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Sharif S, Jazaib Ali MY, Kirazlı Y, Vlok I, Zygourakis C, Zileli M. Acute back pain: The role of medication, physical medicine and rehabilitation: WFNS spine committee recommendations. World Neurosurg X 2024; 23:100273. [PMID: 38807862 PMCID: PMC11130729 DOI: 10.1016/j.wnsx.2024.100273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 02/01/2024] [Indexed: 05/30/2024] Open
Abstract
Objectives To formulate the most current, evidence-based recommendations for the role of medication, physical medicine, and rehabilitation in the management of acute low back pain lasting <4 weeks. Methods A systematic literature search in PubMed and Google Scholar databases was performed from 2012 to 2022 using the search terms "acute low back pain," "drugs," "bed rest," "physical medicine," rehabilitation." Standardized screening criteria resulted in a total of 39 articles that were analyzed, including 16 RCTs, 8 prospective studies, 6 retrospective studies, and 9 systematic reviews. This up-to-date information was reviewed and presented at two separate meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. Two rounds of the Delphi method were utilized to vote on the statements and arrive at a positive or negative consensus. Results and conclusion The WFNS Spine Committee finalized twelve recommendation guidelines on the role of medication, physical medicine and rehabilitation in the management of acute LBP. We advocate for a uniform approach to the treatment of these patients, including proper patient education and utilizing drugs with proven efficacy and minimal side effects. First-line pharmacologic agents are acetaminophen and NSAIDs; muscle relaxants can be used for spasms and pain reduction, and opioids should be minimized. Continued activity, rather than bed rest, is recommended, and lumbar spine orthotics may be used to reduce pain and augment functional status. Thermotherapy, cryotherapy, TENs, spinal manipulative therapy, and acupuncture may all be used as adjuncts to improve acute LBP.
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Affiliation(s)
- Salman Sharif
- Department of Neurosurgery, Liaquat National Hospital & Medical College, Karachi, Pakistan
| | | | - Yeşim Kirazlı
- Department of Physical Medicine and Rehabilitation, Ege University, Izmir, Turkey
| | - Ian Vlok
- Department of Neurosurgery, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Corinna Zygourakis
- Department of Neurosurgery, Sanko University Faculty of Medicine, Gaziantep, Turkey
| | - Mehmet Zileli
- Department of Neurosurgery, Stanford University School of Medicine, California, USA
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2
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Jermini-Gianinazzi I, Blum M, Trachsel M, Trippolini MA, Tochtermann N, Rimensberger C, Liechti FD, Wertli MM. Management of acute non-specific low back pain in the emergency department: do emergency physicians follow the guidelines? Results of a cross-sectional survey. BMJ Open 2023; 13:e071893. [PMID: 37541755 PMCID: PMC10407374 DOI: 10.1136/bmjopen-2023-071893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVES Clinical guidelines for acute non-specific low back pain (LBP) recommend avoiding imaging studies or invasive treatments and to advise patients to stay active. The aim of this study was to evaluate the management of acute non-specific LBP in the emergency departments (ED). SETTING We invited all department chiefs of Swiss EDs and their physician staff to participate in a web-based survey using two clinical case vignettes of patients with acute non-specific LBP presenting to an ED. In both cases, no neurological deficits or red flags were present. Guideline adherence and low-value care was defined based on current guideline recommendations. RESULTS In total, 263 ED physicians completed at least one vignette, while 212 completed both vignettes (43% residents, 32% senior/attending physicians and 24% chief physicians). MRI was considered in 31% in vignette 1 and 65% in vignette 2. For pain management, non-steroidal anti-inflammatory drugs, paracetamol and metamizole were mostly used. A substantial proportion of ED physicians considered treatments with questionable benefit and/or increased risk for adverse events such as oral steroids (vignette 1, 12% and vignette 2, 19%), muscle relaxants (33% and 38%), long-acting strong opioids (25% and 33%) and spinal injections (22% and 43%). Although guidelines recommend staying active, 72% and 67% of ED physicians recommended activity restrictions. CONCLUSION Management of acute non-specific LBP in the ED was not in agreement with current guideline recommendations in a substantial proportion of ED physicians. Overuse of imaging studies, the use of long-acting opioids and muscle relaxants, as well as recommendations for activity and work restrictions were prevalent and may potentially be harmful.
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Affiliation(s)
- Ilaria Jermini-Gianinazzi
- Emergency Department, Ospedale Regionale di Bellinzona e Valli Bellinzona, Bellinzona, Ticino, Switzerland
| | - Manuel Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria Trachsel
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maurizio Alen Trippolini
- School of Health Professions, Berne University of Applied Sciences, Bern, Switzerland
- Evidence-based Insurance Medicine (EbIM), Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nicole Tochtermann
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Caroline Rimensberger
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Dominik Liechti
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria M Wertli
- Department of General Internal Medicine, Kantonsspital Baden AG, Baden, Aargau, Switzerland
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Coenen P, de Wind A, van de Ven P, de Maaker-Berkhof M, Koes B, Buchbinder R, Hartvigsen J, Anema JHR. The slow de-implementation of non-evidence-based treatments in low back pain hospital care-Trends in treatments using Dutch hospital register data from 1991 to 2018. Eur J Pain 2023; 27:212-222. [PMID: 36317649 PMCID: PMC10099564 DOI: 10.1002/ejp.2052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 10/13/2022] [Accepted: 10/29/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Low back pain (LBP) is the leading cause of disability worldwide and has an excessive societal burden. Accumulating evidence has shown that some medical approaches such as imaging in absence of clear indications, medication and some invasive treatments may contribute to the problem rather than alleviating it. OBJECTIVES To determine the extent of de-implementation of non-evidence-based hospital treatments for LBP care in the Netherlands in the last three decades. METHODS Using a register-based population-level observational study with Dutch hospital data, providing a nearly complete coverage of hospital admissions in the Netherlands in 1991-2018, we assessed five frequently applied non-evidence-based hospital treatments for LBP. Time trends in treatment use (absolute and per 100,000 inhabitants) were plotted and analysed using Poisson regression. RESULTS The use of bed rest for non-specific LBP and hernia nuclei pulposi, and discectomy for spinal stenosis decreased 91%, 81% and 86% since the availability of evidence/guidelines, respectively. De-implementation, beyond 84%, was reached after 18 and 17 years for bed rest for non-specific LBP and discectomy respectively, while it was not reached after 28 years for bed rest for hernia nuclei pulposi. For spinal fusion and invasive pain treatment, there was an initial increase followed by a reduction. Overall, these treatments reduced by 85% and 75%, respectively. CONCLUSIONS In the Netherlands, de-implementation of five non-recommended hospital LBP treatments, if at all, took several decades. Although de-implementation was substantial, slow de-implementation has likely resulted in considerable waste of resources and avoidable harm to many patients in Dutch hospitals. SIGNIFICANCE Medically intensive approaches to low-back pain care contribute to the high societal burden of this disease. There have been calls to avoid such care. Using Dutch hospital data, we showed that de-implementation of five non-recommended hospital low-back pain treatments, if at all, took several decades (i.e. ≥17 years) after availability of evidence and guidelines. Slow de-implementation has likely resulted in considerable waste of resources and avoidable harm to hospital patients; better ways for de-implementation of non-evidence-based care are needed.
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Affiliation(s)
- Pieter Coenen
- Department of Public and Occupational Health, Amsterdam UMC, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Astrid de Wind
- Department of Public and Occupational Health, Amsterdam UMC, Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter van de Ven
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Marianne de Maaker-Berkhof
- Department of Public and Occupational Health, Amsterdam UMC, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Bart Koes
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash Department of Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | - Johannes Han R Anema
- Department of Public and Occupational Health, Amsterdam UMC, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Delloye E, Wauters V, Masabarakiza JB, Dupriez F. 'Adequacy between medical prescription and intake of analgesics for acute low back and neck pain after presentation at the emergency department - do we prescribe too many tablets?'. Acta Clin Belg 2022; 77:510-514. [PMID: 33760719 DOI: 10.1080/17843286.2021.1899696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Acute low back and neck pain account for 3% to 6% of emergency room consultations. In Europe, analgesic prescriptions are issued in boxes. This study, therefore, aims to assess whether this type of packaging is adapted to the real needs of patients. METHODS This is a prospective observational multicenter study. Out of a total of 101 eligible patients who consulted the emergency department with acute low back or neck pain of muscular origin, 60 patients were included for statistical analysis. Follow-up was conducted by phone 10 to 14 days after admission. Different parameters were evaluated: the recovery, the amount of remaining tablets, and the demographic characteristics of patients. RESULTS Seventy-five percent of the evaluated patients were asymptomatic at follow-up and no longer taking the prescribed treatment. For all types of prescribed analgesics, a significant number of tablets remained in the drug boxes (P < 0.0001). After the resolution of symptoms, 90% of the studied patients reported a drug surplus. No significant difference was found in terms of patient demographic characteristics. The results were similar for both neck and low back pain subgroups. CONCLUSION This study suggests that in case of acute low back and neck pain, a significant number of patients who return home after an emergency department consultation have a surplus of analgesics after recovery. These drugs could induce misuse. Moreover, this surplus gives rise to economic and environmental questions. One solution could be to prescribe a number of tablets depending on patients' pathology instead of entire boxes.
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Affiliation(s)
| | - Vanessa Wauters
- Hôpital Jolimont
- Jolimont Hospital: Centre Hospitalier Jolimont, BELGIUM
| | | | - Florence Dupriez
- Cliniques Universitaires Saint-Luc
- Cliniques Universitaires Saint-Luc, BELGIUM
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Chan KY, Tsai WC, Chiang CY, Sheu ML, Huang CY, Tsai YC, Tsai CY, Lu CJ, Ho ZP, Lai DW. Ameliorative Potential of Hot Compress on Sciatic Nerve Pain in Chronic Constriction Injury-Induced Rat Model. Front Synaptic Neurosci 2022; 14:859278. [PMID: 35685245 PMCID: PMC9171142 DOI: 10.3389/fnsyn.2022.859278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/25/2022] [Indexed: 11/24/2022] Open
Abstract
Hot compress modalities are used to ameliorate pain despite prevalent confusion about which modality should be used and when. Most recommendations for hot compresses are based on empirical experience, with limited evidence to support its efficacy. To obtain insight into the nerve transmission mechanism of hot compresses and to identify the nerve injury marker proteins specifically associated with sciatic nerve pain, we established a rat model of chronic constriction injury (CCI) and performed mechanical allodynia, electrophysiology, and histopathological analysis. All CCI rats exhibited geometric representation of the affected hind paw, which indicated a hyper-impact on both mechanical gait and asymmetry of gait on day 28. The CCI model after 28 days of surgery significantly reduced compound muscle action potential (CMAP) amplitude, but also significantly reduced latency. Administration of hot compress for 3 weeks (heated at 40–42°C, cycle of 40 min, and rest for 20 min, three cycles each time, three times per week) significantly increased the paw withdrawal thresholds in response to stimulation by Von Frey fibers and reversed the CCI-induced reduced sciatic functional index (SFI) scores. Hot compress treatment in the CCI model improved CMAP amplitude and latency. The S100 protein expression level in the CCI+Hot compression group was 1.5-fold higher than in the CCI group; it dramatically reduced inflammation, such as tumor necrosis factor alpha and CD68 expression in nerve injury sites. Synaptophysin (Syn) expression in the CCI+Hot compression group was less than threefold in the CCI group at both nerve injury sites and brain (somatosensory cortex and hippocampus). This finding indicates that local nerve damage and inflammation cause significant alterations in the sensorimotor strip, and hot compress treatment could significantly ameliorate sciatic nerve pain by attenuating Syn and inflammatory factors from local pathological nerves to the brain. This study determines the potential efficacy and safety of hot compress, and may have important implications for its widespread use in sciatic nerve pain treatment.
