Clinical efficacy of imaging modalities in the diagnosis of low-back pain disorders

What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain? A systematic review of qualitative studies

OBJECTIVES

The global burden of low back pain is the highest ranked condition contributing to years of living with disability. Exercise is moderately effective, and adherence to exercise may improve if participants are engaged. Identification of elements that enhance engagement would enable clinicians to prescribe appropriate interventions. The review objective was to identify and synthesize qualitative empirical studies that have explored beliefs about exercise therapy of people with nonspecific chronic low back pain.

METHODS

Two independent reviewers conducted a structured review and metasynthesis informed by Cochrane and Campbell Collaboration guidelines and the PRISMA statement. Fifteen papers were included for data extraction, method quality assessment, and thematic analysis.

RESULTS

Four key themes emerged: (1) perceptions and classification of exercise; (2) role and impact of the health professional; (3) exercise and activity enablers/facilitators; (4) exercise and activity barriers. Participants believed that there were distinctions between general activity, real/fitness exercise, and medical exercise. Levels of acquired skills and capability and participant experience with exercise culture require consideration in program design. People participating in exercise classes and group work may be more comfortable when matched for abilities and experience. When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement, people make a reasoned decision to discontinue.

DISCUSSION

People are likely to prefer and participate in exercise or training programs and activities that are designed with consideration of their preferences, circumstances, fitness levels, and exercise experiences.

Military rank and the symptoms of lumbar disc herniation in young Korean soldiers

OBJECTIVE

There are many factors associated with the symptom presentation of lumbar disc herniation (LDH). However, there are only few reports regarding the clinical feature of LDH in military medicine. The objective of this study is to determine the factors that affected the symptoms of LDH in young Korean soldiers.

METHODS

One hundred thirty male soldiers, diagnosed with LDH, were enrolled in this study. They were divided into four groups, according to their military ranks: private, private first class, corporal, and sergeant. The visual analog scale for low back pain (VAS-LBP), the VAS for leg pain (VAS-LP), and the Oswestry Disability Index (ODI) were evaluated. The education level and military rank were also reviewed and their relationship with the degree of symptoms was investigated.

RESULTS

The mean age for the male subjects enrolled was 20.7 ± 1.2. The mean VAS-LBP, VAS-LP, and ODI were 6.6% ± 1.7%, 7.1% ± 1.9%, and 46.0% ± 16.3%, respectively. There was no statistically significant relationship between the degree of symptoms and the radiologic findings. However, the military rank had an inverse correlation with the VAS scores and the ODI (P < 0.05).

CONCLUSION

Our data showed that the military rank was associated with the symptom presentation of LDH and reflected the characteristics of military life.

The dilemma of diagnostic uncertainty when treating people with chronic low back pain: a qualitative study

OBJECTIVE

To investigate how physiotherapists prescribe execise for people with non-specific chronic low back pain in the absence of definitive or differential diagnoses.

DESIGN

Four guided focus groups were conducted to gather the views of physiotherapists working in primary care.

SUBJECTS AND SETTING

Twenty-three primary care physiotherapists from metropolitan Melbourne, Australia, were identified from professional organization member lists and publicly available records. They were recruited via email and assembled for focus groups based on eligibility, availability and location.

MAIN MEASURES

Discussions were audio-taped, transcribed verbatim and analysed for themes by three independent researchers.

RESULTS

The 'dilemma created by diagnostic uncertainty' emerged as a significant overarching theme with the following subthemes. Physiotherapists: (1) perceive that care-seekers want a clear diagnosis, (2) are challenged by diagnostic uncertainty, (3) are critical when patients fail to improve, (4) feel unprepared by traditional education models and (5) seek support from experienced colleagues. Physiotherapists report needing to: (1) educate care-seekers about their injury/diagnosis, despite diagnostic uncertainty, and (2)observe rapid health outcome improvements. They exhibit potentially negative behaviours, including blame attribution, when this does not occur.

