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Cervera-Irimia J, Tomé-Bermejo F. [Caudal epidural steroid injection in the treatment of chronic discogenic low back pain. Comparative, prospective and randomized study]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013; 57:324-32. [PMID: 24071051 DOI: 10.1016/j.recot.2013.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/07/2013] [Accepted: 05/09/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE There is no consensus on the treatment of chronic low back pain of disc origin in the medical literature. The few prospective, randomized, controlled studies evaluating the effectiveness of caudal epidural steroid injections (CESI) have obtained contradictory results. The aim of this study is to evaluate the efficacy of CEI in reducing pain and improving the associated disability. MATERIAL AND METHOD This is a prospective, randomized, case-control study of a group of 46 patients with chronic low back disc pain. Patients were randomly allocated into 2 groups to either receive fluoroscopy guided CESI (CESI-group), or oral non-steroidal anti-inflammatory drugs (NSAID-group). All patients were clinically evaluated at 4, 12, and 24 weeks, and according to the indications of the Spanish Society for Study of Diseases of the Spine (GEER). RESULTS Lumbar pain, measured by the visual analog scale (VAS) and the Oswestry Low Back Pain Disability Questionnaire (ODQ), did not improve significantly during follow-up in any of the two study groups (P>.05). Younger patients, women, patients with shorter duration of symptoms, low physical job demand, without leg pain, and sport-active, included in CESI-group showed a trend towards better results, but none reached statistical significance (P>.05). CONCLUSIONS The present study has not demonstrated the superiority of CESI over NSAIDs in treating chronic low back pain of disc origin. While CESI could show some improvement in patients with degenerative lumbar disc disease, we consider it should be used with caution, informing patients about realistic expectations on the success of treatment.
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Affiliation(s)
- J Cervera-Irimia
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Virgen de la Salud, Toledo, España
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102
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Morlion B. Chronic low back pain: pharmacological, interventional and surgical strategies. Nat Rev Neurol 2013; 9:462-73. [DOI: 10.1038/nrneurol.2013.130] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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103
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Eardley S, Brien S, Little P, Prescott P, Lewith G. Professional kinesiology practice for chronic low back pain: single-blind, randomised controlled pilot study. ACTA ACUST UNITED AC 2013; 20:180-8. [PMID: 23860019 DOI: 10.1159/000346291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic low back pain is a highly prevalent condition with no definitive treatment. Professional Kinesiology Practice (PKP) is a little known complementary medicine technique using non-standard muscle testing; no previous effectiveness studies have been performed. METHODS This is an exploratory, pragmatic single-blind, 3-arm randomised sham-controlled pilot study with waiting list control (WLC) in private practice UK (2007-2009). 70 participants scoring ≥4 on the Roland and Morris Disability Questionnaire (RMDQ) were randomised to real or sham PKP receiving 1 treatment weekly for 5 weeks or a WLC. WLC's were re-randomised to real or sham after 6 weeks. The main outcome was a change in RMDQ from baseline to end of 5 weeks of real or sham PKP. RESULTS With an effect size of 0.7 real treatment was significantly different to sham (mean difference RMDQ score = -2.9, p = 0.04, 95% CI -5.8 to -0.1). Compared to WLC, real and sham groups had significant RMDQ improvements (real -9.0, p < 0.01, 95% CI -12.1 to -5.8; effect size 2.1; sham -6.1, p < 0.01, 95% CI -9.1 to -3.1; effect size 1.4). Practitioner empathy (CARE) and patient enablement (PEI) did not predict outcome; holistic health beliefs (CAMBI) did, though. The sham treatment appeared credible; patients did not guess treatment allocation. 3 patients reported minor adverse reactions. CONCLUSIONS Real treatment was significantly different from sham demonstrating a moderate specific effect of PKP; both were better than WLC indicating a substantial non-specific and contextual treatment effect. A larger definitive study would be appropriate with nested qualitative work to help understand the mechanisms involved in PKP.
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Affiliation(s)
- S Eardley
- Complementary and Integrative Medicine Research, Primary Medical Care, University of Southampton, UK.
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104
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Cuesta-Vargas AI, González-Sánchez M. Obesity effect on a multimodal physiotherapy program for low back pain suffers: patient reported outcome. J Occup Med Toxicol 2013; 8:13. [PMID: 23663679 PMCID: PMC3658872 DOI: 10.1186/1745-6673-8-13] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 05/08/2013] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Several studies have linked obesity to the increased likelihood of lower back pain, but there are no studies focussing on the effectiveness of a multimodal physiotherapy programme (MPP) in obese subjects who suffer from chronic non-specific lower back pain (CNLBP). The aim of this study was to compare the effectiveness of an MPP in obese (G1) (body mass index (BMI):≥30) and non-obese (G2) (BMI:<30) patients with CNLBP. METHODS A quasi-experimental study with pre- and post-intervention evaluations of an MPP (lasting 8 weeks) was conducted on obese and non-obese patients with CNLBP. A total of 53 people were included in the study: G1, composed of 19 patients (10 men and 9 women) with a BMI of 33.75 and a mean age of 52.94 years, and G2, composed of 34 patients (18 men and 16 women) with a mean age of 49.19 years and an average BMI of 25.56. All patients were measured to calculate pre-intervention (baseline) and post-intervention (8 weeks) changes in disability (RMQ) and health related quality of life in physical and mental health component state of SF12 and quality of life (EQ-5D and EQ-VAS). RESULTS Post-intervention, non-obese group shown significant high improve than obese group in disability (RMQ: 4.00), physical component state of SF-12: (-7.26) and quality of life (EQ-VAS.: -10.49). CONCLUSIONS In patients with CNLBP, a BMI more than or equal to 30 minimises the effects of an MPP lasting 8 weeks.
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Affiliation(s)
- Antonio I Cuesta-Vargas
- Department of Physiotherapy, Faculty of Health Sciences, University of Malaga, Malaga, Spain.
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105
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Volinn E, Yang B, He J, Sheng X, Ying J, Zuo Y. Do outcomes of acupuncture for back pain differ according to varying sociocultural contexts? The view from China. J Altern Complement Med 2013; 19:435-44. [PMID: 23186130 PMCID: PMC3651679 DOI: 10.1089/acm.2010.0786] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES What are the outcomes of acupuncture for back pain? According to well-regarded trials, acupuncture is little better for back pain than biomedicine, and active acupuncture is no better than sham acupuncture. These trials occurred in the West. Patients are inside the clinic a miniscule amount of time in relation to the time they are outside the clinic and enmeshed in the wider sociocultural context. Nevertheless, trials have largely overlooked potential effects of sociocultural context. The main objective of this article is to draw attention to designated features of sociocultural context that, as compared with outcomes obtained in the West, may enhance outcomes of acupuncture for back pain in China. Additional objectives of the article are to reconceptualize "sociocultural context" so that it is measurable, and to measure pre-existing acquaintance with acupuncture and other forms of Traditional Chinese Medicine (TCM) within the sociocultural context of China. DESIGN/SETTING/SUBJECTS Back pain patients (N=86) were recruited from the Acupuncture Clinic and Pain Clinic of West China Hospital (Chengdu, Sichuan Province). Patients completed questionnaires on their use of TCM before they came to the Acupuncture Clinic and their families' use of TCM. RESULTS Most patients had used TCM, and those who did so likely used it repeatedly, which indicated substantial acquaintance with TCM beliefs in the cultural context. Patients whose families used TCM were also likely to use it themselves, which indicated that TCM use was anchored in the social context of the family. CONCLUSIONS Although multiple studies substantiate biologic mechanisms of acupuncture, there is not necessarily a fixed relationship between those mechanisms and people's experience of them. Rather, sociocultural context may interact with biologic mechanisms and mediate this experience. The theory proposed here explains why outcomes of acupuncture for back pain will potentially be more pronounced in the sociocultural context of China than in the West.