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Affiliation(s)
- Kwan-Yu Chan
- Department of Rehabilitation, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Wen-Ching Tsai
- Department of Rehabilitation, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Chien-Yi Chiang
- Cardiovascular and Mitochondrial Related Disease Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Meei-Ling Sheu
- Institute of Biomedical Sciences, National Chung Hsing University, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chih-Yang Huang
- Cardiovascular and Mitochondrial Related Disease Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Department of Medical Laboratory Science and Biotechnology, Asia University, Taichung, Taiwan
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
- Center of General Education, Buddhist Tzu Chi Medical Foundation, Tzu Chi University of Science and Technology, Hualien, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Yi-Ching Tsai
- Immunomedicine Group, Department of Molecular Biology and Cell Research, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Chia-Yun Tsai
- Experimental Animal Center, Department of Molecular Biology and Cell Research, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Chia-Jung Lu
- Neurodiagnostic center, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Zih-Ping Ho
- Department of Medical Research, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - De-Wei Lai
- Experimental Animal Center, Department of Molecular Biology and Cell Research, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
- *Correspondence: De-Wei Lai, ;
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The Efficacy and Effectiveness of Education for Preventing and Treating Non-Specific Low Back Pain in the Hispanic Cultural Setting: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19020825. [PMID: 35055646 PMCID: PMC8776076 DOI: 10.3390/ijerph19020825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/31/2021] [Accepted: 01/10/2022] [Indexed: 02/04/2023]
Abstract
A systematic review was conducted to assess the efficacy and effectiveness of education programs to prevent and treat low back pain (LBP) in the Hispanic cultural setting. Electronic and manual searches identified 1148 unique references. Nine randomized clinical trials (RCTs) were included in this review. Methodological quality assessment and data extraction followed the recommendations from the Cochrane Back Pain Review Group. Education programs which were assessed focused on active management (3 studies), postural hygiene (7), exercise (4) and pain neurophysiology (1). Comparators were no intervention, usual care, exercise, other types of education, and different combinations of these procedures. Five RCTs had a low risk of bias. Results show that: (a) education programs in the school setting can transmit potentially useful knowledge for LBP prevention and (b) education programs for patients with LBP improve the outcomes of usual care, especially in terms of disability. Education on pain neurophysiology improves the results of education on exercise, and education on active management is more effective than “sham” education and education on postural hygiene. Future studies should assess the comparative or summatory effects of education on exercise, education on pain neurophysiology and education on active management, as well as explore their efficiency.
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7
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Hirase T, Okita M, Nakai Y, Akaida S, Shono S, Makizako H. Pain and physical activity changes during the COVID-19 state of emergency among Japanese adults aged 40 years or older: A cross-sectional study. Medicine (Baltimore) 2021; 100:e27533. [PMID: 34731148 PMCID: PMC8519207 DOI: 10.1097/md.0000000000027533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/29/2021] [Indexed: 01/05/2023] Open
Abstract
Understanding the relationship between pain and physical activity (PA) levels is beneficial for maintaining good health status. However, the impact of pain on changes in PA during the coronavirus disease 2019 (COVID-19) pandemic is unknown. The purpose of this study was to examine whether PA levels pre-, during, and post-COVID-19 state of emergency differ between Japanese adults who had pain after the COVID-19 state of emergency and those who did not.Data were collected from a cross-sectional online survey conducted between October 19 and 28, 2020. The analytic sample consisted of 1967 Japanese adults aged ≥40 years who completed the online survey. Participants completed questionnaires on the presence of pain and duration of PA, defined as the total PA time per week based on activity frequency and time. Participants were asked to report their PA at 3 time points: October 2019 (before the COVID-19 pandemic), April 2020 (during the COVID-19 state of emergency), and October 2020 (after the COVID-19 state of emergency).Among participants aged ≥60 years who reported pain in October 2020, the total PA time was significantly lower than participants who did not report having pain. Furthermore, the total PA time in April 2020 was significantly lower than that in October 2019; however, no significant difference in total PA time was observed between April and October 2020. Among participants aged 40 to 59 years, no significant differences were observed in total PA times at the 3 time points between those with and without pain. In addition, the total PA time in October 2020 significantly increased compared to that in April 2020, although it significantly decreased in April 2020 compared to October 2019.This study suggests that older adults with pain have lower PA levels after the COVID-19 state of emergency.
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Affiliation(s)
- Tatsuya Hirase
- Department of Physical Therapy Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, Japan
| | - Minoru Okita
- Department of Physical Therapy Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, Japan
| | - Yuki Nakai
- Sport Science Area, Department of Mechanical Systems Engineering, Faculty of Engineering, Daiichi Institute of Technology, 1-10-2 Kokubuchuou, Kagoshima, Japan
| | - Shoma Akaida
- Graduate School of Health Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Japan
| | - Saki Shono
- Graduate School of Health Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Japan
| | - Hyuma Makizako
- Department of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Japan
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Abstract
Low back pain is a common problem that is the leading cause of disability and is associated with high costs. Evaluation focuses on identification of risk factors indicating a serious underlying condition and increased risk for persistent disabling symptoms in order to guide selective use of diagnostic testing (including imaging) and treatments. Nonpharmacologic therapies, including exercise and psychosocial management, are preferred for most patients with low back pain and may be supplemented with adjunctive drug therapies. Surgery and interventional procedures are options in a minority of patients who do not respond to standard treatments.
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Affiliation(s)
- Roger Chou
- Oregon Health & Science University, Portland, Oregon
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Vanti C, Turone L, Panizzolo A, Guccione AA, Bertozzi L, Pillastrini P. Vertical traction for lumbar radiculopathy: a systematic review. Arch Physiother 2021; 11:7. [PMID: 33715638 PMCID: PMC7958699 DOI: 10.1186/s40945-021-00102-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 02/08/2021] [Indexed: 12/24/2022] Open
Abstract
Background Only low-quality evidence is currently available to support the effectiveness of different traction modalities in the treatment of lumbar radiculopathy (LR). Yet, traction is still very commonly used in clinical practice. Some authors have suggested that the subgroup of patients presenting signs and symptoms of nerve root compression and unresponsive to movements centralizing symptoms may benefit from lumbar traction. The aim of this study is to conduct a systematic review of randomized controlled trials (RCTs) on the effects of vertical traction (VT) on pain and activity limitation in patients affected by LR. Methods We searched the Cochrane Controlled Trials Register, PubMed, CINAHL, Scopus, ISI Web of Science and PEDro from their inception to March 31, 2019 to retrieve RCTs on adults with LR using VT to reduce pain and activity limitation. We considered only trials reporting complete data on outcomes. Two reviewers selected the studies, extracted the results, and performed the quality assessment using the Risk of Bias and GRADE tools. Results Three studies met the inclusion criteria. Meta-analysis was not possible due to the heterogeneity of the included studies. We found very low quality evidence for a large effect of VT added to bed rest when compared to bed rest alone (g = − 1.01; 95% CI = -2.00 to − 0.02). Similarly, VT added to medication may have a large effect on pain relief when compared to medication alone (g = − 1.13; 95% CI = -1.72 to − 0.54, low quality evidence). Effects of VT added to physical therapy on pain relief were very small when compared to physical therapy without VT (g = − 0.14; 95% CI = -1.03 to 0.76, low quality evidence). All reported effects concerned short-term effect up to 3 months post-intervention. Conclusions With respect to short-term effects, VT may have a positive effect on pain relief if added to medication or bed rest. Long-term effects of VT are currently unknown. Future higher quality research is very likely to have an important impact on our confidence in the estimate of effect and may change these conclusions. Supplementary Information The online version contains supplementary material available at 10.1186/s40945-021-00102-5.
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Affiliation(s)
- Carla Vanti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - Luca Turone
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy.
| | - Alice Panizzolo
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - Andrew A Guccione
- Department of Rehabilitation Science, College of Health and Human Services, George Mason University, Fairfax, VA, 22030, USA
| | - Lucia Bertozzi
- School of Physical Therapy, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Paolo Pillastrini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
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10
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Karlsson M, Bergenheim A, Larsson MEH, Nordeman L, van Tulder M, Bernhardsson S. Effects of exercise therapy in patients with acute low back pain: a systematic review of systematic reviews. Syst Rev 2020; 9:182. [PMID: 32795336 PMCID: PMC7427286 DOI: 10.1186/s13643-020-01412-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 06/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute low back pain is associated with pain and disability, but symptoms are often self-healing. The effectiveness of exercise therapy for acute low back pain remains uncertain with conflicting evidence from systematic reviews. The aim of this systematic review of systematic reviews was to assess the overall certainty of evidence for the effects of exercise therapy, compared with other interventions, on pain, disability, recurrence, and adverse effects in adult patients with acute low back pain. METHODS PubMed, the Cochrane library, CINAHL, PEDro, Open Grey, Web of Science, and PROSPERO were searched for systematic reviews of randomized controlled trials. Methodological quality was assessed independently by two authors using AMSTAR. Meta-analyses were performed if possible, using data from the original studies. Data for pain, disability, recurrence, and adverse effects were analyzed. Certainty of evidence was assessed using GRADE. RESULTS The searches retrieved 2602 records, of which 134 publications were selected for full-text screening. Twenty-four reviews were included, in which 21 randomized controlled trials (n = 2685) presented data for an acute population, related to 69 comparisons. Overlap was high, 76%, with a corrected covered area of 0.14. Methodological quality varied from low to high. Exercise therapy was categorized into general exercise therapy, stabilization exercise, and McKenzie therapy. No important difference in pain or disability was evident when exercise therapy was compared with sham ultrasound, nor for the comparators usual care, spinal manipulative therapy, advice to stay active, and educational booklet. Neither McKenzie therapy nor stabilization exercise yielded any important difference in effects compared with other types of exercise therapy. Certainty of evidence varied from very low to moderate. CONCLUSIONS The findings suggest very low to moderate certainty of evidence that exercise therapy may result in little or no important difference in pain or disability, compared with other interventions, in adult patients with acute low back pain. A limitation of this systematic review is that some included reviews were of low quality. When implementing findings of this systematic review in clinical practice, patients' preferences and the clinician's expertise also should be considered, to determine if and when exercise therapy should be the intervention of choice. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD46146, available at: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=46146 .
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Affiliation(s)
- Marc Karlsson
- Region Skåne, Healthcare Centre Oxie, Malmö, Sweden.,Department of Health and Rehabilitation, Unit of Physiotherapy, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Anna Bergenheim
- Department of Health and Rehabilitation, Unit of Physiotherapy, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Närhälsan Uddevalla Rehabilitation, Uddevalla, Sweden.,Region Västra Götaland, Research and Development Primary Health Care, Kungsgatan 12, 6th floor, SE-412 19, Gothenburg, Sweden
| | - Maria E H Larsson
- Department of Health and Rehabilitation, Unit of Physiotherapy, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Research and Development Primary Health Care, Kungsgatan 12, 6th floor, SE-412 19, Gothenburg, Sweden
| | - Lena Nordeman
- Department of Health and Rehabilitation, Unit of Physiotherapy, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Research and Development Primary Health Care, Kungsgatan 12, 6th floor, SE-412 19, Gothenburg, Sweden
| | - Maurits van Tulder
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Department Physiotherapy & Occupational Therapy, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Susanne Bernhardsson
- Department of Health and Rehabilitation, Unit of Physiotherapy, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden. .,Region Västra Götaland, Research and Development Primary Health Care, Kungsgatan 12, 6th floor, SE-412 19, Gothenburg, Sweden.