CONCLUSIONS

Physiotherapists appear under-prepared for the challenges of working with people with chronic conditions. Quality research is warranted to determine best practice in supporting practitioners in the development of suitable therapeutic behaviours to deal with this challenging patient interface.

'Listen to me, tell me': a qualitative study of partnership in care for people with non-specific chronic low back pain

OBJECTIVE

To investigate and summarize participant experience of exercise programmes for non-specific chronic low back pain and the effects of these experiences on exercise participation and engagement.

SUBJECTS

Three groups of six adults (>18 years) who speak, read and understand English and who had participated in an exercise programme for non-specific chronic low back pain.

METHOD

Qualitative research methods were used and three focus groups were conducted by an experienced facilitator. Each group was guided with a set of pre-determined questions and participants were encouraged to give personal opinions. Transcribed data were read independently by two researchers and analysed thematically according to Grounded Theory.

RESULTS

Preference for partnership in care emerged as a significant theme from all focus group transcripts. The following subthemes emerged: (1) engagement with the health care process; (2) 'listen to me; I know my own body'; (3) 'tell me: explain it to me'. People with non-specific chronic low back pain want an active role in their rehabilitation. They expressed anger and frustration at not being listened to, not being provided with adequate explanations and education and not being given credit for knowing their own bodies. Tension existed between patients' wanting a genuine voice in the partnership and them wanting a care-provider to give explicit diagnosis and best management instruction.

CONCLUSION

A gap exists between care-seeker experiences of, and preferences for, exercise programmes for back pain. Care-seekers consider that care-providers should adopt a willingness to listen and consider care-seeker's experiences when designing exercise programmes.

Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power

BACKGROUND CONTEXT

The "centralization phenomenon" (CP) is the progressive retreat of referred pain towards the spinal midline in response to repeated movement testing (a McKenzie evaluation). A previous study suggested that it may have utility in the clinical diagnosis of discogenic pain and may assist patient selection for discography and specific treatments for disc pain.

PURPOSE

Estimation of the diagnostic predictive power of centralization and the influence of disability and patient distress on diagnostic performance, using provocation discography as a criterion standard for diagnosis, in chronic low back pain patients.

STUDY DESIGN/SETTING

This study was a prospective, blinded, concurrent, reference standard-related validity design carried out in a private radiology clinic specializing in diagnosis of chronic spinal pain.

PATIENT SAMPLE

Consecutive patients with persistent low back pain were referred to the study clinic by orthopedists and other medical specialists for interventional radiological diagnostic procedures. Patients were typically disabled and displayed high levels of psychosocial distress. The sample included patients with previous lumbar surgery, and most had unsuccessful conservative therapies previously.

DIAGNOSIS

results of provocation discography.

INDEX TEST

The CP. Psychometric evaluation: Roland-Morris, Zung, Modified Somatic Perception questionnaires, Distress Risk Assessment Method, and 100-mm visual analog scales for pain intensity.

METHODS

Patients received a single physical therapy examination, followed by lumbar provocation discography. Sensitivity, specificity, and likelihood ratios of the CP were estimated in the group as a whole and in subgroups defined by psychometric measures.

RESULTS

A total of 107 patients received the clinical examination and discography at two or more levels and post-discography computed tomography. Thirty-eight could not tolerate a full physical examination and were excluded from the main analysis. Disability and pain intensity ratings were high, and distress was common. Sensitivity, specificity, and positive likelihood ratios for centralization observed during repeated movement testing for pain distribution and intensity changes were 40%, 94%, and 6.9 respectively. In the presence of severe disability, sensitivity, specificity, and positive likelihood ratios were 46%, 80%, 3.2 and for distress, 45%, 89%, 4.1. In the subgroups with moderate, minimal, or no disability, sensitivity and specificity were 37%, 100% and for no or minimal distress 35%, 100%.

CONCLUSIONS

Centralization is highly specific to positive discography but specificity is reduced in the presence of severe disability or psychosocial distress.