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Affiliation(s)
- Ernest Volinn
- Department of Anesthesiology, Pain Research Center, School of Medicine, University of Utah, Salt Lake City, UT 84108, USA.
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106
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Karstens S, Hermann K, Froböse I, Weiler SW. Predictors for half-year outcome of impairment in daily life for back pain patients referred for physiotherapy: a prospective observational study. PLoS One 2013; 8:e61587. [PMID: 23620772 PMCID: PMC3631224 DOI: 10.1371/journal.pone.0061587] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 03/12/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE From observational studies, there is only sparse information available on the predictors of development of impairment in daily life for patients receiving physiotherapy. Therefore, our aim was to identify factors which predict impairment in daily life for patients with back pain 6 months after receiving physiotherapy. METHODS We conducted a prospective cohort study with 6-month follow-up. Patients were enrolled for treatment in private physiotherapy practices. Patients with a first physiotherapy referral because of thoracic or low back pain, aged 18 to 65 years were included. Primary outcome impairment was measured utilising the 16-item version of the Musculoskeletal Function Assessment Questionnaire. Therapy was documented on a standardized form. Baseline scores for impairment in daily life, symptom characteristics, sociodemographic and psychosocial factors, physical activity, nicotine consumption, intake of analgesics, comorbidity and delivered primary therapy approach were investigated as possible predictors. Univariate and multiple linear regression analyses were performed. RESULTS A total of 792 patients participated in the study (59% female, mean age 44.4 (SD 11.4), with 6-month follow-up results available from 391 patients. In univariate analysis 17 variables reached significance. In multiple linear regression identified predictors were: impairment in daily life before therapy, mental disorders, duration of the complaints, self-prognosis on work ability, rheumatoid arthritis, age, form of stress at work and physical activity. The variables explain 34% of variance (adjusted R(2), p<0.001). CONCLUSIONS With minimal information available from observational studies on the predictors of development of back problems for physiotherapy patients, this study adds new knowledge for forming appropriate referral guidelines. Impairment in daily life before therapy, mental disorder as comorbidity and the duration of the complaints can be named as outstanding factors. The results of this study can be used to facilitate comparison of patient therapy goals with the prognosis in everyday practice.
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Affiliation(s)
- Sven Karstens
- Institute of Health Promotion and Clinical Movement Science, German Sport University Cologne, Cologne, Germany.
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107
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Quality of systematic reviews on specific spinal stabilization exercise for chronic low back pain. J Orthop Sports Phys Ther 2013; 43:242-50. [PMID: 23321935 DOI: 10.2519/jospt.2013.4346] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVE To evaluate the quality of systematic reviews (SRs) on specific stabilization exercises for chronic low back pain (LBP). BACKGROUND Multiple SRs regarding the effectiveness of lumbar stabilization exercises for people with chronic LBP have been published. As more SRs are published, the more it is recognized that, like other forms of research, methodological quality affects the validity of, and conclusions drawn from, the data. METHODS A search of MEDLINE, CINAHL, and Embase was completed. Additionally, the PEDro database was screened and hand searching was completed. Included SRs had to contain randomized controlled trials examining a specific stabilization exercise program for the treatment of chronic LBP. Additionally, the assessed outcome measures had to include pain and/or disability measures. Literature reviews and clinical practice guidelines were excluded. Three reviewers independently assessed each SR for methodological quality. RESULTS The search produced 665 SRs for review, of which 8 fulfilled the inclusion criteria. Consensus quality assessment scores ranged from 13/26 to 26/26, with an average of 20.7 points. Percent agreement and kappa values for individual criteria scores ranged from 50% to 92% and 0.25 to 0.85, respectively. Agreement was moderate to substantial across individual items, except for criterion 1. The intraclass correlation coefficient for overall score was 0.98 (95% confidence interval: 0.96, 0.99). CONCLUSION This review of SRs identified several high-quality reviews that indicated some benefit of specific stabilization exercise programs for patients with nonspecific chronic LBP. LEVEL OF EVIDENCE Therapy, level 1a.
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108
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Cuesta-Vargas AI, González-Sánchez M, Casuso-Holgado MJ. Effect on health-related quality of life of a multimodal physiotherapy program in patients with chronic musculoskeletal disorders. Health Qual Life Outcomes 2013; 11:19. [PMID: 23414183 PMCID: PMC3577634 DOI: 10.1186/1477-7525-11-19] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 02/13/2013] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Musculoskeletal disorders are major causes of morbidity in the world, and these conditions have a strong negative influence in terms of health-related quality of life. The purpose of this study was to evaluate the effect of an 8-week multimodal physical therapy program on general health state and health-related quality of life in patients with chronic musculoskeletal disorders. METHODS There were 244 participants in this prospective cohort analysis with 8-week follow-up. The primary outcome was general health state (physical and mental components), determined with the Short Form-12 Health Survey (SF-12). The secondary outcome was health related quality of life, determined with the EuroQoL-5D and VAS. The intervention was evaluated by comparing pre- and post-outcome measurements. T-tests were performed for paired data. RESULTS Differences were statistically significant for physical health state: +1.68 (p < 0.05) (baseline: 42.38); mental health state: +3.15 (p < 0.001) (baseline: 46.57); and health related quality of life: +0.18 (EuroQoL 5D) (baseline: 46.57) and +7.22 (EuroQoL_VAS) (p < 0.001) (baseline: 60.81). Intervention resulted in clinically relevant changes in terms of percentage improvement from baseline scores. CONCLUSIONS Eight weeks of a Multimodal Physical Therapy Program seemed to moderately enhance the general health state and HRQoL of patients with chronic musculoskeletal diseases. This kind of therapeutic exercise can be recommended to patients with chronic low back pain, chronic neck pain and osteoarthritis, at least in the short term.
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Affiliation(s)
- Antonio Ignacio Cuesta-Vargas
- School of Clinical Science, Queensland University of Technology, Brisbane, Australia
- Physiotherapy Department, University of Malaga, Malaga, Spain
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109
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Transcranial Direct Current Stimulation of the Motor Cortex in the Treatment of Chronic Nonspecific Low Back Pain. Clin J Pain 2013; 29:26-34. [DOI: 10.1097/ajp.0b013e318247ec09] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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110
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Affiliation(s)
- Andreas Werber
- Stiftung Orthopädische Universitätsklinik, Universitätsklinikum Heidelberg.
