reliability of Osteopathic Sacral Palpatory Diagnostic Tests Among Osteopathy Students

Context

Somatic dysfunctions are a key element of osteopathic practice. The evaluation of somatic dysfunctions is achieved by assessment of the TART (tissue texture abnormality, asymmetry, restriction of motion, tenderness) parameters. The reliability of a diagnostic method is the crux of successful treatment. Interrater reliability of osteopathic palpatory diagnostic tests have been studied on different anatomical areas, but there are no studies on the evaluation of all of the TART parameters on the sacrum.

Objective

To evaluate the interrater reliability of osteopathic sacral palpatory diagnostic tests. The hypothesis was that 3 trained osteopathy students at the end of their curriculum could achieve at least moderate agreement on osteopathic sacral palpatory diagnostic tests.

Methods

Three students from the Centre pour l’Étude, la Recherche et la Diffusion Ostéopathiques school in Rome, Italy, at the end of their curriculum participated as raters and received consensus training. Eligible subjects among students of the same school were recruited on a voluntary basis to be tested. All of the raters tested the sacrum by evaluating the TART parameters on every subject for 3 minutes. Raters were blinded to the other raters’ findings. Interrater reliability was evaluated using Fleiss κ statistics.

Results

Fifty-two subjects (20 women) were enrolled in the study. Mean (SD) age was 25.9 (7.03) years; height, 1.73 (0.09) ms; weight, 68.73 (14.2) kg; and body mass index, 22.66 (3.58). Agreement was fair for tissue texture abnormality (κ=0.28), asymmetry (κ=0.29), restriction of motion (κ=0.32), and tenderness (κ=0.34); agreement was slight for landmark position (κ=0.06) and diagnosis of somatic dysfunction (κ=0.17).

Conclusion

Results showed a level of agreement ranging from slight to fair in the assessment of the TART parameters among raters, who were in their last year of osteopathy school. The tenderness parameter was the most reliable. Our findings are consistent with other interrater reliability studies carried out in different body regions, contributing to show an overall heterogeneous level of diagnostic reliability in osteopathy.

Clinical classification criteria for nonspecific low back pain: A Delphi-survey of clinical experts

BACKGROUND

Nonspecific low back pain (NSLBP) is a common problem. Attempts have been made to classify NSLBP patients into homogenous subgroups. Classification systems based on identifying the underlying mechanism(s) driving the disorder are clinically useful to guide specific interventions.

OBJECTIVE

To establish consensus among experts regarding clinical criteria suggestive of a dominance of 'articular', 'myofascial', 'neural', 'central', and 'sensorimotor control' dysfunction patterns (DPs) in NSLBP patients.

STUDY DESIGN

A 2-phase sequential design of a focus group and Delphi-study.

METHODS

A focus group with 10 academic experts was organized to elaborate on the different DPs discernible in LBP patients. Consecutively, a 3-round online Delphi-survey was designed to obtain consensual symptoms and physical examination findings for the 5 DPs resulting from the focus group.

RESULTS

Fifteen musculoskeletal physical therapists from Belgium and the Netherlands experienced in assessing and treating LBP patients completed the Delphi-survey. Respectively, 34 (response rate, 100.0%), 20 (58.8%) and 15 (44.12%) respondents replied to rounds 1, 2 and 3. Twenty-two 'articular', 20 'myofascial', 21 'neural', 18 'central' and 11 'sensorimotor control' criteria reached a predefined ≥80% consensus level. For example, after round 2, 85.0% of the Delphi-experts agreed to identify 'referred pain below the knee' as a subjective examination criterion suggestive for a predominant 'neural DP'.

CONCLUSION

These indicators suggestive of a clinical dominance of the proposed DPs could help clinicians to assess and diagnose NSLBP patients. Future reliability and validity testing is needed to determine how these criteria may help to improve physical therapy outcome for NSLBP patients.

Low back pain and gastroesophageal reflux in patients with COPD: the disease in the breath

COPD is a worsening condition that leads to a pathologic degeneration of the respiratory system. It represents one of the most important causes of mortality and morbidity in the world, and it is characterized by the presence of associated comorbidity. This article analyzes gastroesophageal reflux disease (GERD) and low back pain (LBP) in patients with COPD and tries to produce anatomo-clinical considerations on the reasons of the presence of these comorbidities. The considerations of the authors are based on the anatomic functions and characteristics of the respiratory diaphragm that are not always considered, from which elements useful to comprehend the symptomatic status of the patient can be deduced, finally improving the therapeutic approach. The information contained in the article can be of help to the clinician and for physiotherapy, and to all health professionals who gravitate around the patient’s care, improving the approach to the diaphragm muscle.

Muscle Atrophy Measurement as Assessment Method for Low Back Pain Patients

Low back pain is one of the most common pain disorders defined as pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, sometimes with accompanying leg pain. The meaning of the symptomatic atrophy of paraspinal muscles and some pelvic muscles has been proved. Nowadays, a need for new diagnostic tools for specific examination of low back pain patients is posited, and it has been proposed that magnetic resonance imaging assessment toward muscle atrophy may provide some additional information enabling the subclassification of that group of patients.

Lumbar Disc Herniation

PURPOSE OF REVIEW

Substantial advancements have been made in the cause, diagnosis, imaging, and treatment options available for patients with lumbar disc herniation (LDH). We examined the current evidence and highlight the concepts on the frontline of discovery in LDH.

RECENT FINDINGS

There are a myriad of novel etiologies of LDH detailed in recent literature including inflammatory factors and infectious microbes. In the clinical setting, recent data focuses on improvements in computer tomography as a diagnostic tool and non-traditional injection options including tumor necrosis alpha inhibitors and platelet-rich plasma. Operative treatment outcomes have focused on minimally invasive endoscopic approaches and demonstrated robust 5-year post-operative outcomes. Advances in the molecular etiology of LDH will continue to drive novel treatment options. The role of endoscopic treatment for LDH will continue to evolve. Further research into10-year outcomes will be necessary as this surgical approach continues to gain widespread popularity.