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11
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Abstract
Low back pain is the leading cause of incapacitation and medical rehabilitation. The purpose of this German National Health Care Guideline "Nonspecific low back pain" is to optimize the care of patients with low back pain. This guideline was drawn up by 29 professional societies and organizations. In the case of nonspecific low back pain, a detailed medical history and physical examination should be carried out first, but no further diagnostics unless there are indications of the so-called "red flags". For symptomatic treatment, medicine should be given in low doses, and physical activity should be in the foreground. A physician should act as a point of contact throughout the course of the disease, and the patient must be continuously educated and motivated to have a healthy lifestyle, including regular physical activity.
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Affiliation(s)
- Wolfgang Reith
- Klinik für Diagnostische, und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66424, Homburg-Saar, Deutschland.
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12
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Affiliation(s)
- Frank Janssen
- Tagesklinik für Schmerztherapie, Muskuloskelettales Zentrum, Kliniken des Landkreises Neumarkt i. d. OPf., Nürnberger Str. 12, D-92318, Neumarkt i. d. OPf., Deutschland.
| | - Stefanie Füssel
- Muskuloskelettales Zentrum, Kliniken des Landkreises Neumarkt i. d. OPf., Neumarkt i. d. OPf., Deutschland
| | - Nadja Hanisch
- Muskuloskelettales Zentrum, Kliniken des Landkreises Neumarkt i. d. OPf., Neumarkt i. d. OPf., Deutschland
| | - Alexander Schuh
- Muskuloskelettales Zentrum, Kliniken des Landkreises Neumarkt i. d. OPf., Neumarkt i. d. OPf., Deutschland
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13
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The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain. J Clin Med 2019; 8:jcm8091334. [PMID: 31466408 PMCID: PMC6780711 DOI: 10.3390/jcm8091334] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 08/22/2019] [Accepted: 08/22/2019] [Indexed: 02/06/2023] Open
Abstract
Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.
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Gianola S, Castellini G, Andreano A, Corbetta D, Frigerio P, Pecoraro V, Redaelli V, Tettamanti A, Turolla A, Moja L, Valsecchi MG. Effectiveness of treatments for acute and sub-acute mechanical non-specific low back pain: protocol for a systematic review and network meta-analysis. Syst Rev 2019; 8:196. [PMID: 31395091 PMCID: PMC6688358 DOI: 10.1186/s13643-019-1116-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 07/24/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Non-specific low back pain (LBP) is the leading cause of disability worldwide. Acute LBP usually has a good prognosis, with rapid improvement within the first 6 weeks. However, the majority of patients develop chronic LBP and suffer from recurrences. For clinical management, a plethora of treatments is currently available but evidence of the most effective options is lacking. The objective of this study will be to identify the most effective interventions to relieve pain and reduce disability in acute and sub-acute non-specific LBP. METHODS/DESIGN We will search electronic databases (MEDLINE, Embase, CENTRAL) from inception onwards. The eligible population will be individuals with non-specific LBP older than 18 years, both males and females, who experience pain less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Eligible interventions and comparators will include all conservative rehabilitation or pharmacological treatments provided by any health professional; the only eligible study design will be a randomized controlled trial. The primary outcomes will be pain intensity and back-specific functional status. Secondary outcomes will be any adverse events. Studies published in languages other than English will also potentially be included. Two reviewers will independently screen the titles and abstracts retrieved from a literature search, as well as potentially relevant full-text articles. General characteristics, potential effect modifiers, and outcome data will be extracted from the included studies, and the risk of bias will be appraised. Conflicts at all levels of screening and abstraction will be resolved through team discussions. After describing the results of the review, if appropriate, a random effects meta-analysis and network meta-analysis will be conducted in a frequentist setting, assuming equal heterogeneity across all treatment comparisons and accounting for correlations induced by multi-arm studies using a multivariate normal model. DISCUSSION Our systematic review will address the uncertainties in the use of pharmacological or non-pharmacological treatments, and their relative efficacy, for acute and subacute LBP. These findings will be useful for patients, healthcare providers, and policymakers. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018102527.
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Affiliation(s)
- Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Anita Andreano
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Epidemiology Unit, Agency for Health Protection of Milan, Milan, Italy
| | - Davide Corbetta
- Rehabilitation and Functional Recovery Department, IRCCS San Raffaele Hospital, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Pamela Frigerio
- Child and Adolescent Neuropsychiatric Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Valentina Pecoraro
- Department of Laboratory Medicine, OCSAE, Azienda USL of Modena, Modena, Italy
| | | | - Andrea Tettamanti
- Rehabilitation and Functional Recovery Department, IRCCS San Raffaele Hospital, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Turolla
- Laboratory for Neurorehabilitation Technologies, Fondazione Ospedale San Camillo IRCCS, Venice, Italy
| | - Lorenzo Moja
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Maria Grazia Valsecchi
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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Corral-Gudino L, Rivas-Lamazares A, González-Fernández A, Rodríguez-María M, Aguilera-Sanz C, Tierra-Rodríguez A, Runza-Buznego P, Hernández-Martín E, Ortega-Gil M, Bahamonde-Carrasco A. Does my patient really need this at admission? Seven opportunities for improving value in patient care during their hospitalization. Eur J Intern Med 2019; 66:92-98. [PMID: 31230851 DOI: 10.1016/j.ejim.2019.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Besides the main treatment for their disease, hospital patients receive multiple care measures which include venous lines (VL), urinary catheters (UC), dietary restrictions (DR), mandatory bed rest (BR), deep venous thrombosis prophylaxis (VTP), stress ulcer prophylaxis (SUP) and anticoagulation bridge therapy for atrial fibrillation (BAF). In many cases these practices are of low value. METHODS We analysed patients admitted to Internal Medicine wards throughout 2018 (2714 inpatients). We used different methodologies to identify low-value clinical practices. RESULTS BR or DR at admission were recommended in 37% (32-44) and 24% (19-30) of the patients respectively. In 81% (71-87) and 33% (21-45) of the cases this restriction was deemed unnecessary. Ninety-six percent (92-98) had VL and 25% (19-32) UC. VL were not used in 10% (6-12), UC had no indications for insertion in 21% (11-35) and for maintenance in 31% (12-46) patients. Fifty-seven percent (49-64) of the patients were administered VTP and 69% (62-76) were prescribed SUP. Twenty-two percent (15-31) of patients with VTP and 52% (43-60) with SUP had no indication. Chronic anticoagulation for AF was interrupted in 65% (53-75) with BAF was prescribed in 38% (25-52) of them. An intervention to reduce low-value care supporting clinical practices addressed only to the Internal Medicine Wards showed very poor results. CONCLUSION These results demonstrate that there is ample room for reduction of low-value care. Interventions to implement clinical guidelines at admissions should be addressed to cover the entire admission process, from the emergency room to the ward. Partial approaches are discouraged.
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Affiliation(s)
- Luis Corral-Gudino
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain; Internal Medicine Department, Hospital Universitario Río Hortega, Calle Dulzaina n°2, 47012 Valladolid, Spain.
| | - Alicia Rivas-Lamazares
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Ana González-Fernández
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Miriam Rodríguez-María
- Hospital Pharmacy Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Carmen Aguilera-Sanz
- Haematology Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Ana Tierra-Rodríguez
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Paula Runza-Buznego
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Ester Hernández-Martín
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Martín Ortega-Gil
- Nurse Supervisor of Quality Improvement, Nurse Division, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Alberto Bahamonde-Carrasco
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
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16
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Meyer T, Wulff K. Issues of comorbidity in clinical guidelines and systematic reviews from a rehabilitation perspective. Eur J Phys Rehabil Med 2019; 55:364-371. [DOI: 10.23736/s1973-9087.19.05786-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Setchell J, Costa N, Ferreira M, Hodges PW. What decreases low back pain? A qualitative study of patient perspectives. Scand J Pain 2019; 19:597-603. [DOI: 10.1515/sjpain-2019-0018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/28/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background and aims
This study aimed to determine, from the perspective of individuals living with the condition, what decreases their low back pain (LBP). LBP affects most people at some point during their life. The condition has a meaningful effect on people’s lives including pain, reduced physical and social function, mood fluctuations, and a reduced ability to work. Despite a considerable amount of research on the topic, few strategies to reduce LBP are considered successful, and there has been little investigation into what individuals with the condition believe reduce it. This study aimed to address this gap in the literature by investigating what individuals with the condition believe reduces their LBP.
Methods
We employed a descriptive qualitative design using a custom-built online survey. Participants were 130 adults in Australia who self-identified as having current or having had previous LBP with or without co-morbidities. Data from the survey responses were analysed using content analysis to determine which management approaches participants considered to be effective in reducing their LBP.
Results
Participants most commonly said that they believed their LBP was reduced by: heat/cold (86, 66%), medication (84, 64.1%), and rest (78, 60%). Next most common was activity/exercise (73, 55.7%). Other factors such as consulting a health professional (52, 39.7%), stretching/therapeutic exercise (50, 38.1%), resting from aggravating activities (45, 34.3%), and psychological changes (41, 31.3%) were mentioned, but considerably less often.
Conclusions
Current literature points to the inefficacy of many of the factors participants reported as helping to reduce the effects of their condition, including the treatments that were most commonly listed by the participants in this study, namely: heat/cold, medication and rest. A possible cause of this discrepancy might be that individuals with LBP consider temporary relief (on a scale of hours) to be an acceptable outcome, whereas clinical trials tend to consider efficacy by long term outcomes (on a scale of weeks, months or years).
Implications
There are several implications of this research. From one perspective, there is the implication that public education about efficacious treatments may need to be enhanced as there is a discrepancy between research findings and the perspectives of individuals living with LBP. On the other hand, these findings also suggest that it is timely to re-examine the focus of LBP research to consider outcomes that are valuable to people living with the condition, which this study implies should include short term or temporary effects. The findings may also help clinicians tailor management to suit the individual patients by increasing the awareness that patient and research perspectives may at times diverge.
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Affiliation(s)
- Jenny Setchell
- The University of Queensland , School of Health and Rehabilitation Sciences , Brisbane , Australia
| | - Nathalia Costa
- The University of Queensland , School of Health and Rehabilitation Sciences , Brisbane , Australia
| | - Manuela Ferreira
- Institute of Bone and Joint Research/The Kolling Institute, Sydney Medical School , The University of Sydney , Sydney , Australia
| | - Paul W. Hodges
- The University of Queensland , School of Health and Rehabilitation Sciences , Brisbane , Australia
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18
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Cruz LC, Alamgir HA, Sheth P, Nabeel I. Development of a return to work tool for primary care providers for patients with low back pain: A pilot study. J Family Med Prim Care 2019; 7:1185-1192. [PMID: 30613495 PMCID: PMC6293894 DOI: 10.4103/jfmpc.jfmpc_262_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Context Low back pain (LBP) is a common cause of disability in adults and primary care physicians (PCPs) are commonly the first medical practitioners to assess these patients. Despite this, PCPs often feel unprepared to make return to work (RTW) recommendations. Aims The purpose of our project was to develop RTW guidelines for patients with LBP in the form of an accessible and adaptable electronic medical records (EMR) integrated tool. Settings and Design All licensed physicians and physician extenders who see patients over the age of 18 years, presenting with acute LBP who are currently employed were eligible for participation. PCPs were randomized with and without the RTW guidelines and charts were reviewed to assess if PCPs made RTW recommendations. Subjects and Methods RTW guidelines were developed using the Oswestry LBP Disability Questionnaire and the Official Disability Guidelines and integrated into the EMR. Statistical Analysis Used A Chi-square analysis was used to compare physicians in the interventional and control groups. Results Forty-four PCPs were randomized into the intervention group and 37 into the control group. In the intervention group, 301 patient encounters met the inclusion criteria for acute LBP. Of these, RTW recommendations were used in 7.3% encounters. Comparatively, there were 256 cases of LBP in the control group and RTW recommendations were offered in 1.6% of encounters (P < 0.001). Conclusion This study showed that PCPs with access to the RTW guidelines in an EMR-integrated tool were significantly more likely to make such recommendations.
