Age as a predicting factor in the therapy outcome of multidisciplinary treatment of patients with chronic low back pain—a prospective longitudinal clinical study in 405 patients

Disability and return to work after a multidisciplinary intervention for (sub)acute low back pain: A systematic review

Objective

This systematic review aimed to examine pain, functional status and return to work after a multidisciplinary intervention, with or without additional workplace intervention, for (sub)acute low back pain among adults.

Data sources

A comprehensive search was completed (November 2022) in six electronic databases (Embase, MEDLINE, Web of Science, Cochrane, CENTRAL and Scopus) and in the reference list of all identified studies.

Review methods

The search results were screened against predefined eligibility criteria by two independent researchers. Included articles were systematic reviews or randomized controlled trials examining the effect of a multidisciplinary intervention, with or without workplace intervention, in working adults with (sub)acute low back pain. Relevant information was summarized and clustered, and the methodological quality and certainty of evidence were assessed respectively using the RoB 2-tool, the ROBIS tool and the GRADE criteria.

Results

The search resulted in a total of 3020 articles. After the screening process, 12 studies remained (11 randomized controlled trials and 1 systematic review), which studied overall 2751 patients, with a follow-up period of at least 12 months.

Conclusions

A multidisciplinary intervention is favorable compared to usual care for pain intensity and functional status but this is less clear for return to work. Comparable work-related effects were found when comparing a multidisciplinary intervention with a less extensive intervention, whereas uncertainties exist regarding outcomes of pain intensity and functional status. Furthermore, adding a workplace intervention to usual care and subdividing patients based on work-related characteristics seems beneficial for return to work.

Pain coping strategies and their association with quality of life in people with Parkinson's disease: A cross-sectional study

OBJECTIVE

To develop multidimensional approaches for pain management, this study aimed to understand how PD patients cope with pain.

DESIGN

Cross-sectional, cohort study.

SETTING

Monocentric, inpatient, university hospital.

PARTICIPANTS

52 patients with Parkinson's disease (without dementia) analysed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Motor function, nonmotor symptoms, health-related quality of life (QoL), and the Coping Strategies Questionnaire were assessed. Elastic net regularization and multivariate analysis of variance (MANOVA) were used to study the association among coping, clinical parameters, and QoL.

RESULTS

Most patients cope with pain through active cognitive (coping self-statements) and active behavioral strategies (increasing pain behaviors and increasing activity level). Active coping was associated with lower pain rating. Regarding QoL domains, active coping was associated with better physical functioning and better energy, whereas passive coping was associated with poorer emotional well-being. However, as demonstrated by MANOVA, the impact of coping factors (active and passive) on the Short Form 36 domains was negligible after correction for age, motor function, and depression.

CONCLUSION

Passive coping strategies are the most likely coping response of those with depressive symptoms, whereas active coping strategies are the most likely coping response to influence physical function. Although coping is associated with pain rating, the extent that pain coping responses can impact on QoL seems to be low.

What Influences Outcomes From Inpatient Multidisciplinary Pain Management Programs?: A Systematic Review and Meta-analysis

OBJECTIVES

Although inpatient multidisciplinary pain management programs (PMPs) are effective for chronic pain, not all patients benefit equally and there is limited evidence regarding predictors of outcome. This meta-analysis aimed to identify patient or program characteristics associated with outcomes from inpatient PMPs, and to examine the time course of effects following discharge.

MATERIALS AND METHODS

Medline, EBSCO, and Scopus were searched to identify articles reporting outcomes from inpatient multidisciplinary PMPs. Information was extracted on study design, participant and program characteristics, and outcomes. Effect sizes were computed for pain, physical function, depression, anxiety, and mental health outcomes. Study-level predictors of outcome were investigated with moderator analyses and meta-regression. A risk of bias assessment and sensitivity analyses were conducted and the GRADE criteria for prognostic studies were applied to assess confidence in findings.

RESULTS

In all, 85 studies (111 cohorts; 15,255 participants) were included. Three quarters of studies demonstrated low risk of bias. Larger effect sizes (for at least 1 outcome measure) occurred in studies where participants had more severe pain (greater intensity/longer duration), participants with alcohol or drug problems were not excluded, samples comprised mixed pain conditions, and programs included a cognitive component and/or a passive therapy component. Effect sizes for pain and physical function were maintained at follow-up, but effect sizes for depression and anxiety declined over time.

DISCUSSION

Inpatient multidisciplinary PMPs may be well suited to patients with severe or long-lasting pain. Programs should adopt broad patient inclusion criteria, and outcomes were similar for programs based on cognitive-behavioral versus mindfulness/acceptance-based therapies.

Early Changes in Pain Acceptance Predict Pain Outcomes in Interdisciplinary Treatment for Chronic Pain

Studies have shown that pain acceptance is associated with a better pain outcome. The current study explored whether changes in pain acceptance in the very early treatment phase of an interdisciplinary cognitive-behavioral therapy (CBT)-based treatment program for chronic pain predict pain outcomes. A total of 69 patients with chronic, non-malignant pain (at least 6 months) were treated in a day-clinic for four-weeks. Pain acceptance was measured with the Chronic Pain Acceptance Questionnaire (CPAQ), pain outcomes included pain intensity (Numeric Rating Scale, NRS) as well as affective and sensory pain perception (Pain Perception Scale, SES-A and SES-S). Regression analyses controlling for the pre-treatment values of the pain outcomes, age, and gender were performed. Early changes in pain acceptance predicted pain intensity at post-treatment measured with the NRS (B = −0.04 (SE = 0.02); T = −2.28; p = 0.026), affective pain perception at post-treatment assessed with the SES-A (B = −0.26 (SE = 0.10); T = −2.79; p = 0.007), and sensory pain perception at post-treatment measured with the SES-S (B = −0.19 (SE = 0.08); T = −2.44; p = 0.017). Yet, a binary logistic regression analysis revealed that early changes in pain acceptance did not predict clinically relevant pre-post changes in pain intensity (at least 2 points on the NRS). Early changes in pain acceptance were associated with pain outcomes, however, the impact was beneath the threshold defined as clinically relevant.