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111
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Lefebvre R, Peterson D, Haas M. Evidence-Based Practice and Chiropractic Care. J Evid Based Complementary Altern Med 2012; 18:75-79. [PMID: 23875117 DOI: 10.1177/2156587212458435] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Evidence-based practice has had a growing impact on chiropractic education and the delivery of chiropractic care. For evidence-based practice to penetrate and transform a profession, the penetration must occur at 2 levels. One level is the degree to which individual practitioners possess the willingness and basic skills to search and assess the literature. Chiropractic education received a significant boost in this realm in 2005 when the National Center for Complementary and Alternative Medicine awarded 4 chiropractic institutions R25 education grants to strengthen their research/evidence-based practice curricula. The second level relates to whether the therapeutic interventions commonly employed by a particular health care discipline are supported by clinical research. A growing body of randomized controlled trials provides evidence of the effectiveness and safety of manual therapies.
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112
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Gerhardt A, Hartmann M, Tesarz J, Janke S, Leisner S, Seidler G, Eich W. Subgroups of musculoskeletal pain patients and their psychobiological patterns - the LOGIN study protocol. BMC Musculoskelet Disord 2012; 13:136. [PMID: 22862787 PMCID: PMC3476389 DOI: 10.1186/1471-2474-13-136] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 07/23/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain conditions of the musculoskeletal system are very common and have tremendous socioeconomic impact. Despite its high prevalence, musculoskeletal pain remains poorly understood and predominantly non-specifically and insufficiently treated.The group of chronic musculoskeletal pain patients is supposed to be heterogeneous, due to a multitude of mechanisms involved in chronic pain. Psychological variables, psychophysiological processes, and neuroendocrine alterations are expected to be involved. Thus far, studies on musculoskeletal pain have predominantly focused on the general aspects of pain processing, thus neglecting the heterogeneity of patients with musculoskeletal pain. Consequently, there is a need for studies that comprise a multitude of mechanisms that are potentially involved in the chronicity and spread of pain. This need might foster research and facilitate a better pathophysiological understanding of the condition, thereby promoting the development of specific mechanism-based treatments for chronic pain. Therefore, the objectives of this study are as follows: 1) identify and describe subgroups of patients with musculoskeletal pain with regard to clinical manifestations (including mental co-morbidity) and 2) investigate whether distinct sensory profiles or 3) distinct plasma levels of pain-related parameters due to different underlying mechanisms can be distinguished in various subgroups of pain patients. METHODS/DESIGN We will examine a population-based chronic pain sample (n = 100), a clinical tertiary care sample (n = 100) and pain-free patients with depression or post-traumatic stress disorder and pain-free healthy controls (each n = 30, respectively). The samples will be pain localisation matched by sex and age to the population-based sample. Patients will undergo physical examination and thorough assessments of mental co-morbidity (including psychological trauma), perceptual and central sensitisation (quantitative sensory testing), descending inhibition (conditioned pain modulation, the diffuse noxious inhibitory control-like effect), as well as measurement of the plasma levels of nerve growth factor and endocannabinoids. DISCUSSION The identification of the underlying pathophysiologic mechanisms in different subgroups of chronic musculoskeletal pain patients will contribute to a mechanism-based subgroup classification. This will foster the development of mechanism-based treatments and holds promise to treat patients more sufficient.
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Affiliation(s)
- Andreas Gerhardt
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany.
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113
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Hush JM, Marcuzzi A. Prevalence of neuropathic features of back pain in clinical populations: implications for the diagnostic triage paradigm. Pain Manag 2012; 2:363-72. [DOI: 10.2217/pmt.12.36] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Contemporary clinical assessment of back pain is based on the diagnostic triage paradigm. The most common diagnostic classification is nonspecific back pain, considered to be of nociceptive etiology. A small proportion are diagnosed with radicular pain, of neuropathic origin. In this study we review the body of literature on the prevalence of neuropathic features of back pain, revealing that the point prevalence is 17% in primary care, 34% in mixed clinical settings and 53% in tertiary care. There is evidence that neuropathic features of back pain are not restricted to typical clinical radicular pain phenotypes and may be under-recognized, particularly in primary care. The consequence of this is that in the clinic, diagnostic triage may erroneously classify patients with nonspecific back pain or radicular pain. A promising alternative is the development of mechanism-based pain phenotyping in patients with back pain. Timely identification of contributory pain mechanisms may enable greater opportunity to select appropriate therapeutic targets and improve patient outcomes.
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Affiliation(s)
- Julia M Hush
- Faculty of Human Sciences, Macquarie University, Balaclava Rd, North Ryde, NSW 2109, Australia
| | - Anna Marcuzzi
- The University of Pisa, Lungarno Pacinotti, 43-56126, Italy
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Tesarz J, Schuster AK, Hartmann M, Gerhardt A, Eich W. Pain perception in athletes compared to normally active controls: A systematic review with meta-analysis. Pain 2012; 153:1253-1262. [DOI: 10.1016/j.pain.2012.03.005] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 03/05/2012] [Accepted: 03/05/2012] [Indexed: 02/05/2023]
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Caporaso F, Pulkovski N, Sprott H, Mannion AF. How well do observed functional limitations explain the variance in Roland Morris scores in patients with chronic non-specific low back pain undergoing physiotherapy? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 21 Suppl 2:S187-95. [PMID: 22430540 DOI: 10.1007/s00586-012-2255-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 02/26/2012] [Accepted: 02/28/2012] [Indexed: 12/19/2022]
Abstract
PURPOSE Self-rated activity limitations in patients with non-specific chronic low back pain (cLBP) do not correlate well with performance in traditional tests of impairment (e.g. back strength, ROM, etc.). Tests using more "functional activities" have therefore been recommended as alternative "objective" outcome measures. We examined the relationship between a battery of such tests and self-reported activity limitations, before and in response to physiotherapy, and the influence of psychological factors on the relationship. METHODS 37 patients with cLBP took part (45 ± 12 years; 23 female, 14 male); 32 completed 9 weeks' physiotherapy. Before and after therapy, the patients completed the Roland Morris (RM) disability questionnaire and questionnaires to assess fear avoidance beliefs, catastrophising and psychological disturbance. They also performed eight simple functional tests (stair climb, prolonged flexion, stand to floor, lift test, sock test, roll-up test, pick-up test, fingertip-to-floor test). RESULTS Baseline RM scores were significantly (p < 0.05) correlated with all but one of the functional test scores (ranging from r = -0.34 (half-flexion) to 0.56 (pick-up test), and with a functional test index score for all tests together (r = 0.60, p < 0.0001). The correlation between the change-scores (after treatment) for RM and for the functional test index was 0.55 (p = 0.001). Psychological factors explained 7-23 % variance in RM scores (baseline, post-therapy, and change scores), beyond that which was explained by the functional tests. Effect sizes for patients with a self-rated "good global outcome" were 1.23 for RM and 0.75 for the functional test index; for those with a "poor outcome", they were -0.08 and 0.23, respectively. CONCLUSION Moderately high correlations (for both absolute and change scores) were observed between the subjective and observed measures of activity limitation. This indicates that to some extent they are assessing the same underlying construct, but it also suggests that each is delivering a certain amount of unique information. Psychological factors explained some of the discrepancy between the two types of measure. Both were responsive to therapy, and their change scores reflected well the patients' global outcome ratings. The two methods of assessing activity limitations should serve to complement one another in the assessment of treatment outcome.