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Affiliation(s)
- Lisanne C Cruz
- Department of Rehabilitation Medicine, Icahn School of Medicine, Mount Sinai Hospital, New York, USA
| | - Hasanat A Alamgir
- Department of Health Policy and Management, New York Medical College, New York, USA
| | - Parag Sheth
- Department of Rehabilitation Medicine, Icahn School of Medicine, Mount Sinai Hospital, New York, USA
| | - Ismail Nabeel
- Department of Environmental Medicine and Public Health, Icahn School of Medicine, Mount Sinai Hospital, New York, USA
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Schott C, Zirke S, Schmelzle JM, Kaiser C, Fernández LAI. Effectiveness of lumbar orthoses in low back pain: Review of the literature and our results. Orthop Rev (Pavia) 2018; 10:7791. [PMID: 30662686 PMCID: PMC6315306 DOI: 10.4081/or.2018.7791] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/09/2018] [Indexed: 11/23/2022] Open
Abstract
Back pain and diseases of the spine are today a health disorder of outstanding epidemiological, medical, and health economic importance. The cost of care for patients with lumbosciatic complaints are steadily increasing. Accordingly, the guidelines and treatments are constantly renewed. One concept is the orthotic care. In the following we want to give an overview of the literature and the effectiveness of lumbar orthoses in low back pain supplemented by our own data. A prospective randomized study with 230 patients, divided into three groups, each with two subgroups. Three Orthoses by the TIGGES-Zours GmbH were prescribed; a demountable two-step lumbar orthosis, three-step bridging orthosis and a four-step flexion orthosis modular system. Each were compared to the nonmodular equivalent. All six groups showed improvement in pain intensity and functional capacity at 6 and 12 weeks. The modular groups were found to have improvement in the frequency of use. The subjective effectiveness and sensitivity for the modular and non-modular groups was assessed as being good. In the literature, there are no clear guidelines for an orthotic supply. The studies do not seem to be meaningful and universal due to the difficult ascertainability of pain. There is a need for further research here. Nevertheless, the authors of this review are of the opinion that the implementation of trunk orthoses is void of side effects and beneficial to patients. The modular systems seem to have an advantage as well as higher patient satisfaction.
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Affiliation(s)
| | - Sonja Zirke
- Institut für Wirbelsäulenforschung, Bochum, Germany
| | | | - Christel Kaiser
- Department of Orthopedics and Trauma Surgery, University Hospital, Essen, Germany
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Rabbi M, Aung MS, Gay G, Reid MC, Choudhury T. Feasibility and Acceptability of Mobile Phone-Based Auto-Personalized Physical Activity Recommendations for Chronic Pain Self-Management: Pilot Study on Adults. J Med Internet Res 2018; 20:e10147. [PMID: 30368433 PMCID: PMC6229514 DOI: 10.2196/10147] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/12/2018] [Accepted: 06/19/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic pain is a globally prevalent condition. It is closely linked with psychological well-being, and it is often concomitant with anxiety, negative affect, and in some cases even depressive disorders. In the case of musculoskeletal chronic pain, frequent physical activity is beneficial. However, reluctance to engage in physical activity is common due to negative psychological associations (eg, fear) between movement and pain. It is known that encouragement, self-efficacy, and positive beliefs are effective to bolster physical activity. However, given that the majority of time is spent away from personnel who can give such encouragement, there is a great need for an automated ubiquitous solution. OBJECTIVE MyBehaviorCBP is a mobile phone app that uses machine learning on sensor-based and self-reported physical activity data to find routine behaviors and automatically generate physical activity recommendations that are similar to existing behaviors. Since the recommendations are based on routine behavior, they are likely to be perceived as familiar and therefore likely to be actualized even in the presence of negative beliefs. In this paper, we report the preliminary efficacy of MyBehaviorCBP based on a pilot trial on individuals with chronic back pain. METHODS A 5-week pilot study was conducted on people with chronic back pain (N=10). After a week long baseline period with no recommendations, participants received generic recommendations from an expert for 2 weeks, which served as the control condition. Then, in the next 2 weeks, MyBehaviorCBP recommendations were issued. An exit survey was conducted to compare acceptance toward the different forms of recommendations and map out future improvement opportunities. RESULTS In all, 90% (9/10) of participants felt positive about trying the MyBehaviorCBP recommendations, and no participant found the recommendations unhelpful. Several significant differences were observed in other outcome measures. Participants found MyBehaviorCBP recommendations easier to adopt compared to the control (βint=0.42, P<.001) on a 5-point Likert scale. The MyBehaviorCBP recommendations were actualized more (βint=0.46, P<.001) with an increase in approximately 5 minutes of further walking per day (βint=4.9 minutes, P=.02) compared to the control. For future improvement opportunities, participants wanted push notifications and adaptation for weather, pain level, or weekend/weekday. CONCLUSIONS In the pilot study, MyBehaviorCBP's automated approach was found to have positive effects. Specifically, the recommendations were actualized more, and perceived to be easier to follow. To the best of our knowledge, this is the first time an automated approach has achieved preliminary success to promote physical activity in a chronic pain context. Further studies are needed to examine MyBehaviorCBP's efficacy on a larger cohort and over a longer period of time.
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Affiliation(s)
- Mashfiqui Rabbi
- Department of Statistics, Harvard University, Cambridge, MA, United States
| | - Min Sh Aung
- Information Science Department, Cornell University, Ithaca, NY, United States
| | - Geri Gay
- Information Science Department, Cornell University, Ithaca, NY, United States
| | - M Cary Reid
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States
| | - Tanzeem Choudhury
- Information Science Department, Cornell University, Ithaca, NY, United States
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21
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Hayashi K, Kako M, Suzuki K, Takagi Y, Terai C, Yasuda S, Kadono I, Seki T, Hiraiwa H, Ushida T, Nishida Y. Impact of variation in physical activity after total joint replacement. J Pain Res 2018; 11:2399-2406. [PMID: 30425553 PMCID: PMC6200437 DOI: 10.2147/jpr.s178853] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Patients who undergo total knee arthroplasty (TKA) or total hip arthroplasty (THA) often develop postoperative pain. Exercise approaches are recommended postoperatively; however, the impact of excessive variation in physical activity is unclear. The purpose of the present preliminary study was to investigate the impact of excessive variation in physical activity using the accelerometer in the early period after TKA or THA. PATIENTS AND METHODS Seventy-two patients were enrolled in the study. Forty patients underwent initial TKA, and 32 initial THA. Physical activity was measured for 8 days from postoperative day 3 to 10. Patients with substantial correlation between physical activity and postoperative day were classified as the "good-pacing" group. Patients with no correlation between them were classified as the "poor-pacing" group. They were also evaluated using a pain visual analog scale (VAS), pain catastrophizing scale, and hospital anxiety and depression scale. RESULTS The average age was 68 years, and 59 patients (82%) were women. The average maximum number of steps per day was 2,181. There were 45 patients with good pacing and 27 with poor pacing. The poor-pacing group showed significantly lower maximum number of steps per day, higher postoperative average VAS score, higher postoperative worst VAS score, and longer duration of postoperative hospital stay than the good-pacing group. CONCLUSION Patients with excessive variation in physical activity showed severe postoperative pain and prolonged postoperative hospital stay. The postoperative variation in physical activity could be an outcome for improvement in patients after lower-limb arthroplasty.
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Affiliation(s)
- Kazuhiro Hayashi
- Multidisciplinary Pain Center, Aichi Medical University, Nagakute, Japan,
- Department of Rehabilitation, Aichi Medical University Hospital, Nagakute, Japan,
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan,
| | - Masato Kako
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan,
| | - Kentaro Suzuki
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan,
| | - Yui Takagi
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan,
| | - Chiaki Terai
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan,
| | - Shotaro Yasuda
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan,
| | - Izumi Kadono
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan,
| | - Taisuke Seki
- Department of Orthopaedic Surgery, Nagoya University Graduate School and School of Medicine, Nagoya, Japan
| | - Hideki Hiraiwa
- Department of Orthopaedic Surgery, Nagoya University Graduate School and School of Medicine, Nagoya, Japan
| | - Takahiro Ushida
- Multidisciplinary Pain Center, Aichi Medical University, Nagakute, Japan,
| | - Yoshihiro Nishida
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan,
- Department of Orthopaedic Surgery, Nagoya University Graduate School and School of Medicine, Nagoya, Japan
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Micay R, Richards D, Hutchison MG. Feasibility of a postacute structured aerobic exercise intervention following sport concussion in symptomatic adolescents: a randomised controlled study. BMJ Open Sport Exerc Med 2018; 4:e000404. [PMID: 30018795 PMCID: PMC6045733 DOI: 10.1136/bmjsem-2018-000404] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2018] [Indexed: 01/23/2023] Open
Abstract
Objective The utility of structured exercise for rehabilitation purposes early in the postacute phase (ie, beyond the initial 24–48 hours of advised rest) following sport-related concussion (SRC) remains largely unexplored. This study examined the feasibility of implementing a standardised aerobic exercise (AE) intervention in the postacute stage of SRC recovery in a sample of adolescent students with SRC compared with usual care. Methods Symptomatic adolescents with SRC were randomised to one of two groups: Aerobic Exercise (n=8) or Usual Care (n=7). The AE intervention, beginning on day 6 postinjury, comprised eight sessions with progressive increases in intensity and duration on a cycle ergometer. Usual care consisted of rest followed by physician-advised progressions in activity levels in an unsupervised setting. All participants were evaluated by physician at weeks 1, 2, 3 and 4 postconcussion. Outcome measures included: (1) Intervention feasibility: symptom status pre-post exercise sessions and completion of intervention and (2) Clinical recovery: symptom status at weeks 1, 2, 3 and 4 postinjury and medical clearance date. Results All participants completed the exercise sessions as part of the AE intervention and symptom exacerbation was not associated with any exercise session. The AE group experienced greater symptom resolution compared with the Usual Care Group across the recovery timeline. Conclusion A structured AE protocol appears to be safe and feasible to administer in the postacute stage of SRC recovery in adolescents and should be explored as part of a full Phase III Clinical Trial.
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Affiliation(s)
- Rachel Micay
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Doug Richards
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Michael G Hutchison
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
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Van Boxem K, Rijsdijk M, Hans G, de Jong J, Kallewaard JW, Vissers K, van Kleef M, Rathmell JP, Van Zundert J. Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group. Pain Pract 2018; 19:61-92. [PMID: 29756333 PMCID: PMC7379698 DOI: 10.1111/papr.12709] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review. METHODS A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries. RESULTS Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected. CONCLUSION Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.
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Affiliation(s)
- Koen Van Boxem
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Mienke Rijsdijk
- Pain Clinic, Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Guy Hans
- Multidisciplinary Pain Center, Antwerp University Hospital, Edegem, Belgium.,Laboratory for Pain Research, University of Antwerp, Wilrijk, Belgium
| | - Jasper de Jong
- Department of Pain Management, Westfriesgasthuis, Hoorn, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management, Rijnstate Ziekenhuis, Arnhem, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - James P Rathmell
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium.,Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
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Lim YH, Song JM, Choi EH, Lee JW. Effects of Repetitive Peripheral Magnetic Stimulation on Patients With Acute Low Back Pain: A Pilot Study. Ann Rehabil Med 2018; 42:229-238. [PMID: 29765876 PMCID: PMC5940599 DOI: 10.5535/arm.2018.42.2.229] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 08/17/2017] [Indexed: 01/13/2023] Open
Abstract
Objective To investigate the effects of real repetitive peripheral magnetic stimulation (rPMS) treatment compared to sham rPMS treatment on pain reduction and functional recovery of patients with acute low back pain. Methods A total of 26 patients with acute low back pain were randomly allocated to the real rPMS group and the sham rPMS group. Subjects were then administered a total of 10 treatment sessions. Visual analogue scale (VAS) was assessed before and after each session. Oswestry Disability Index (ODI) and Roland-Morris Disability Questionnaire (RMDQ) were employed to assess functional recovery at baseline and after sessions 5 and 10. Results Real rPMS treatment showed significant pain reduction immediately after each session. Sustained and significant pain relief was observed after administering only one session in the real rPMS group. Significant functional improvement was observed in the real rPMS group compared to that in the sham rPMS group after sessions 5 and 10 based on ODI and after session 5 based on RMDQ. Conclusion Real rPMS treatment has immediate effect on pain reduction and sustained effect on pain relief for patients with acute low back pain compared to sham rPMS.