Similar prediction of mortality by the health assessment questionnaire in patients with rheumatoid arthritis and the general population

BACKGROUND

The self report health assessment questionnaire (HAQ) quantifies disability in activities of daily living (ADL). In patients with rheumatoid arthritis, the HAQ predicts mortality, work disability, and hip replacement surgery. It has been widely used in rheumatology, but population based data are rare.

OBJECTIVE

To determine whether the HAQ predicts mortality in patients with rheumatoid arthritis (n = 1095) and community controls (n = 1490).

METHODS

A mailed questionnaire including the HAQ, visual analogue scales for pain and global health, comorbidities, education level, height, weight, and smoking status was administered in June 2000. Two years later, the vital status of the subjects was ascertained from the Finnish Population Register database.

RESULTS

There were 41 deaths (10.1%) among the 404 patients with rheumatoid arthritis who had a baseline HAQ > or =1 (indicating at least some difficulty in most ADL), and 16 (2.3%) among 691 patients with HAQ <1 (p<0.001); in the community controls the values were 20 (13.6%) among 147 with HAQ > or =1, and 14 (1.0%) among 1343 with HAQ <1 (p<0.001). A higher HAQ score was an independent predictor of mortality in patients with rheumatoid arthritis (hazard ratio 2.73 (95% confidence interval, 1.86 to 4.02); p<0.001) and in community controls (2.75 (1.61 to 4.70); p<0.001).

CONCLUSIONS

The HAQ predicts mortality in the community population as well as in patients with rheumatoid arthritis. People with similar levels of disability appear to have a similar likelihood of mortality over two years.

Influence of imaging on clinical decision making in the treatment of lower back pain

PURPOSE

To assess the impact of cross-sectional imaging with magnetic resonance (MR) imaging or computed tomography (CT) on clinical decision making for patients with lower back pain (LBP).

MATERIALS AND METHODS

A randomized controlled before-and-after study was performed in 145 patients who had symptomatic lumbar spinal disorders and had been referred to orthopedists or neurosurgeons. Participants were a subgroup within a multicenter pragmatic randomized comparison of two imaging policies on LBP treatment: "imaging" versus "no imaging," unless a clear indication developed. Paired assessments were made of diagnosis, diagnostic confidence, proposed treatment, treatment confidence at trial entry and follow-up, and expectations of imaging. Data were analyzed according to the groups as randomized.

RESULTS

At follow-up, there were no statistically significant differences between the groups with respect to diagnosis or treatment plans. Significant increases in diagnostic and therapeutic confidence between trial entry and follow-up were observed for both groups, with a significantly greater increase in diagnostic confidence (P =.01) in the imaging group.

CONCLUSION

Imaging may increase diagnostic confidence but has minimal influence on diagnostic or therapeutic decisions for patients with LBP. The results highlight the need for evidence-based guidelines for imaging in LBP treatment.

Posterior disk displacement: morphologic assessment and measurement reliability-lumbar spine

BACKGROUND

Magnetic resonance imaging is often used to assess for disk displacement after manipulation, but limited information about the true incidence of iatrogenic herniations exists. To design a study that evaluates for a causal relationship, preliminary data must be obtained relating to the size of different types of disk displacement. The reliability of chiropractic radiologists in assessing disks and a comparison of different measuring devices should also be evaluated.

OBJECTIVE

To identify average measurements for normal and displaced disks and to assess the reliability of measurements by chiropractic radiologists.

STUDY DESIGN

Intraobserver and interobserver reliability study assessing disk displacement on magnetic resonance scans.

METHODS

Three evaluators assessed the disks on 122 magnetic resonance scans from two imaging centers. Six categories were graded, and digitizer and ruler measurements were compared. Forty-four scans were reassessed for intraobserver agreement. Intraobserver and interobserver variations were measured with intraclass correlation coefficient and kappa statistical analysis. Measurement device correlation was assessed with Pearson's r.