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Affiliation(s)
- F Caporaso
- Division of Rheumatology, University Hospital Zürich, Zurich, Switzerland
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117
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Abstract
Poor efficiency in terms of treatment of unspecific back pain and related chronic pain syndromes has led to the necessity of general care guidelines addressing evidence-based strategies for treatment of lower back pain (LBP). Systematically validated and reviewed algorithms have been established for all kinds of unspecific back pain, covering both acute and chronic syndromes. Concerning the impact of psychosocial risk factors in the development of chronic LBP, multimodal treatment is preferred to monomodal strategies. Self-responsible acting on the part of the patient should be supported while invasive methods in particular, i.e. operative treatment, should be avoided due to lacking evidence in outcome efficiency.
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Affiliation(s)
- A Werber
- Stiftung Orthopädische Universitätsklinik, Universitätsklinikum Heidelberg, Schlierbacher Landstr. 200a, 69118, Heidelberg, Deutschland.
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118
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Abstract
Non-specific low back pain has become a major public health problem worldwide. The lifetime prevalence of low back pain is reported to be as high as 84%, and the prevalence of chronic low back pain is about 23%, with 11-12% of the population being disabled by low back pain. Mechanical factors, such as lifting and carrying, probably do not have a major pathogenic role, but genetic constitution is important. History taking and clinical examination are included in most diagnostic guidelines, but the use of clinical imaging for diagnosis should be restricted. The mechanism of action of many treatments is unclear, and effect sizes of most treatments are low. Both patient preferences and clinical evidence should be taken into account for pain management, but generally self-management, with appropriate support, is recommended and surgery and overtreatment should be avoided.
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Affiliation(s)
- Federico Balagué
- Department of Rheumatology, Physical Medicine, and Rehabilitation, Hôpital Fribourgeois-Hôpital cantonal, Fribourg and Geneva University, Geneva, Switzerland.
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119
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Sensitivity of Single-domain Versus Multiple-domain Outcome Measures to Identify Responders in Chronic Low-back Pain. Clin J Pain 2012; 28:1-7. [DOI: 10.1097/ajp.0b013e3182236209] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 21:575-98. [PMID: 22072093 DOI: 10.1007/s00586-011-2045-6] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 09/14/2011] [Accepted: 10/07/2011] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The effect size for exercise therapy in the treatment of chronic non-specific low back pain (cLBP) is only modest. This review aims to analyse the specificity of the effect by examining the relationship between the changes in clinical outcome (pain, disability) and the changes in the targeted aspects of physical function (muscle strength, mobility, muscular endurance) after exercise therapy. METHODS We searched for exercise therapy trials for cLBP published up to 15 April 2010 in Medline, Embase, Cochrane Library, Cinahl, and PEDro. Two independent reviewers selected studies according to the inclusion criteria. DATA EXTRACTION one author extracted the data of the articles. RESULTS DATA SYNTHESIS 16 studies with a total of 1,476 participants met the inclusion criteria. There was little evidence supporting a relationship between the changes in pain or physical function and the changes in performance for the following measures: mobility (no correlation in 9 studies, weak correlation in 1 study), trunk extension strength (7 and 2, respectively), trunk flexion strength (4 and 1, respectively) and back muscle endurance (7 and 0, respectively). Changes in disability showed no correlation with changes in mobility in three studies and a weak correlation in two; for strength, the numbers were four (no correlation) and two (weak correlation), respectively. CONCLUSIONS The findings do not support the notion that the treatment effects of exercise therapy in cLBP are directly attributable to changes in the musculoskeletal system. Future research aimed at increasing the effectiveness of exercise therapy in cLBP should explore the coincidental factors influencing symptom improvement.
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Affiliation(s)
- F Steiger
- Institute of Human Movement Sciences and Sport, ETH Zürich, Zurich, Switzerland
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Slade SC, Molloy E, Keating JL. The dilemma of diagnostic uncertainty when treating people with chronic low back pain: a qualitative study. Clin Rehabil 2011; 26:558-69. [PMID: 21971757 DOI: 10.1177/0269215511420179] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate how physiotherapists prescribe execise for people with non-specific chronic low back pain in the absence of definitive or differential diagnoses. DESIGN Four guided focus groups were conducted to gather the views of physiotherapists working in primary care. SUBJECTS AND SETTING Twenty-three primary care physiotherapists from metropolitan Melbourne, Australia, were identified from professional organization member lists and publicly available records. They were recruited via email and assembled for focus groups based on eligibility, availability and location. MAIN MEASURES Discussions were audio-taped, transcribed verbatim and analysed for themes by three independent researchers. RESULTS The 'dilemma created by diagnostic uncertainty' emerged as a significant overarching theme with the following subthemes. Physiotherapists: (1) perceive that care-seekers want a clear diagnosis, (2) are challenged by diagnostic uncertainty, (3) are critical when patients fail to improve, (4) feel unprepared by traditional education models and (5) seek support from experienced colleagues. Physiotherapists report needing to: (1) educate care-seekers about their injury/diagnosis, despite diagnostic uncertainty, and (2)observe rapid health outcome improvements. They exhibit potentially negative behaviours, including blame attribution, when this does not occur. CONCLUSIONS Physiotherapists appear under-prepared for the challenges of working with people with chronic conditions. Quality research is warranted to determine best practice in supporting practitioners in the development of suitable therapeutic behaviours to deal with this challenging patient interface.
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Affiliation(s)
- Susan Carolyn Slade
- Department of Physiotherapy, Faculty of Medicine Nursing and Health Sciences, Victoria, Australia.
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Abstract
Degenerative disk disease is a strong etiologic risk factor of chronic low back pain (LBP). A multidisciplinary approach to treatment is often warranted. Patient education, medication, and cognitive behavioral therapies are essential in the treatment of chronic LBP sufferers. Surgical intervention with a rehabilitation regime is sometimes advocated. Prognostic factors related to the outcome of different treatments include maladaptive pain coping and genetics. The identification of pain genes may assist in determining individuals susceptible to pain and in patient selection for appropriate therapy. Biologic therapies show promise, but clinical trials are needed before advocating their use in humans.
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Miciak M, Gross DP, Joyce A. A review of the psychotherapeutic ‘common factors’ model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scand J Caring Sci 2011; 26:394-403. [DOI: 10.1111/j.1471-6712.2011.00923.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hancock M, Maher C, Macaskill P, Latimer J, Kos W, Pik J. MRI findings are more common in selected patients with acute low back pain than controls? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 21:240-6. [PMID: 21822662 DOI: 10.1007/s00586-011-1955-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 05/26/2011] [Accepted: 07/24/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE The purpose of this study is to investigate if lumbar disc pathology identified on MRI scans is more common in patients with acute, likely discogenic, low back pain than matched controls. METHODS We compared rates of MRI findings between 30 cases with low back pain and 30 pain-free controls. Cases were patients presenting for care with likely discogenic low back pain (demonstrated centralisation with repeated movement testing), of moderate intensity and with minimal past history of back pain. Controls were matched for age, gender and past history of back pain. Cases and controls underwent MRI scanning which was read for the presence of a range of MRI findings by two blinded assessors. RESULTS The presence of disc degeneration, modic changes and disc herniation significantly altered the odds of a participant being a case or control. For example subjects were 5.2 times more likely to be a case than a control when disc degeneration grade of ≥3 was present, and 6.0 times more likely with modic changes. The presence of a high-intensity zone or annular tear was found to significantly alter odds for one assessor but not the other assessor. CONCLUSION MRI findings including disc degeneration, modic changes and herniation are more common in selected people with current acute (likely discogenic) low back pain than in controls without current low back pain. Further investigation of the value of MRI findings as prognostic factors and as treatment effect modifiers is required to assess the potential clinical importance of these findings.