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Affiliation(s)
- Young-Ho Lim
- Department of Physical Medicine and Rehabilitation, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Ji Min Song
- Department of Physical Medicine and Rehabilitation, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Eun-Hi Choi
- Department of Rehabilitation Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Jang Woo Lee
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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Mendes AAMT, de Freitas SMSF, Amorin CF, Cabral CMN, Padula RS. Electromyographic activity of the erector spinae: The short-effect of one workday for welders with nonspecific chronic low back pain, an observational study. J Back Musculoskelet Rehabil 2018; 31:147-154. [PMID: 28826171 DOI: 10.3233/bmr-169733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study aimed to evaluate the effect of one workday on pain and perceived exertion, muscular strength, and electromyographic activity of the erector spinae muscles in welders with and without low back pain. This is an observational cohort study. PARTICIPANTS Twenty-two welders, metallurgical shipbuilding, were equally divided into 2 groups: low back pain and no low back pain. Pain and perceived exertion. Muscular strength by maximal voluntary contractions and electromyographic activity of right and left erector spinae muscles during maximal voluntary contractions and in the 3 welding positions for 2 periods of the workday (in the morning and at the end of the workday). RESULTS At the end of workday, the pain increased significantly for the low back pain group (t(22) = 2.448; P= 0.023). The perceived exertion also increased significantly for both groups at the end of workday groups (F(1,22) = 8.570, P= 0.000) and periods (F(1,22) = 8.142, P= 0.000). There were no significant differences between groups and workday periods for muscular strength and electromyographic activity during maximal voluntary contractions of the erector spinae. There was no significance difference for electromyographic activity between groups and workday period and in the 3 welding positions. CONCLUSION Although the pain and perceived exertion increased at the end of the workday, these results did not interfere in muscular strength and electromyographic activity of right and left erector spinae muscles. Thus, we can conclude that welders with chronic low back pain had a good physical capacity (muscular strength) and that muscle performance was maintained.
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Prevalence and factors associated with a higher risk of neck and back pain among permanent wheelchair users: a cross-sectional study. Spinal Cord 2017; 56:392-405. [PMID: 29284794 DOI: 10.1038/s41393-017-0029-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/08/2017] [Accepted: 10/10/2017] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVES To determine the prevalence of, and factors associated with, spinal pain among wheelchair users. SETTING Four Spanish hospitals specialized in providing care for wheelchair users. METHODS Persons who had used a wheelchair for a median (IRQ) of 10 (5;19) years, 27% of them due to reasons other than spinal cord injury, were recruited consecutively (n = 750). Data on 43 demographic, psychosocial, ergonomic, and clinical variables were collected, and analyzed. Main outcome measures were: point prevalence of neck (NP), thoracic (TP), low back pain (LBP), and pain at any spinal level (PASL); and factors associated with them. RESULTS Point prevalence was 56% for NP, 54% for TP, 45% for LBP, and 76% for PSAL. PASL was associated with a lower quality of life (OR (95% CI) 0.91 (0.86; 0.97)). Multivariable regression models showed that the main factors associated with significant pain (≥1.5 VAS points) were: (a) For NP: cervical spinal injury and wheelchair seat cushion thickness, (b) For TP: thoracic spinal injury and sagittal index, (c) For LBP: thoracic or lumbar spinal injury, with some sensitivity remaining, (d) For PASL: being female, living alone, and using a non-power wheelchair. Discrimination (AUC) of these models ranged between 0.638 and 0.818. p-values in the Hosmer-Lemeshow test ranged between 0.420 and 0.701. CONCLUSIONS Prevalence of spinal pain among wheelchair users is high. It is associated with a lower quality of life. Future studies should assess whether using a power wheelchair affects PASL, and if the thickness of seat cushion affects NP. SPONSORSHIP Spanish Back Pain Research Network.
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Chenot JF, Greitemann B, Kladny B, Petzke F, Pfingsten M, Gabriele Schorr S. Non-Specific Low Back Pain. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:883-890. [PMID: 29321099 PMCID: PMC5769319 DOI: 10.3238/arztebl.2017.0883] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 07/28/2017] [Accepted: 10/26/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND For many years, low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. The goal of the German Disease Management Guideline (NDMG) on nonspecific low back pain is to improve the treatment of patients with this condition. METHODS The current update of the NDMG on non-specific low back pain is based on articles retrieved by a systematic search of the literature for systematic reviews. Its recommendations for diagnosis and treatment were developed by a collaborative effort of 29 scientific medical societies and organizations and approved in a formal consensus process. RESULTS If the history and physical examination do not arouse any suspicion of a dangerous underlying cause, no further diagnostic evaluation is indicated for the time being. Passive, reactive measures should be taken only in combination with activating measures, or not at all. When drugs are used for symptomatic treatment, patients should be treated with the most suitable drug in the lowest possible dose and for as short a time as possible. CONCLUSION A physician should be in charge of the overall care process. The patient should be kept well informed over the entire course of his or her illness and should be encouraged to adopt a healthful lifestyle, including regular physical exercise.
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Affiliation(s)
- Jean-François Chenot
- Section Family Medicine, Institute for Community Medicine, University Hospital of Greifswald
| | | | - Bernd Kladny
- Department of Orthopedics, Fachklinik Herzogenaurach
| | - Frank Petzke
- ain Clinic, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Göttingen
| | - Michael Pfingsten
- ain Clinic, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Göttingen
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Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. CMAJ 2017; 189:E1386-E1395. [PMID: 29133540 PMCID: PMC5687927 DOI: 10.1503/cmaj.170527] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Adrian Traeger
- School of Public Health (Traeger, Maher), Sydney Medical School, University of Sydney, Sydney, Australia; Monash Department of Clinical Epidemiology (Buchbinder), Cabrini Institute, Malvern, Australia; Department of Epidemiology and Preventive Medicine (Buchbinder), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Whitlam Orthopaedic Research Centre (Harris), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Rachelle Buchbinder
- School of Public Health (Traeger, Maher), Sydney Medical School, University of Sydney, Sydney, Australia; Monash Department of Clinical Epidemiology (Buchbinder), Cabrini Institute, Malvern, Australia; Department of Epidemiology and Preventive Medicine (Buchbinder), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Whitlam Orthopaedic Research Centre (Harris), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Ian Harris
- School of Public Health (Traeger, Maher), Sydney Medical School, University of Sydney, Sydney, Australia; Monash Department of Clinical Epidemiology (Buchbinder), Cabrini Institute, Malvern, Australia; Department of Epidemiology and Preventive Medicine (Buchbinder), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Whitlam Orthopaedic Research Centre (Harris), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Chris Maher
- School of Public Health (Traeger, Maher), Sydney Medical School, University of Sydney, Sydney, Australia; Monash Department of Clinical Epidemiology (Buchbinder), Cabrini Institute, Malvern, Australia; Department of Epidemiology and Preventive Medicine (Buchbinder), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Whitlam Orthopaedic Research Centre (Harris), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
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Miller J, Barber D, Donnelly C, French S, Green M, Hill J, MacDermid J, Marsh J, Norman K, Richardson J, Taljaard M, Wideman T, Cooper L, McPhee C. Determining the impact of a new physiotherapist-led primary care model for back pain: protocol for a pilot cluster randomized controlled trial. Trials 2017; 18:526. [PMID: 29121989 PMCID: PMC5680754 DOI: 10.1186/s13063-017-2279-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/10/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Back pain is a leading contributor to disability, healthcare costs, and lost work. Family physicians are the most common first point of contact in the healthcare system for people with back pain, but physiotherapists (PTs) may be able to support the primary care team through evidence-based primary care. A cluster randomized trial is needed to determine the clinical, health system, and societal impact of a primary care model that integrates physiotherapists at the first visit for people with back pain. Prior to conducting a future fully powered cluster randomized trial, we need to demonstrate feasibility of the methods. Therefore, the purpose of this pilot study will be to: 1) Determine feasibility of patient recruitment, assessment procedures, and retention. 2) Determine the feasibility of training and implementation of a new PT-led primary care model for low back pain (LBP) 3) Explore the perspectives of patients and healthcare providers (HCPs) related to their experiences and attitudes towards the new service delivery model, barriers/facilitators to implementation, perceived satisfaction, perceived value, and impact on clinic processes and patient outcomes. METHODS This pilot cluster randomized controlled trial will enroll four sites and randomize them to implement a new PT-led primary care model for back pain or a usual physician-led primary care model. All adults booking a primary care visit for back pain will be invited to participate. Feasibility outcomes will include: recruitment and retention rates, completeness of assessment data, PT training participation and confidence after training, and PT treatment fidelity. Secondary outcomes will include the clinical, health system, cost, and process outcomes planned for the future fully powered cluster trial. Results will be analyzed and reported descriptively and qualitatively. To explore perspectives of both HCPs and patients, we will conduct semi-structured qualitative interviews with patients and focus groups with HCPs from participants in the PT-led primary care sites. DISCUSSION If this pilot demonstrates feasibility, a fully powered trial will provide evidence that has the potential to transform primary care for back pain. The full trial will inform future service design, whether these models should be more widely implemented, and training agendas. TRIAL REGISTRATION ClinicalTrials.gov, NCT03320148 . Submitted for registration on 17 September 2017.
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Affiliation(s)
- Jordan Miller
- School of Rehabilitation Therapy, Queen's University, 31 George Street, Kingston, Ontario, K7L 3N6, Canada.
| | - David Barber
- Department of Family Medicine, Queen's University, Kingston, Canada
| | - Catherine Donnelly
- School of Rehabilitation Therapy, Queen's University, 31 George Street, Kingston, Ontario, K7L 3N6, Canada
| | - Simon French
- School of Rehabilitation Therapy, Queen's University, 31 George Street, Kingston, Ontario, K7L 3N6, Canada
| | - Michael Green
- Department of Family Medicine, Queen's University, Kingston, Canada
| | | | - Joy MacDermid
- Physical Therapy, Western University, London, Canada
| | | | - Kathleen Norman
- School of Rehabilitation Therapy, Queen's University, 31 George Street, Kingston, Ontario, K7L 3N6, Canada
| | - Julie Richardson
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | | | - Timothy Wideman
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
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[Conservative treatment of nonspecific, chronic low back pain : Evidence of the efficacy - a systematic literature review]. DER ORTHOPADE 2017; 45:573-8. [PMID: 27075679 DOI: 10.1007/s00132-016-3248-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Non-specific chronic low back pain (NSCLBP): Which conservative therapy shows an evident effectiveness - A review of the current literature. MATERIALS AND METHODS Our results are based on literature reviews of current randomised control studies, reviews and meta-analysis drawn from the Cochrane Library and Medline-Database between the years 2004 until 2015. German and English Studies were included. We focused on different conservative Treatments of NSCLBP, which are listed at, the NVL-Guidelines. Based on the given evidence we evaluated their effectiveness. RESULTS As part of the review we identified 4657 Publications, 85 were included in this study. Therapeutic options such as bed rest, TENS, Massage, Spine Supports, Back Schools and Antidepressants showed no evident effectiveness. Injections, NSAR analgesic therapy, Thermotherapy and Opioid analgesic therapy indicated a short-time effectiveness. A long term success (> 6 weeks) however, can not be shown. Only the Movement therapy can, in the summation of the included studies, postulate an evident (Evidence Level I) long-term effect treating NSCLBP. Only a few therapy options indicate a significant evident effectiveness for treating NSCLBP conservatively. At short notice methods such as injection therapy, thermo-therapy and analgesic therapies with NSAR and/or opioids help coping the acute phase. In the long term only movement therapy seems to provide an evident effectiveness. In the case of therapy-refractory NSCLBP a multimodal therapy should be considered.