RESULTS

Clear size differences between different types of disk displacement were noted. Interexaminer measurement reliability was 0.78 to 0.84. Agreement concerning the presence of disk displacement was 85% (kappa = 0.68), and the classification of disk displacements was 76% (kappa = 0.60). Intraexaminer measurement reliability was 0.40 to 0.49. Intraexaminer agreement concerning the presence of disk displacement was 76% (kappa = 0.52), and the classification of disk displacements was 62% to 69% (kappa = 0.38 to 0.46). Normal versus bulged disk distinctions demonstrated the most disagreement. The ruler and digitizer correlation coefficient was 0.968.

CONCLUSIONS

Different disk types demonstrated distinct size averages. Interexaminer agreement was good concerning disk assessment and measurements. Intraexaminer agreement was lower than expected. A millimetric ruler is an acceptable alternative to digital measurement devices.

The diagnostic and therapeutic impact of MRI: an observational multi-centre study

AIM

To provide information about the diagnostic and therapeutic impact of magnetic resonance imaging (MRI) and to compare the findings across diagnostic groups.

MATERIALS AND METHODS

A prospective, observational study of 2017 consecutive referrals for MRI of the head, spine or knee at four imaging centres. Clinicians completed questionnaires before MRI stating initial diagnoses, diagnostic confidence and treatment plans. After imaging, a second questionnaire evaluated clinicians' revised diagnosis and treatment plans in the light of imaging findings. Patients were grouped into nine diagnostic categories for analysis. Comparison between pre- and post-imaging was used to assess the diagnostic and therapeutic impact of MRI.

RESULTS

In seven of nine diagnostic groups MRI findings were associated with a diagnostic impact. Diagnoses were revised or discarded following normal MR findings and diagnostic confidence was increased by confirmative MR findings. There was no statistically significant diagnostic impact for suspected pituitary or cerebello-pontine angle lesions. In five of nine diagnostic groups (knee meniscus, knee ligament, multiple sclerosis, lumbar and cervical spine) MRI findings had a clear impact on treatment plans.

CONCLUSION

This study demonstrates that in most diagnostic categories, MRI influences diagnosis and treatment. However, experimental studies are needed to prove that these diagnostic and therapeutic impacts lead to improved health.Hollingworth (2000). Clinical Radiology55, 825-831.

Pain sensitivity as a correlate of clinical status in individuals with chronic low back pain

STUDY DESIGN

A cross-sectional study of baseline correlates of clinical pain and functional status in consecutive patients being treated for chronic low back pain.

OBJECTIVES

To determine if an individual's global pain sensitivity, measured by experimental pain threshold to pressure at various regions of the body, is associated with baseline measures of clinical pain and physical functioning.

SUMMARY OF BACKGROUND DATA

Previous studies have demonstrated that in individuals with chronic low back pain, clinical pain and functional status are significantly associated with demographic, structural, and psychosocial factors. However, a large portion of variance remains unexplained. Because pain sensitivity (tenderness) has been shown to occur as a continuum in the population, the authors sought to determine if such sensitivity might be associated with clinical status in chronic low back pain, beyond what is known regarding demographic, structural, and psychosocial factors.

METHODS

Forty-five patients with chronic low back pain were assessed for a variety of demographic, structural, and psychosocial factors, which previously have been shown to contribute to clinical status. In addition, all patients underwent testing for pain tolerance and threshold at various areas of the body.

RESULTS

Age, degree of structural abnormality observed on magnetic resonance imaging, and depressive symptoms were all significantly correlated with either clinical pain or functional status. Pain sensitivity, the target of this investigation, accounted for significant proportions of variance in functional status and pain, even after controlling for demographic, structural, and psychosocial variables.

CONCLUSIONS

These pilot data suggest that an individual's experimental pain threshold (a measure of tenderness) is associated with baseline functional status and pain in cases of chronic low back pain and may represent an important domain warranting further investigation.

Primary care and pain medicine. A community solution to the public health problem of chronic pain

The author emphasizes that pain is an important public health problem that demands attention. He discusses ineffective management and its causes, administrative and socioeconomic problems perpetuating poor care, problems in technology transfer, organizational models, specialists and subspecialists, and other topics.