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Affiliation(s)
- Mark Hancock
- Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe, Sydney, NSW 1825, Australia.
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Bronfort G, Maiers MJ, Evans RL, Schulz CA, Bracha Y, Svendsen KH, Grimm RH, Owens EF, Garvey TA, Transfeldt EE. Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. Spine J 2011; 11:585-98. [PMID: 21622028 DOI: 10.1016/j.spinee.2011.01.036] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 12/03/2010] [Accepted: 01/26/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Several conservative therapies have been shown to be beneficial in the treatment of chronic low back pain (CLBP), including different forms of exercise and spinal manipulative therapy (SMT). The efficacy of less time-consuming and less costly self-care interventions, for example, home exercise, remains inconclusive in CLBP populations. PURPOSE The purpose of this study was to assess the relative efficacy of supervised exercise, spinal manipulation, and home exercise for the treatment of CLBP. STUDY DESIGN/SETTING An observer-blinded and mixed-method randomized clinical trial conducted in a university research clinic in Bloomington, MN, USA. PATIENT SAMPLE Individuals, 18 to 65 years of age, who had a primary complaint of mechanical LBP of at least 6-week duration with or without radiating pain to the lower extremity were included in this trial. OUTCOME MEASURES Patient-rated outcomes were pain, disability, general health status, medication use, global improvement, and satisfaction. Trunk muscle endurance and strength were assessed by blinded examiners, and qualitative interviews were performed at the end of the 12-week treatment phase. METHODS This prospective randomized clinical trial examined the short- (12 weeks) and long-term (52 weeks) relative efficacy of high-dose, supervised low-tech trunk exercise, chiropractic SMT, and a short course of home exercise and self-care advice for the treatment of LBP of at least 6-week duration. The study was approved by local institutional review boards. RESULTS A total of 301 individuals were included in this trial. For all three treatment groups, outcomes improved during the 12 weeks of treatment. Those who received supervised trunk exercise were most satisfied with care and experienced the greatest gains in trunk muscle endurance and strength, but they did not significantly differ from those receiving chiropractic spinal manipulation or home exercise in terms of pain and other patient-rated individual outcomes, in both the short- and long-term. CONCLUSIONS For CLBP, supervised exercise was significantly better than chiropractic spinal manipulation and home exercise in terms of satisfaction with treatment and trunk muscle endurance and strength. Although the short- and long-term differences between groups in patient-rated pain, disability, improvement, general health status, and medication use consistently favored the supervised exercise group, the differences were relatively small and not statistically significant for these individual outcomes.
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Affiliation(s)
- Gert Bronfort
- Wolfe Harris Center for Clinical Studies, Northwestern Health Sciences University, Bloomington, MN 55431,
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Exercise, Manual Therapy, and Education with or Without High-Intensity Deep-Water Running for Nonspecific Chronic Low Back Pain. Am J Phys Med Rehabil 2011; 90:526-34; quiz 535-8. [DOI: 10.1097/phm.0b013e31821a71d0] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hahne AJ, Ford JJ, Surkitt LD, Richards MC, Chan AYP, Thompson SL, Hinman RS, Taylor NF. Specific treatment of problems of the spine (STOPS): design of a randomised controlled trial comparing specific physiotherapy versus advice for people with subacute low back disorders. BMC Musculoskelet Disord 2011; 12:104. [PMID: 21599941 PMCID: PMC3121656 DOI: 10.1186/1471-2474-12-104] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 05/20/2011] [Indexed: 11/29/2022] Open
Abstract
Background Low back disorders are a common and costly cause of pain and activity limitation in adults. Few treatment options have demonstrated clinically meaningful benefits apart from advice which is recommended in all international guidelines. Clinical heterogeneity of participants in clinical trials is hypothesised as reducing the likelihood of demonstrating treatment effects, and sampling of more homogenous subgroups is recommended. We propose five subgroups that allow the delivery of specific physiotherapy treatment targeting the pathoanatomical, neurophysiological and psychosocial components of low back disorders. The aim of this article is to describe the methodology of a randomised controlled trial comparing specific physiotherapy treatment to advice for people classified into five subacute low back disorder subgroups. Methods/Design A multi-centre parallel group randomised controlled trial is proposed. A minimum of 250 participants with subacute (6 weeks to 6 months) low back pain and/or referred leg pain will be classified into one of five subgroups and then randomly allocated to receive either physiotherapy advice (2 sessions over 10 weeks) or specific physiotherapy treatment (10 sessions over 10 weeks) tailored according to the subgroup of the participant. Outcomes will be assessed at 5 weeks, 10 weeks, 6 months and 12 months following randomisation. Primary outcomes will be activity limitation measured with a modified Oswestry Disability Index as well as leg and back pain intensity measured on separate 0-10 Numerical Rating Scales. Secondary outcomes will include a 7-point global rating of change scale, satisfaction with physiotherapy treatment, satisfaction with treatment results, the Sciatica Frequency and Bothersomeness Scale, quality of life (EuroQol-5D), interference with work, and psychosocial risk factors (Orebro Musculoskeletal Pain Questionnaire). Adverse events and co-interventions will also be measured. Data will be analysed according to intention to treat principles, using linear mixed models for continuous outcomes, Mann Whitney U tests for ordinal outcomes, and Chi-square, risk ratios and risk differences for dichotomous outcomes. Discussion This trial will determine the difference in outcomes between specific physiotherapy treatment tailored to each of the five subgroups versus advice which is recommended in guidelines as a suitable treatment for most people with a low back disorder. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000834257.
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Affiliation(s)
- Andrew J Hahne
- Musculoskeletal Research Centre and School of Physiotherapy, La Trobe University, Bundoora, Victoria 3086, Australia.