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Nonsurgical Treatment Choices by Individuals with Lumbar Intervertebral Disc Herniation in the United States: Associations with Long-term Outcomes. Am J Phys Med Rehabil 2017; 96:557-564. [PMID: 28045705 DOI: 10.1097/phm.0000000000000685] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The objectives of this study were to (1) evaluate differences between patients with lumbar intervertebral disc herniation who received physical therapy (PT) and those who did not; (2) identify factors associated with receiving PT; and (3) examine the influence of PT on clinical outcomes over the course of 1 yr. DESIGN An observational cohort study using data from the Spine Patient Outcomes Research Trial was conducted. This study included 363 patients with intervertebral disc herniation who received nonsurgical management within 6 wks of enrollment. Baseline characteristics were compared between patients who received PT and those who did not. Multivariate logistic regression examined factors predictive of patients receiving PT. Mixed effects models were used to compare primary outcomes (Short-Form Survey 36 bodily pain and physical function and modified Oswestry Index) at 3 and 6 mos and 1 yr after enrollment. RESULTS Forty percent of the nonsurgical cohort received PT. Higher disability scores, neurological deficit, and patient preference predicted PT use. Compared with other nonsurgical management strategies, standard care PT was not associated with a significant difference in pain, disability, or surgery over 1 yr. CONCLUSIONS Many patients with intervertebral disc herniation seek secondary care for persisting symptoms and pursue nonsurgical management. The best management strategy is unclear and further research is needed to examine appropriate sequencing and selection of treatment.
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The effects of a brief educational intervention on medical students’ knowledge, attitudes and beliefs towards low back pain. Scand J Pain 2017; 16:101-104. [DOI: 10.1016/j.sjpain.2017.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/30/2017] [Accepted: 04/01/2017] [Indexed: 11/21/2022]
Abstract
Abstract
Background and aims
Knowledge, attitudes and beliefs towards low back pain (LBP) can significantly impact a health care provider’s clinical decision making. Several studies have investigated interventions designed to change practitioner attitudes and beliefs towards LBP, however no such studies involving medical students have been identified.
Methods
This study explored medical students ‚ knowledge, attitudes and beliefs towards LBP before and after a brief educational intervention on LBP. Responses from medical students (n = 93) were evaluated before and after a 15-min educational video on back pain. The intervention was developed using Camtasia™ video editor and screen recorder. Knowledge, attitudes and beliefs were measured using the “Modified Back Beliefs Questionnaire”, with items from two previously reported questionnaires on back beliefs. The questionnaire asks participants to indicate their agreement with statements about LBP on a 5-point Likert scale. Preferred responses were based on guidelines for the evidence-based management of LBP. The primary analysis evaluated total score on the nine-inevitability items of the Back Beliefs Questionnaire (“inevitability score”).
Results
Following the brief intervention there was a significant improvement in the inevitability score (post-workshop mean [SD] 20.8 [4.9] vs pre-workshop mean [SD] 26.9 [4.2]; mean difference (MD) 6.1, p < 0.001; lower score more favourable 1) and large improvements in the proportion of students providing correct responses to items on activity (pre: 49% vs post: 79%), bed rest (41% vs 75%), imaging (44% vs 74%) and recovery (25% vs 66%).
Conclusions
After watching the educational video students’ knowledge, beliefs and attitudes towards LBP improved and thus aligned more closely with evidence-based guidelines.
Implications
Medical doctors are at the forefront of managing low back pain in the community, however there is a need to strengthen musculoskeletal education in medical training programmes. The results from this research suggest educational interventions on back pain do not need to be extensive in order to have favourable outcomes on medical students’ knowledge, attitudes and beliefs towards back pain. The translational effects of these changes into clinical practice are not known.
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Babatunde OO, Jordan JL, Van der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One 2017; 12:e0178621. [PMID: 28640822 PMCID: PMC5480856 DOI: 10.1371/journal.pone.0178621] [Citation(s) in RCA: 207] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 05/16/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND & AIMS Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care. METHODS A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach. RESULTS Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options. CONCLUSION This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.
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Affiliation(s)
- Opeyemi O. Babatunde
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Joanne L. Jordan
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Danielle A. Van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Jonathan C. Hill
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Nadine E. Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Joanne Protheroe
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
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Chan AY, Ford JJ, Surkitt LD, Richards MC, Slater SL, Davidson M, Hahne AJ. Individualised functional restoration plus guideline-based advice vs advice alone for non-reducible discogenic low back pain: a randomised controlled trial. Physiotherapy 2017; 103:121-130. [DOI: 10.1016/j.physio.2016.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 08/03/2016] [Indexed: 11/16/2022]
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Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017; 4:CD011279. [PMID: 28436583 PMCID: PMC5461882 DOI: 10.1002/14651858.cd011279.pub3] [Citation(s) in RCA: 243] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure. OBJECTIVES To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions. METHODS We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively. MAIN RESULTS We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance. AUTHORS' CONCLUSIONS The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.
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Affiliation(s)
| | | | - Clare Clarke
- Division of Population Health Sciences, University of DundeeNinewells Hospital & Medical SchoolKirsty Semple WayDundeeUKDD2 4DB
| | - Denis Martin
- Teesside UniversityInstitute of Health and Social CareParksideMiddlesbroughUKTS1 3BA
| | - Lesley A Colvin
- University of Edinburgh, Western General HospitalAnaesthesia & Pain MedicineEdinburghUK
| | - Blair H Smith
- University of DundeeDivision of Population Health SciencesDundeeUKDD2 4BF
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Brämberg EB, Bergström G, Jensen I, Hagberg J, Kwak L. Effects of yoga, strength training and advice on back pain: a randomized controlled trial. BMC Musculoskelet Disord 2017; 18:132. [PMID: 28356091 PMCID: PMC5372262 DOI: 10.1186/s12891-017-1497-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/21/2017] [Indexed: 12/19/2022] Open
Abstract
Background Among the working population, non-specific low-back pain and neck pain are one of the most common reasons for sickness absenteeism. The aim was to evaluate the effects of an early intervention of yoga - compared with strength training or evidence-based advice - on sickness absenteeism, sickness presenteeism, back and neck pain and disability among a working population. Methods A randomized controlled trial was conducted on 159 participants with predominantly (90%) chronic back and neck pain. After screening, the participants were randomized to kundalini yoga, strength training or evidence-based advice. Primary outcome was sickness absenteeism. Secondary outcomes were sickness presenteeism, back and neck pain and disability. Self-reported questionnaires and SMS text messages were completed at baseline, 6 weeks, 6 and 12 months. Results The results did not indicate that kundalini yoga and strength training had any statistically significant effects on the primary outcome compared with evidence-based advice. An interaction effect was found between adherence to recommendations and sickness absenteeism, indicating larger significant effects among the adherers to kundalini yoga versus evidence-based advice: RR = 0.47 (CI 0.30; 0.74, p = 0.001), strength training versus evidence-based advice: RR = 0.60 (CI 0.38; 0.96, p = 0.032). Some significant differences were also found for the secondary outcomes to the advantage of kundalini yoga and strength training. Conclusions Guided exercise in the forms of kundalini yoga or strength training does not reduce sickness absenteeism more than evidence-based advice alone. However, secondary analyses reveal that among those who pursue kundalini yoga or strength training at least two times a week, a significantly reduction in sickness absenteeism was found. Methods to increase adherence to treatment recommendations should be further developed and applied in exercise interventions. Trial Registration Clinicaltrials.gov NCT01653782, date of registration: June, 28, 2012, retrospectively registered.
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Affiliation(s)
- Elisabeth Björk Brämberg
- Unit of Intervention and Implementation Research for Worker Health, Institute of Environmental Medicine, Nobels väg 13, Karolinska Institutet, 171 77, Stockholm, Sweden.
| | - Gunnar Bergström
- Unit of Intervention and Implementation Research for Worker Health, Institute of Environmental Medicine, Nobels väg 13, Karolinska Institutet, 171 77, Stockholm, Sweden.,Centre for Occupational and Environmental Medicine, Stockholm County Council, Solnavägen 4, 113 65, Stockholm, Sweden
| | - Irene Jensen
- Unit of Intervention and Implementation Research for Worker Health, Institute of Environmental Medicine, Nobels väg 13, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Jan Hagberg
- Unit of Intervention and Implementation Research for Worker Health, Institute of Environmental Medicine, Nobels väg 13, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Lydia Kwak
- Unit of Intervention and Implementation Research for Worker Health, Institute of Environmental Medicine, Nobels väg 13, Karolinska Institutet, 171 77, Stockholm, Sweden
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Abstract
Non-specific low back pain affects people of all ages and is a leading contributor to disease burden worldwide. Management guidelines endorse triage to identify the rare cases of low back pain that are caused by medically serious pathology, and so require diagnostic work-up or specialist referral, or both. Because non-specific low back pain does not have a known pathoanatomical cause, treatment focuses on reducing pain and its consequences. Management consists of education and reassurance, analgesic medicines, non-pharmacological therapies, and timely review. The clinical course of low back pain is often favourable, thus many patients require little if any formal medical care. Two treatment strategies are currently used, a stepped approach beginning with more simple care that is progressed if the patient does not respond, and the use of simple risk prediction methods to individualise the amount and type of care provided. The overuse of imaging, opioids, and surgery remains a widespread problem.
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Affiliation(s)
- Chris Maher
- Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, University of Sydney, Camperdown, NSW, Australia.
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Monash Department of Clinical Epidemiology, Cabrini Hospital, Monash University, Melbourne, VIC, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017; 1:CD011279. [PMID: 28087891 PMCID: PMC6469540 DOI: 10.1002/14651858.cd011279.pub2] [Citation(s) in RCA: 355] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure. OBJECTIVES To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions. METHODS We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively. MAIN RESULTS We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance. AUTHORS' CONCLUSIONS The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.
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Affiliation(s)
- Louise J Geneen
- University of DundeeDivision of Population Health SciencesDundeeUK
| | - R Andrew Moore
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)Pain Research UnitChurchill HospitalOxfordUKOX3 7LE
| | - Clare Clarke
- Division of Population Health Sciences, University of DundeeNinewells Hospital & Medical SchoolKirsty Semple WayDundeeUKDD2 4DB
| | - Denis Martin
- Teesside UniversityInstitute of Health and Social CareParksideMiddlesbroughUKTS1 3BA
| | - Lesley A Colvin
- University of Edinburgh, Western General HospitalAnaesthesia & Pain MedicineEdinburghUK
| | - Blair H Smith
- University of DundeeDivision of Population Health SciencesDundeeUK
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Amorin-Woods LG, Losco BE. 'PICO-D Management'; a decision-aid for evidence-based chiropractic education and clinical practice. Chiropr Man Therap 2016; 24:49. [PMID: 27999660 PMCID: PMC5151136 DOI: 10.1186/s12998-016-0130-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 11/10/2016] [Indexed: 12/21/2022] Open
Abstract
Background Various models and decision-making aids exist for chiropractic clinical practice. Results “PICO-D Man” (Patient-Intervention-Comparator-Outcome-Duration Management) is a decision-aid developed in an educational setting which field practitioners may also find useful for applying defensible evidence-based practice. Clinical decision-making involves understanding and evaluating both the proposed clinicalintervention(s) and the relevant and available management options with respect to describing the patient and their problem, clinical and cost effectiveness, safety, feasibility and time-frame. Conclusions For people consulting chiropractors this decision-aid usually requires the practitioner to consider a comparison of usual chiropractic care, (clinical management including a combination of active care and passive manual interventions), to usual medical care usually including medications, or other allied healthmanagement options while being mindful of the natural history of the persons’ condition.