Low back pain and the lumbar intervertebral disk: clinical considerations for the doctor of chiropractic

BACKGROUND

Low back pain exists in epidemic proportions in the United States. Studies that demonstrate innervation to the intervertebral disk provide evidence that may account for instances of discogenic low back pain encountered in general medical and chiropractic practice. Many patients and health care practitioners believe that intervertebral disk lesions require surgery as the only method of treatment that will result in satisfactory outcome. Surgery rates vary widely across geographic regions. Only one randomized prospective study exists that compares surgical and nonsurgical treatment; it demonstrated essentially equal outcomes in the long run.

OBJECTIVE

To review specific aspects of the examination, history, imaging, and treatment of patients with suspected intervertebral disk lesions and to provide guidelines for conservative management, imaging, and relative and absolute indications for surgical referral.

DATA SOURCES

Review articles, texts, and original articles from indexed refereed sources that discuss the lumbar intervertebral disk in regard to patient history, physical examination, imaging, treatment, and referral for surgery.

RESULTS

Patients with low back pain who do not present with so-called red flags (fever, history of cancer, unexplained weight loss, urinary tract infection, intravenous drug use, saddle anesthesia, or prolonged use of corticosteroids) may be treated initially with conservative methods. Imaging studies are helpful in determining the patient's diagnosis, and computed tomography, magnetic resonance imaging, or other special imaging studies should be ordered judiciously. The only prospective, randomized study of conservative versus surgical management of herniated lumbar intervertebral disk lesions indicates both methods provide adequate outcome in the long run. Little consensus exists on the best method of management for patients with intervertebral disk lesions without absolute indications for surgery.

CONCLUSION

Patients should be screened for "red flags" to determine whether they are candidates for conservative treatment. Magnetic resonance imaging is perhaps the most practical imaging study for evaluation of lumbar disk lesions because it involves no use of ionizing radiation and because magnetic resonance imaging has other advantages over computed tomographic scanning such as excellent delineation of soft tissue structures, direct multiplanar imaging, and excellent characterization of medullary bone. Provocation computed tomography-diskography is an invasive procedure and should be reserved for patients with normal magnetic resonance imaging findings and continuing severe pain who have not been helped by conservative treatment attempts and for whom surgical intervention is contemplated. Both conservative and surgical interventions have been shown to be effective in the treatment of discogenic and radicular pain syndromes.

What help and what confusion can imaging provide?

Low back pain is a very common but benign and, in general, self-limiting disease indicating that only a small proportion of patients will require sophisticated imaging studies. Recent studies have highlighted the fact that a simple relationship of structural abnormalities to low back pain is impossible because similar alterations can be found in symptomatic as well as in asymptomatic individuals. these findings question our current criteria for the diagnosis of low back pain disorders with regard to their discriminative power in differentiating diseased and non-diseased individuals. Structural abnormalities demonstrated by imaging studies should therefore only be interpreted in the light of the clinical findings. This review shows that only a few studies contribute to our understanding of the clinical efficacy of imaging studies in the evaluation of low back pain disorders. There is an absolute need for comprehensive, well conducted studies on the impact of specific imaging modalities on diagnosis and treatment of lumbar spinal disease.

How to recognize and treat specific low back pain?

A wide variety of mechanical and non-mechanical disorders are associated with the clinical symptom of low back pain. Mechanical disorders are the cause of the vast majority of low back pain. Despite this frequency, the specific cause of mechanical low back pain can not be elucidated in spite of extensive diagnostic evaluation in a majority of individuals. Specific causes of low back pain are associated with less frequently occurring systemic illnesses including rheumatic, infectious, neoplastic, gynaecological and vascular disorders. The diagnostic process is more successful in identifying systemic disorders as the specific cause of low back pain. Non-surgical management is effective therapy with most patients with mechanical disorders of any form. Systemic illnesses require interventions directed specifically at healing the affected organ system.