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Cissik JM. The Role of Core Training in Athletic Performance, Injury Prevention, and Injury Treatment. Strength Cond J 2011. [DOI: 10.1519/ssc.0b013e3182076ac3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hopton AK, Thomas KJ, MacPherson H. Willingness to Try Acupuncture Again: Reports from Patients on Their Treatment Reactions in a Low Back Pain Trial. Acupunct Med 2010; 28:185-8. [DOI: 10.1136/aim.2010.002279] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Reactions to treatment are common following acupuncture. Understanding how these reactions are interpreted by patients is largely unexplored. Objective To examine patients’ ratings of the severity and bothersomeness of a range of common treatment reactions, and to assess their impact on willingness to try acupuncture again. Methods Self-reported ratings of the frequency, severity and bothersomeness of treatment reactions from 133 patients in the acupuncture arm of a pragmatic randomised controlled trial of acupuncture for chronic back pain are described and analysed. Results A total of 133 acupuncture patients reported at 3 months reactions that they had experienced at any time during a course of up to 10 acupuncture treatment sessions. They received a total of 1150 treatments, an average of 8.6 sessions per patient. All patients reported treatment reactions, most commonly relaxation (84%, n = 112), which was significantly associated with willingness to try acupuncture again, (χ2 = 7.860, df = 1, p = 0.005). Only 16% (n=21) were unwilling to experience a specific treatment reaction again, and 9% (n = 12) were unwilling to try acupuncture again. The most ‘bothersome’ reaction was a temporary worsening of symptoms (29%, n=38), though this was not associated with an unwillingness to try acupuncture again (χ2 = 0.382, df = 1, p>0.536). Those unwilling to try acupuncture again reported significantly less reduction in their pain at 3 months (mean (SE) SF-36 bodily pain score at 3 months 30.453 (3.598) vs 19.30 (1.128); p=0.003). Conclusion Among this group of patients seeking help for low back pain, the experience of treatment reactions was universal. There was no evidence that the bothersomeness of treatment reactions was associated with patient's willingness to try acupuncture again. The benefit of pain reduction over the course of treatment appeared to outweigh self-rated bothersome reactions to treatment.
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Affiliation(s)
- A K Hopton
- Department of Health Sciences, University of York, York, UK
| | - K J Thomas
- School of Healthcare, University of Leeds, Leeds, UK
| | - H MacPherson
- Department of Health Sciences, University of York, York, UK
- Foundation for Research into Traditional Chinese Medicine, York, UK
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BOMBARDIER CLAIRE, EVANS CHRISJ, KATZ NATHANIEL, MARDEKIAN JACK, ZLATEVA GERGANA, SIMON LEES. Further Qualification of a Therapeutic Responder Index for Patients with Chronic Low Back Pain. J Rheumatol 2010; 38:362-9. [DOI: 10.3899/jrheum.091444] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.Previously, a preliminary patient responder index (RI) in chronic low back pain (CLBP) was developed and validated in 5 placebo-controlled clinical trials. The resulting RI was a > 30% improvement in CLBP and patient global assessment (PGA), and no worsening (< 20%) in the Roland Morris Disability Questionnaire (RMDQ) total score. Our objective was to provide further characterization of the preliminary RI in a trial with an active control.Methods.Data from a 6-week randomized, double-blind study of celecoxib compared to tramadol hydrochloride was analyzed to determine differences by treatment group on the CLBP RI and its components, to compare the CLBP RI with each of its individual components, and to reanalyze the original cutoff points for the responder criteria.Results.Of the celecoxib arm, 50.7%, and of the tramadol hydrochloride arm, 43.7% were classified as responders under the CLBP RI (p = 0.043). The PGA is the most important component in the RI (45% of the sample failed to reach the > 30% improvement criteria on the PGA compared to 34% on the low back pain visual analog scale and only 11% on the RMDQ. The agreement among the CLBP RI with each of its 3 components was largest for the PGA component (κ coefficient 0.849) and smallest for the RMDQ component (κ coefficient 0.207).Conclusion.The RI appears to be particularly sensitive to the cutoff point used for improvement in the PGA component. Further testing of the index in trials with other active comparators is required to gain a fuller understanding of its performance.
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Volinn E, Yang B, He J, Sheng X, Ying J, Volinn W, Zhang J, Zuo Y. West China hospital set of measures in Chinese to evaluate back pain treatment. PAIN MEDICINE 2010; 11:637-47. [PMID: 20546508 DOI: 10.1111/j.1526-4637.2010.00846.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Chinese is the most commonly spoken language in the world, and back pain is as prevalent in China as it is elsewhere. Nevertheless, there is a paucity of measures in Chinese to evaluate back pain treatment. We assemble a set of Chinese measures to evaluate outcomes in diverse domains. A set of measures is necessary, because measures in one domain may vary independently from measures in another. Chinese measures are in four domains: pain intensity, global rating of improvement, physical disability, and emotional functioning. The Oswestry Disability Index (ODI) represents the domain of physical disability, and both the World Health Organization Five-Item Well-being Index (WHO-5) and the Center for Epidemiological Studies-Depression Scale (CES-D depression scale) represent the domain of emotional functioning. DESIGN Measures were cross-culturally adapted into Chinese. The development of Chinese versions of the ODI, the WHO-5, and the CES-D entailed psychometric evaluation. Additionally, we administered the previously validated Chinese SF-36 to evaluate the validity of measures in our set. SETTING The western-style Pain Clinic and the Acupuncture Clinic of West China Hospital (Chengdu, Sichuan Province). PATIENTS Eighty-six patients with nonspecific back pain. RESULTS We found no significant differences between patients from the Pain Clinic and those from the Acupuncture Clinic. For the ODI, the CES-D, and the WHO-5, we evaluated the psychometric properties of reliability, validity, and ceiling and floor effects. We found these properties to be good to excellent. CONCLUSIONS In the Appendix (available online, in supplemental materials for this article), we present the West China Hospital set of measures in Chinese to evaluate back pain treatment.
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Affiliation(s)
- Ernest Volinn
- Pain Research Center, Department of Anesthesiology, University of Utah, Salt Lake City, Utah 84108, USA.
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Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology (Oxford) 2010; 49:2346-56. [DOI: 10.1093/rheumatology/keq245] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Jensen OK, Nielsen CV, Stengaard-Pedersen K. One-year prognosis in sick-listed low back pain patients with and without radiculopathy. Prognostic factors influencing pain and disability. Spine J 2010; 10:659-75. [PMID: 20447871 DOI: 10.1016/j.spinee.2010.03.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 03/02/2010] [Accepted: 03/14/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Previous research has documented various psychosocial risk factors with influence on outcome in low back pain (LBP) patients, but the value of clinical predictors has been less well documented. PURPOSE To identify clinical and psychosocial risk factors at baseline influencing disability and pain at 1 year in LBP patients sick-listed 3 to 16 weeks, and to look for differences between nonspecific LBP and radiculopathy. STUDY DESIGN Cohort study with 1-year follow-up based on a randomized clinical trial. OUTCOME MEASURES Disability and change of disability, pain and change in pain at 1 year. METHODS In a randomized clinical study evaluating multidisciplinary versus brief intervention, 325 patients were followed for 1 year. At baseline, they completed a questionnaire and went through a clinical low back examination, including measure of forward flexion and side flexion as well as tender point examination, a method to estimate diffuse tenderness. Furthermore, degenerative changes on plain X-rays of the lumbar spine were quantified, and sciatica was investigated by magnetic resonance imaging. RESULTS Radiculopathy was verified by magnetic resonance imaging in 111 (34%) patients. At 1 year, questions of disability in daily life activities and pain were answered by 60% and 67%, respectively. The intensity of back+leg pain and disability was closely correlated. Statistically significant predictors for both disability and back+leg pain at 1 year were intensity of back+leg pain, worrying and health anxiety, many tender points, and little or moderate exercise in leisure time. Two additional risk factors were identified in patients with radiculopathy: older age and "drinking alcohol less than once per month." Furthermore, disability at 1 year was associated with initial disability and compensation claim, and back+leg pain at 1 year was associated with fear avoidance about physical activity and the duration of pain. Change in disability was more closely associated with return to work than change in pain. Disc degeneration was not associated with disability or pain at 1 year. General health was not statistically significantly associated with outcome when adjusted for back+leg pain, disability, and worrying and health anxiety. CONCLUSIONS Disability and pain at 1 year were associated with baseline disability and pain, diffuse tenderness, worrying and health anxiety, compensation claim, fear avoidance, and baseline exercise habits. Only in patients with verified nerve root affection, older age, and restrained alcohol seemed to play a role. The multivariate models were insufficient in predicting disability and pain, partly because disability and pain were also strongly associated with return to work.