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Affiliation(s)
- Lyndon G Amorin-Woods
- School of Health Professions, Discipline of Chiropractic 90 South St Murdoch, Perth, 6150 Western Australia
| | - Barrett E Losco
- School of Health Professions, Discipline of Chiropractic 90 South St Murdoch, Perth, 6150 Western Australia
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What Does the Cochrane Collabroation Say About…. Physiother Can 2016; 68:309. [PMID: 27909381 DOI: 10.3138/ptc.68.3.cochrane] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gilmore S, McClelland JA, Davidson M. Does walking after lumbar spinal surgery predict recovery of function at six months? Protocol for a prospective cohort study. BMC Musculoskelet Disord 2016; 17:472. [PMID: 27842523 PMCID: PMC5109719 DOI: 10.1186/s12891-016-1296-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/13/2016] [Indexed: 02/06/2023] Open
Abstract
Background Physiotherapists are commonly involved in the management of patients immediately following lumbar spinal surgery. There is however, very little research to guide physiotherapy intervention in the acute post-operative period, and the advice provided to patients regarding post-operative walking and physical activity has been shown to be highly variable. The primary aim of this research is to establish whether the amount of walking patients perform in the week following lumbar spinal surgery predicts improvement in function at 6 months. Methods This study will be a prospective cohort study design, with a projected sample size of 250 participants. Patients undergoing surgery for the management of a disc prolapse, degenerative disc disease, lumbar spinal stenosis and/or degenerative spondylolysthesis will be invited to participate in this study. Outcome measurement will take place pre-operatively and at six months post-operatively. The primary outcome variable will be self-reported function, measured using the Modified Oswestry Disability Questionnaire and the physical component summary of the SF-36. Each participant will be fitted with an activPAL3 accelerometer to be worn for the first seven post-operative days. This accelerometer will record time spent in active versus sedentary postures, step count and time spent walking. Multivariable logistic regression analysis will be used to investigate the relationship between the total time spent walking over the first seven post-operative days, and outcome at six months. Discussion The results from this research will help to guide patient management during the inpatient phase, by identifying patients who are at risk of poorer outcome due to limited walking time. These patients may benefit from ongoing rehabilitation and outpatient physiotherapy services. This information will also provide a foundation for further research into interventions designed to optimise post-operative activity. Trial registration ACTRN12616000747426, retrospectively registered 7th June 2016.
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Affiliation(s)
- Sarah Gilmore
- St Vincent's Private Hospital, Melbourne, Australia. .,La Trobe University, Melbourne, Australia.
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Lemstra ME. Occupational management in the workplace and impact on Workers' Compensation Board claims, duration, and cost: a prospective longitudinal cohort. Risk Manag Healthc Policy 2016; 9:185-91. [PMID: 27528804 PMCID: PMC4970651 DOI: 10.2147/rmhp.s107721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Few workplaces have prospectively reviewed workplace and worker issues simultaneously and assessed their impact on Workers' Compensation Board (WCB) claims. In January of 2014, each worker in a large workplace in Saskatchewan, Canada, was prospectively followed for 1 year to determine factors that impact injury claim incidence, recovery, and costs. In total, 207 out of 245 workers agreed to complete the baseline survey (84.5%). In 2014, 82.5% of workers had self-reported pain, but only 35.5% submitted a WCB claim. Binary logistic regression was used to compare those with pain who did not submit a WCB injury claim to those with pain who did initiate a WCB claim. Independent risk factors associated with WCB claim incidence included depressed mood (odds ratio [OR] =2.75, 95% confidence interval [CI] 1.44-9.78) and lower job satisfaction (OR =1.70, 95% CI 1.08-10.68). Higher disability duration was independently associated with higher depressed mood (OR =1.60, 95% CI 1.05-4.11) and poor recovery expectation (OR =1.31, 95% CI 1.01-5.78). Higher cost disability claims were independently associated with higher depressed mood (OR =1.51, 95% CI 1.07-6.87) and pain catastrophizing (OR =1.11, 95% CI 1.02-8.11). Self-reported pain, physically assessed injury severity, and measured ergonomic risk of workstation did not significantly predict injury claim incidence, duration, or costs. In January 2015, the workplace implemented a new occupational prevention and management program. The injury incidence rate ratio reduced by 58% from 2014 to 2015 (IRR =1.58, 95% CI =1.28-1.94). The ratio for disability duration reduced by 139% from 2014 to 2015 (RR =2.39, 95% CI =2.16-2.63). Costs reduced from $114,149.07 to $56,528.14 per year. In summary, WCB claims are complex. Recognizing that nonphysical factors, such as depressed mood, influence injury claim incidence, recovery, and costs, can be helpful to claims management.
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Treatment of Lower Back Pain-The Gap between Guideline-Based Treatment and Medical Care Reality. Healthcare (Basel) 2016; 4:healthcare4030044. [PMID: 27417632 PMCID: PMC5041045 DOI: 10.3390/healthcare4030044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/06/2016] [Accepted: 07/12/2016] [Indexed: 11/17/2022] Open
Abstract
Despite the fact that unspecific low back pain is of important impact in general health care, this pain condition is often treated insufficiently. Poor efficiency has led to the necessity of guidelines addressing evidence-based strategies for treatment of lower back pain (LBP). We present some statements of the German medical care reality. Self-responsible action of the patient should be supported while invasive methods in particular should be avoided due to lacking evidence in outcome efficiency. However, it has to be stated that no effective implementation strategy has been established yet. Especially, studies on the economic impact of different implementation strategies are lacking. A lack of awareness of common available guidelines and an uneven distribution of existing knowledge throughout the population can be stated: persons with higher risk suffering from LBP by higher professional demands and lower educational level are not skilled in advised management of LBP. Both diagnostic imaging and invasive treatment methods increased dramatically leading to increased costs and doctor workload without being associated with improved patient functioning, severity of pain or overall health status due to the absence of a functioning primary care gate keeping system for patient selection. Opioids are prescribed on a grand scale and over a long period. Moreover, opioid prescription is not indicated properly, when predominantly persons with psychological distress like somatoform disorders are treated with opioids.
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Elleuch M, El Maghraoui A, Griene B, Nejmi M, Ndongo S, Serrie A. [Formalized consensus: clinical practice recommendations for the management of acute low back pain of the African patient]. Pan Afr Med J 2015; 22:240. [PMID: 26955427 PMCID: PMC4761241 DOI: 10.11604/pamj.2015.22.240.8120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 10/26/2015] [Indexed: 12/03/2022] Open
Abstract
La lombalgie aiguë est la pathologie rhumatismale la plus fréquente en Afrique. L’épidémiologie et la présentation clinique ne diffèrent pas de celles observées sur les autres continents. En revanche, les aspects psycho-sociaux, la disponibilité des traitements, l'accès aux soins et le poids culturel des médecines traditionnelles sont autant de spécificités qui ont conduit à la réalisation du 1er consensus d'experts en rhumatologie pour la prise en charge du patient africain. Destiné aux praticiens, ce travail collaboratif multinational a pour objectif de fournir 11 recommandations de pratiques cliniques simples, fondées sur les preuves, et adaptées aux conditions de l'exercice médical en Afrique. Leur ambition est d'améliorer la prise en charge de la lombalgie aigue par une évaluation initiale clinique pertinente, une diminution des examens radiologiques inutiles, une prescription médicamenteuse adéquate et l'abandon de procédures invasives inappropriées.
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Affiliation(s)
| | | | | | - Mati Nejmi
- Hôpital Cheikh Khalifa Bin Zayed, Casablanca, Maroc
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Olaya-Contreras P, Styf J, Arvidsson D, Frennered K, Hansson T. The effect of the stay active advice on physical activity and on the course of acute severe low back pain. BMC Sports Sci Med Rehabil 2015; 7:19. [PMID: 26322232 PMCID: PMC4551375 DOI: 10.1186/s13102-015-0013-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 08/19/2015] [Indexed: 12/19/2022]
Abstract
Background Disability due to acute low back pain (ALBP) runs parallel with distress and physical inactivity. If low back pain persists, this may lead to long-term sick leave and chronic back pain. This prospective randomized study evaluated the effect on physical activity and on the course of ALBP of two different treatment advices provided in routine care. Methods Ninety-nine patients with acute severe LBP examined within 48 h after pain onset were randomized to the treatment advices “Stay active in spite of pain” (stay active group) or “Adjust activity to the pain” (adjust activity group). Pedometer step count and pain intensity (Numeric Rating Scale, NRS, 0–10) were followed daily during seven days. Linear mixed modeling were employed for statistical analyses. Results The step count change trajectory showed a curvilinear shape with a steep initial increase reaching a plateau after day 3 in both groups, followed by an additional increase to day 7 in the stay active group only. At day 1, the step count was 4560 in the stay active group compared to 4317 in adjust activity group (p = 0.76). Although there were no statistical differences between the two groups in the parameters describing the change trajectory for step count, the increase in step count was larger in the stay active group. At day 7 the step count was 9865 in the stay active group compared to 6609 in the adjust activity group (p = 0.008). The pain intensity (NRS) trajectory was similar in the two groups. Between day 1 and day 7 it decreased linearly from 5.0 to 2.8 in the stay active group (p < 0.001), and from 4.8 to 2.3 in the adjust activity group (p < 0.001). Conclusions Patients with acute severe LBP advised to stay active in spite of the pain exhibited a considerable more active behavior compared to patients adjusting their activity to pain. This result confirms compliance to the treatment advice as well as the utility of the stay active advice to promote additional physical activity for more health benefits in patients with ALBP. There was minimal effect of the treatment advice on the course of ALBP. Trial registration ClinicalTrials.gov (NCT02517762).
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Affiliation(s)
- Patricia Olaya-Contreras
- Department of Orthopedics, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ; Department of Postgraduate Studies, Faculty of Nursing, University of Antioquia, Calle 70 No 52-21, Apartado Aereo, 1226 Medellín, Antioquia Colombia ; Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark
| | - Jorma Styf
- Department of Orthopedics, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Arvidsson
- Unit of Clinical Physiology and Nuclear Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden ; RICH/EXE, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Karin Frennered
- Department of Orthopedics, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tommy Hansson
- Department of Orthopedics, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Haukka E, Martimo KP, Kivekäs T, Horppu R, Lallukka T, Solovieva S, Shiri R, Pehkonen I, Takala EP, MacEachen E, Viikari-Juntura E. Efficacy of temporary work modifications on disability related to musculoskeletal pain or depressive symptoms--study protocol for a controlled trial. BMJ Open 2015; 5:e008300. [PMID: 25986643 PMCID: PMC4442237 DOI: 10.1136/bmjopen-2015-008300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/22/2015] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Previous research suggests that work with a suitable workload may promote health and work retention in people with disability. This study will examine whether temporary work modifications at the early stage of work disability are effective in enhancing return to work (RTW) or staying at work among workers with musculoskeletal or depressive symptoms. METHODS AND ANALYSIS A single-centre controlled trial with modified stepped wedge design will be carried out in eight enterprises and their occupational health services (OHSs) in nine cities in Finland. Patients seeking medical advice due to musculoskeletal pain (≥4 on a scale from 0-10) or depressive symptoms (≥1 positive response to 2 screening questions) and fulfilling other inclusion criteria are eligible. The study involves an educational intervention among occupational physicians to enhance the initiation of work modifications. Primary outcomes are sustained RTW (≥4 weeks at work without a new sickness absence (SA)) and the total number of SA days during a 12-month follow-up. Secondary outcomes are intensity of musculoskeletal pain (scale 0-10), pain interference with work or sleep (scale 0-10) and severity of depressive symptoms (Patient Health Questionnaire, PHQ-9), inquired via online questionnaires at baseline and 3, 6, 9 and 12 months after recruitment. Information on SA days will be collected from the medical records of the OHSs over 12 months, before and after recruitment. The findings will give new information about the possibilities of training physicians to initiate work modifications and their effects on RTW in employees with work disability due to musculoskeletal pain or depressive symptoms. ETHICS AND DISSEMINATION The Coordinating Ethics Committee of Hospital District of Helsinki and Uusimaa has granted approval for this study. The results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN74743666.
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Affiliation(s)
- Eija Haukka
- Health and Work Ability, OHS and Work Health, Finnish Institute of Occupational Health, Helsinki, Finland
- Disability Prevention Research Centre, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Kari-Pekka Martimo
- Disability Prevention Research Centre, Finnish Institute of Occupational Health, Helsinki, Finland
- Client Services, Occupational Health Collaboration, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Teija Kivekäs
- Disability Prevention Research Centre, Finnish Institute of Occupational Health, Helsinki, Finland
- Development of Work and Organizations, Mental Health and Cognition, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Ritva Horppu
- Health and Work Ability, OHS and Work Health, Finnish Institute of Occupational Health, Helsinki, Finland
- Disability Prevention Research Centre, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Tea Lallukka
- Health and Work Ability, OHS and Work Health, Finnish Institute of Occupational Health, Helsinki, Finland
- Disability Prevention Research Centre, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Svetlana Solovieva
- Health and Work Ability, OHS and Work Health, Finnish Institute of Occupational Health, Helsinki, Finland
- Disability Prevention Research Centre, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Rahman Shiri
- Health and Work Ability, OHS and Work Health, Finnish Institute of Occupational Health, Helsinki, Finland
- Disability Prevention Research Centre, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Irmeli Pehkonen
- Health and Work Ability, OHS and Work Health, Finnish Institute of Occupational Health, Helsinki, Finland
- Disability Prevention Research Centre, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Esa-Pekka Takala
- Health and Work Ability, OHS and Work Health, Finnish Institute of Occupational Health, Helsinki, Finland
- Disability Prevention Research Centre, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Ellen MacEachen
- University of Waterloo, School of Public Health and Health Systems, Waterloo, Ontario, Canada
- University of Toronto, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Eira Viikari-Juntura
- Disability Prevention Research Centre, Finnish Institute of Occupational Health, Helsinki, Finland
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Abstract
Back pain is a common presenting complaint to the emergency department. The key to proper evaluation is a history and physical examination focused on determining if any red flags for serious disease are present. If no red flags are present, the patient most likely has nonspecific back pain and their symptoms will resolve in 4 to 6 weeks. No diagnostic testing is required. For patients with red flags, a focused history and examination in conjunction with diagnostic laboratory tests and imaging determine whether the patient has an emergent condition such as herniated disc, epidural compression, or spinal infection.
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Affiliation(s)
- David Della-Giustina
- Emergency Medicine, Yale School of Medicine, 464 Congress Avenue, Suite 260, New Haven, CT 06519-1315, USA.
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48
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Suri P, Hunter DJ, Boyko EJ, Rainville J, Guermazi A, Katz JN. Physical activity and associations with computed tomography-detected lumbar zygapophyseal joint osteoarthritis. Spine J 2015; 15:42-9. [PMID: 25011094 PMCID: PMC4268336 DOI: 10.1016/j.spinee.2014.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 03/25/2014] [Accepted: 06/30/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There are no previous epidemiologic studies examining associations between physical activity and imaging-detected lumbar zygapophyseal joint osteoarthritis (ZJO) in a community-based sample. PURPOSE To determine whether physical activity is associated with prevalent lumbar ZJO on computed tomography (CT). STUDY DESIGN/SETTING A community-based cross-sectional study. PATIENT SAMPLE Four hundred twenty-four older adults from the Framingham Heart Study. OUTCOME MEASURES Participants received standardized CT assessments of lumbar ZJO at the L2-S1 levels. Severe lumbar ZJO was defined according to the presence and/or degree of joint space narrowing, osteophytosis, articular process hypertrophy, articular erosions, subchondral cysts, and intra-articular vacuum phenomenon. This definition of lumbar ZJO was based entirely on CT imaging findings and did not include any clinical criteria such as low back pain. METHODS Physical activity was measured using the Physical Activity Index, which estimate hours per day typically spent in these activity categories: sleeping, sitting, slight activity, moderate activity, and heavy activity. Participants reported on usual frequency of walking, running, swimming, and weightlifting. We used multivariable logistic regression to examine associations between self-reported activity and severe lumbar ZJO, while adjusting for key covariates including age, sex, height, and weight. RESULTS In multivariable analyses, ordinal categories of heavy physical activity duration per day were significantly associated with severe lumbar ZJO (p for trend=.04), with the greatest risk observed for the category 3 or more hours per day, odds ratio 2.13 (95% confidence interval [CI] 0.97-4.67). When heavy activity was modeled as a continuous independent variable, each hour was independently associated with 1.19 times the odds of severe lumbar ZJO (95% CI 1.03-1.38, p=.02). Less vigorous types of physical activity and the type of exercise were not associated with severe lumbar ZJO. Older age, lesser height, and greater weight were independently and significantly associated with severe lumbar ZJO. In multivariable models predicting lumbar ZJO, neither model discrimination nor reclassification improved with the addition of physical activity variables, compared with a multivariable model including age, sex, height, and weight. CONCLUSIONS Our findings demonstrate a statistically significant cross-sectional association between heavy physical activity and CT-detected severe lumbar ZJO. However, the additional discriminatory capability of heavy physical activity above and beyond that contributed by other factors was negligible.
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Affiliation(s)
- Pradeep Suri
- VA Puget Sound Healthcare System, 1660 S. Columbian Way, RCS-117, Seattle, WA, USA; Department of Rehabilitation Medicine, University of Washington School of Medicine, 325 Ninth Avenue, Box 359612, Seattle, WA 98103, USA.
| | - David J Hunter
- Department of Rheumatology, Kolling Institute, University of Sydney, Royal North Shore Hospital, Sydney, Clinical Administration 7C, Pacific Highway, St. Leonards, New South Wales, Australia
| | - Edward J Boyko
- VA Puget Sound Healthcare System, 1660 S. Columbian Way, RCS-117, Seattle, WA, USA; Department of Medicine, University of Washington School of Medicine, RR-512 Health Sciences Building, Box 356420, Seattle, WA 98103, USA
| | - James Rainville
- New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120, USA
| | - Ali Guermazi
- Department of Radiology, Boston University School of Medicine, 820 Harrison Avenue, FGH Building 3rd Floor, Boston, MA 02215, USA
| | - Jeffrey N Katz
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, BC-4-4016, Boston, MA 02446, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, BC-4-4016, Boston, MA 02446, USA
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Fritz JM, Lurie JD, Zhao W, Whitman JM, Delitto A, Brennan GP, Weinstein JN. Associations between physical therapy and long-term outcomes for individuals with lumbar spinal stenosis in the SPORT study. Spine J 2014; 14:1611-21. [PMID: 24373681 PMCID: PMC3997631 DOI: 10.1016/j.spinee.2013.09.044] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 08/26/2013] [Accepted: 09/19/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT A period of nonsurgical management is advocated before surgical treatment for most patients with lumbar spinal stenosis. Currently, little evidence is available to define optimal nonsurgical management. Physical therapy is often used, however its use and effectiveness relative to other nonsurgical strategies has not been adequately explored. PURPOSE Describe the use of physical therapy and other nonsurgical interventions by patients with lumbar spinal stenosis and examine the relationship between physical therapy and long-term prognosis. STUDY DESIGN Secondary analysis of the Spine Patient Outcomes Research Trial (SPORT) combining data from randomized and observational studies. SETTING Thirteen spine clinics in 11 states in the United States. PATIENT SAMPLE Patients with lumbar spinal stenosis receiving nonsurgical management including those who did or did not receive physical therapy within 6 weeks of enrollment. OUTCOME MEASURES Primary outcome measures included crossover to surgery, the bodily pain and physical function scales changes from the Survey Short Form 36 (SF-36), and the modified Oswestry Disability Index. Secondary outcome measures were patient satisfaction and the Sciatica Bothersomeness Index. METHODS Baseline characteristics and rates of crossover to surgery were compared between patients who did or did not receive physical therapy. Baseline factors predictive of receiving physical therapy were examined with logistic regression. Mixed effects models were used to compare outcomes between groups at 3 and 6 months and 1 year after enrollment adjusted for baseline severity and patient characteristics. RESULTS Physical therapy was used in the first 6 weeks by 90 of 244 patients (37%) and was predicted by the absence of radiating pain and being single instead of married. Physical therapy was associated with a reduced likelihood of crossover to surgery after 1 year (21% vs. 33%, p=.045), and greater reductions on the Short Form 36 physical functioning scale after 6 months (mean difference=6.0, 95% confidence interval: 0.2-11.7) and 1 year (mean difference=6.5, 95% confidence interval: 0.6-12.4). There were no differences in bodily pain or Oswestry scores across time. CONCLUSIONS Many patients with lumbar spinal stenosis pursuing conservative management receive physical therapy. Using physical therapy was associated with reduced likelihood of patients receiving surgery within 1 year. Results for other outcomes were mixed with no differences in several measures. Further research is needed to examine the effectiveness of physical therapy relative to other nonsurgical management strategies for patients with lumbar spinal stenosis.
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Affiliation(s)
- Julie M Fritz
- Department of Physical Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT 84108, USA; Physical Therapy Division, Intermountain Healthcare, 5848 South 300 East Murray, Salt Lake City, UT 84107, USA.
| | - Jon D Lurie
- Department of Medicine, Dartmouth Medical School, 1 Rope Ferry Rd, Hanover, NH 03755, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, 35 Centerra Pkwy, Lebanon, NH 03766, USA
| | - Wenyan Zhao
- Department of Orthopaedics, Dartmouth Medical School, One Medical Center Dr, Lebanon, NH 03756, USA
| | - Julie M Whitman
- Fellowship Program, Evidence in Motion, 3000 Equity Place, Suite 105, Louisville, KY 40223, USA
| | - Anthony Delitto
- Department of Physical Therapy, University of Pittsburgh, 6036 Forbes Tower, Pittsburgh, PA 15241, USA
| | - Gerard P Brennan
- Physical Therapy Division, Intermountain Healthcare, 5848 South 300 East Murray, Salt Lake City, UT 84107, USA
| | - James N Weinstein
- Department of Medicine, Dartmouth Medical School, 1 Rope Ferry Rd, Hanover, NH 03755, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, 35 Centerra Pkwy, Lebanon, NH 03766, USA; Department of Orthopaedics, Dartmouth Medical School, One Medical Center Dr, Lebanon, NH 03756, USA
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50
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Abstract
Although simple characterization of discomfort as cramps, heaviness, shooting pains, and so forth can be misleading, history and examination are key to accurate diagnosis. Absence of both dorsalis pedis and posterior tibial pulses strongly suggests peripheral arterial disease (PAD), and the presence of either pulse makes PAD less likely. Hydroxymethylglutaryl coenzyme A reductase inhibitors (statins) are a common cause of lower extremity myalgias. Restless legs syndrome causes nocturnal discomfort but must be distinguished from confounding“mimics." Neurologic causes of leg symptoms include lumbar spinal stenosis, radiculopathy, distal symmetric polyneuropathy, and entrapment neuropathy. Many common causes of leg discomfort can be managed conservatively.
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Affiliation(s)
- Douglas Berger
- General Medicine Service, Department of Medicine, VA Puget Sound, University of Washington, 1660 South Columbian Way, Seattle, WA 98108, USA.
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