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Affiliation(s)
- Ole Kudsk Jensen
- The Spine Center, Department of Internal Medicine, Region Hospital Silkeborg, Denmark.
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Pransky G, Buchbinder R, Hayden J. Contemporary low back pain research - and implications for practice. Best Pract Res Clin Rheumatol 2010; 24:291-8. [PMID: 20227649 DOI: 10.1016/j.berh.2010.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Each month, several journals contain reports on new ways of looking at low back pain-related risk and prognostic factors, new clinical interventions and suggestions for improved care. This is because back pain continues to be a vexing condition to manage. It often defies evaluation, diagnosis and treatment, and is associated with considerable individual suffering and negative societal impact. Although reviewing new and promising strategies is always interesting and gratifying for the reader, it is sobering to reconsider similar efforts over the past decades. Most new ideas for low back pain care have not proven to be effective when subjected to repeated rigorous and independent evaluation. New developments in epidemiologic and clinical understanding, and innovative approaches to non-medical management now appear to provide the best opportunities for improving outcomes. In this article, we review new perspectives and research studies that show promise, and suggest alternatives to current clinical and research paradigms.
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Affiliation(s)
- Glenn Pransky
- Center for Disability Research, Liberty Mutual Research Institute for Safety, University of Massachusetts Medical Center, 71 Frankland Rd., Hopkinton, MA 01748, USA.
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Mannion AF, Caporaso F, Pulkovski N, Sprott H. Goal attainment scaling as a measure of treatment success after physiotherapy for chronic low back pain. Rheumatology (Oxford) 2010; 49:1734-8. [PMID: 20511346 DOI: 10.1093/rheumatology/keq160] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES In some chronic conditions, patient-specific tools with individualized items have proved to be more sensitive outcome instruments than fixed-item tools; their use has not yet been investigated in chronic low back pain (cLBP). METHODS Eleven males and 21 females [mean age 44.0 (12.3) years] with cLBP, undergoing a spine-stabilization physiotherapy programme, completed the Roland Morris (RM) Disability Scale and a 0-10 pain scale pre- and post-therapy. Post-therapy, goal attainment scaling (GAS) scores were calculated regarding achievement of 2-6 priority GAS goals established pre-therapy; global outcome of therapy was assessed on a 5-point Likert scale. RESULTS Approximately one-fifth of the individualized goals were not covered by items of the RM. Of the 121 individualized goals, 41 (34%) were achieved at the expected level, 42 (35%) were exceeded and 38 (31%) were not reached. GAS scores correlated with change scores for pain (r = 0.61, P < 0.0001) and RM (r = 0.49, P = 0.006). Sixty-five per cent of the patients had a successful outcome according to GAS (i.e. a score >or=50); 55%, according to global outcome (therapy helped/helped a lot); 39%, according to the RM score change (score decrease >or=30%); and 44%, according to the pain score change (score decrease >or=30%). CONCLUSIONS GAS demonstrates the achievement of important goals undetected by fixed-item measures and is a valid and sensitive outcome measure for assessing the success of rehabilitation in patients with cLBP.
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Affiliation(s)
- Anne F Mannion
- Department of Research and Development, Spine Center Division, Schulthess Klinik, Lengghalde 2, 8008 Zürich, Switzerland.
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What is 'manipulation'? A reappraisal. ACTA ACUST UNITED AC 2010; 15:286-91. [PMID: 20080431 DOI: 10.1016/j.math.2009.12.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2008] [Revised: 11/03/2009] [Accepted: 12/21/2009] [Indexed: 11/19/2022]
Abstract
Due primarily to its colloquial function, 'manipulation' is a poor term for distinguishing one healthcare intervention from another. With reports continuing to associate serious adverse events with manipulation, particularly relating to its use in the cervical spine, it is essential that the term be used appropriately and in accordance with a valid definition. The purpose of this paper is to identify empirically-derived features that we propose to be necessary and collectively sufficient for the formation of a valid definition for manipulation. A final definition is not offered. However, arguments for and against the inclusion of features are presented. Importantly, these features are explicitly divided into two categories: the 'action' (that which the practitioner does to the recipient) and the 'mechanical response' (that which occurs within the recipient). The proposed features are: 1) A force is applied to the recipient; 2) The line of action of this force is perpendicular to the articular surface of the affected joint; 3) The applied force creates motion at a joint; 4) This joint motion includes articular surface separation; 5) Cavitation occurs within the affected joint.
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Hopton A, MacPherson H. Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses. Pain Pract 2010; 10:94-102. [PMID: 20070551 DOI: 10.1111/j.1533-2500.2009.00337.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES There is controversy as to whether or not acupuncture is more effective than placebo. To help clarify this debate, we synthesized the evidence gathered from systematic reviews on the pooled data of high-quality randomized controlled trials comparing acupuncture to sham acupuncture for chronic pain. METHOD Systematic reviews of acupuncture for the most commonly occurring forms of chronic pain (back, knee, and head) published between 2003 and 2008 were sourced from Ovid databases: Medline, Allied and Complementary Medicine database, Cochrane Library and Web of Science during December 2008. Eight systematic reviews with meta-analyses of pooled data were eligible for inclusion. Data were extracted for short- and longer-term outcomes for the most commonly occurring forms of pain. Two independent reviewers assessed methodological quality. RESULTS For short-term outcomes, acupuncture showed significant superiority over sham for back pain, knee pain, and headache. For longer-term outcomes (6 to12 months), acupuncture was significantly more effective for knee pain and tension-type headache but inconsistent for back pain (one positive and one inconclusive). In general, effect sizes (standardized mean differences) were found to be relatively small. DISCUSSION The accumulating evidence from recent reviews suggests that acupuncture is more than a placebo for commonly occurring chronic pain conditions. If this conclusion is correct, then we ask the question: is it now time to shift research priorities away from asking placebo-related questions and shift toward asking more practical questions about whether the overall benefit is clinically meaningful and cost-effective?
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Affiliation(s)
- Ann Hopton
- Department of Health Sciences, University of York, York YO10 5DD, U.K.
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Abstract
Musculoskeletal problems are the most common cause of restriction in daily life in most countries. Most health care for musculoskeletal problems is provided in primary care settings, and back pain and joint problems together represent the largest workload of cases of chronic disease seen and managed there. This article reflects on aspects of the occurrence, natural history, prognosis, and management of common joint problems in primary care. Although the biomedical model has contributed to major advances, a model that embraces chronic pain management and its psychological and social components is needed. In particular, primary care is the ideal arena to achieve high-impact secondary prevention of pain and disability in people with osteoarthritis. Physical therapists are in a crucial position in primary care to provide support for self-management of this condition, especially for interventions related to exercise and behavioral change.
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Rabinovitch DL, Peliowski A, Furlan AD. Influence of lumbar epidural injection volume on pain relief for radicular leg pain and/or low back pain. Spine J 2009; 9:509-17. [PMID: 19398387 DOI: 10.1016/j.spinee.2009.03.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2008] [Revised: 02/24/2009] [Accepted: 03/05/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Epidural injections are commonly used to treat low back disorders. It has been proposed that in addition to the anti-inflammatory effects, injected material displaces the dura forward and inward, producing a stretch of the nerve roots that leads to lysis of neural adhesions. Despite this, there are no controlled trials investigating the effect of volume injected with pain as an independent outcome. PURPOSE Review the existing literature to assess the effect of epidural injection volume on relief of radicular leg and low back pain. STUDY DESIGN A systematic review of published clinical trials to assess the correlation between volume of epidural injection and relief of radicular leg and low back pain. METHODS We searched MEDLINE (1966 to January 2009), EMBASE (1980 to January 2009), The Cochrane Library, and the reference lists of retrieved articles. The literature search was limited to English and Human subjects. Studies were included if they involved the following: 1) a controlled clinical trial; 2) epidural injections in treatment groups compared with control injections; 3) the same approach to epidural space in both groups; and 4) pain relief as an independent outcome. Trials that measured pain relief for radicular leg and low back pain, before and after epidural injections were included. Using the Cochrane Back Review Group recommendations, pain relief data were extracted independently by two reviewers into four categories: immediate (<or=6 weeks); short-term (>6 weeks-3 months); intermediate (>or=3 months-1 year); and long-term (>or=1 year). Common effect sizes were calculated for each data point. Quality of the trials was assessed (two independent authors) using the 11-item criteria list recommended in the method guidelines for systematic reviews for the Cochrane Back Review Group. The data were analyzed by calculating the following: correlations between volume difference and effect size at each data point; and comparing the average effect sizes in the studies with same volume in both groups to ones with different volumes. RESULTS Fifteen studies fulfilled the inclusion/exclusion criteria. The correlation between volume difference and pain relief was 0.8027 (p=.002) for the immediate category, 0.5019 (p=.168) for the short-term category, and 0.9470 (p=.014) for the intermediate category. Insufficient data were available to calculate the correlation coefficient in the long-term category. There was a statistically significant difference when comparing the mean effect size where the volume injected was the same between the two groups (mean, standard deviation [SD]: 0.07, -0.26) with those where the volumes were different between comparison groups (mean, SD: 0.81, -0.6), irrespective of the medications injected. CONCLUSIONS These preliminary results suggest a positive correlation between larger volumes of fluid injected in the epidural space and greater relief of radicular leg pain and/or low back pain. Clinicians should not change their practice, until further high-quality clinical studies confirm these findings.
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Affiliation(s)
- Deborah L Rabinovitch
- Division of Physiatry, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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145
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Haldeman S. Thoracic pain in adolescents: another untreatable disease that could consume resources and increase disability? Spine J 2009; 9:339-40. [PMID: 19233735 DOI: 10.1016/j.spinee.2009.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 01/10/2009] [Indexed: 02/03/2023]
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146
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Artus M, van der Windt D. Small effects of treatments for non-specific low back pain: how can we improve patients' outcomes? Rheumatology (Oxford) 2009; 48:464-5. [PMID: 19297416 DOI: 10.1093/rheumatology/kep048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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147
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Rickards LD. Therapeutic needling in osteopathic practice: An evidence-informed perspective. INT J OSTEOPATH MED 2009. [DOI: 10.1016/j.ijosm.2009.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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148
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Effectiveness of traditional bone setting in treating chronic low back pain: A randomised pilot trial. Complement Ther Med 2009; 17:23-8. [DOI: 10.1016/j.ctim.2008.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Revised: 06/25/2008] [Accepted: 08/21/2008] [Indexed: 11/20/2022] Open
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149
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Machado LAC, Kamper SJ, Herbert RD, Maher CG, McAuley JH. Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology (Oxford) 2008; 48:520-7. [PMID: 19109315 DOI: 10.1093/rheumatology/ken470] [Citation(s) in RCA: 152] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Estimates of treatment effects reported in placebo-controlled randomized trials are less subject to bias than those estimates provided by other study designs. The objective of this meta-analysis was to estimate the analgesic effects of treatments for non-specific low back pain reported in placebo-controlled randomized trials. METHODS Medline, Embase, Cinahl, PsychInfo and Cochrane Central Register of Controlled Trials databases were searched for eligible trials from earliest records to November 2006. Continuous pain outcomes were converted to a common 0-100 scale and pooled using a random effects model. RESULTS A total of 76 trials reporting on 34 treatments were included. Fifty percent of the investigated treatments had statistically significant effects, but for most the effects were small or moderate: 47% had point estimates of effects of <10 points on the 100-point scale, 38% had point estimates from 10 to 20 points and 15% had point estimates of >20 points. Treatments reported to have large effects (>20 points) had been investigated only in a single trial. CONCLUSIONS This meta-analysis revealed that the analgesic effects of many treatments for non-specific low back pain are small and that they do not differ in populations with acute or chronic symptoms.
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Affiliation(s)
- L A C Machado
- The George Institute for International Health, Sydney, Australia
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150
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Abstract
STUDY DESIGN A systematic review of randomized controlled trials (RCTs). OBJECTIVE To explore the evidence for the effectiveness of acupuncture for nonspecific low back pain (LBP). SUMMARY OF BACKGROUND DATA Since the most recent systematic reviews on RCTs on acupuncture for LBP, 6 RCTs have been published, which may impact on the previous conclusions. METHODS Searches were completed for RCTs on all types of acupuncture for patients with nonspecific LBP published in English. Methodologic quality was scored using the Van Tulder scale. Trials were deemed to be high quality if they scored more than 6/11 on the Van Tulder scale, carried out appropriate statistical analysis, with at least 40 patients per group, and did not exceed 20% and 30% dropouts at short/intermediate and long-term follow-up, respectively. High quality trials were given more weight when conducting the best evidence synthesis. Studies were grouped according to the control interventions, i.e., no treatment, sham intervention, conventional therapy, acupuncture in addition to conventional therapy. Treatment effect size and clinical significance were also determined. The adequacy of acupuncture treatment was judged by comparison of recommendations made in textbooks, surveys, and reviews. RESULTS Twenty-three trials (n = 6359) were included and classified into 5 types of comparisons, 6 of which were of high quality. There is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief. There is strong evidence that acupuncture can be a useful supplement to other forms of conventional therapy for nonspecific LBP, but the effectiveness of acupuncture compared with other forms of conventional therapies still requires further investigation. CONCLUSION Acupuncture versus no treatment, and as an adjunct to conventional care, should be advocated in the European Guidelines for the treatment of chronic LBP.
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