Pharmacotherapies in Geriatric Chronic Pain Management

Pharmacologic management of chronic pain in older adults is one component of the multimodal, interdisciplinary management of this complex condition. In this article, we summarize several of the key barriers to effective pharmacologic management in older adults and review the existing (albeit limited) evidence for its effectiveness and safety, especially in a medically complex population with multimorbidity. This review covers topical formulations, acetaminophen, oral nonsteroidal antiinflammatory drugs, and adjuvant therapies. The article concludes with a suggested approach to managing chronic pain in the older patient, incorporating goals and expectations for treatment as well as careful monitoring of medication adjustments.

Integrative medicine for chronic pain: A cohort study using a process-outcome design in the context of a department for internal and integrative medicine

INTRODUCTION

Integrative medicine inpatient treatment has been shown to improve physical and mental health in patients with internal medicine conditions. The aim of this study was to investigate the effectiveness of a 2-week integrative medicine inpatient treatment in patients with chronic pain syndromes and the association of treatment success with patient-related process variables.

METHODS

Inpatients with chronic pain syndromes participating in a 2-week integrative medicine inpatient program were included. Patients' pain intensity, pain disability, pain perception, quality of life, depression, and perceived stress were measured on admission, discharge, and 6 months after discharge. Likewise process variables including ability and will to change, emotional/rational disease acceptance, mindfulness, life and health satisfaction, and easiness of life were assessed.

RESULTS

A total of 310 inpatients (91% female, mean age 50.7 ± 12.4 year, 26.5% low back pain, and 22.9% fibromyalgia) were included. Using mixed linear models, significant improvements in pain intensity, pain disability, pain perception, quality of life, depression, and perceived stress were found (all P < 0.05). Ability to change and implementation, disease acceptance, mindfulness, life and health satisfaction, and light heartedness/easiness likewise improved (all P < 0.05). Improved outcomes were associated with increases in process variables, mainly ability to change and implementation, disease acceptance, life and health satisfaction, and light heartedness/easiness (R = 0.03-0.40).

CONCLUSIONS

Results of this study suggest that a 2-week integrative medicine inpatient treatment can benefit patients with chronic pain conditions. Functional improvements are associated with improved ability to change and implementation, disease acceptance, and satisfaction.

Strategies for Coping with Chronic Lower Back Pain in Patients with Long Physiotherapy Wait Time

BACKGROUND Treatment efficacy for the increasing prevalence of back pain is a great challenge for both health care providers and individuals coping with this problem. This study aimed to evaluate pain coping strategies used by primary care patients with chronic lower back pain (CLBP) as a supplementation of medical diagnosis before a physiotherapy programme. MATERIAL AND METHODS A total of 88 people were divided into 3 age groups: young adults (21-40 years old), middle-aged adults (41-60 years old), and the elderly (over 60 years old). Data was gathered from rehabilitation centers and primary medical care facilities. A cross-sectional design was used. The Coping Strategies Questionnaire (CSQ) was completed before the physiotherapy course. RESULTS Patients complained of CLBP for 11.32±6.81 years on average. The most common strategies to cope with back pain included declaring that the pain is manageable, praying and hoping, as well as increased behavioral activity. Statistically significant differences in coping strategies were found between age groups. The elderly patients were more likely to "declare coping with pain" in comparison to the younger age groups (p<0.01). People over 60 years of age were more likely to declare active coping with pain, while young people reported catastrophizing. CONCLUSIONS Patients in different age groups had various difficulties in pain coping. Most of them required support in self-management of pain in addition to physiotherapy. The basic assessment of pain coping strategies should be consistently taken into account and included in rehabilitation protocols in chronic pain treatment.

Importance of participation in major life areas matters for return to work

INTRODUCTION

The complexity of the process and outcome of vocational rehabilitation yearns for a multifaceted approach. This article investigates whether importance of participation in major life areas for men and women predicts the outcome of vocational rehabilitation.

METHODS

This longitudinal study provides measure points at the start of the intervention (T1), at the end of the intervention (T2) and at a follow-up 6-12 months after completing the rehabilitation program (T3). Associations were assessed by nominal logistic regression.

RESULTS

The importance of participation in work was positively associated to return to work (RTW), while the importance of participation in leisure activities and importance of participation in family was negatively associated with RTW after the rehabilitation. Gender and number of children also contributed significantly to the regression model.

CONCLUSION

To identify individuals' subjective evaluation of the importance of participation may be of value in explaining return or not RTW and contribute to explain gender differences in outcomes. It may also inform rehabilitation counselors in collaboration with clients and facilitate tailoring interventions to the individual's needs.

Predictors of multidisciplinary treatment outcome in patients with chronic musculoskeletal pain

PURPOSE

The present study aimed to identify predictors of rehabilitation outcome for patients with chronic musculoskeletal pain (CMP) and psychological problems.

METHODS

A retrospective cohort study including 230 adult patients with CMP admitted for multidisciplinary pain rehabilitation. Potential predictors were patient characteristics, duration of complaints, baseline functioning, pain, personality, coping style, fear of movement, psychological distress and type of treatment. Outcome measures were physical functioning, mental health, pain and patient-reported effect. Multiple (logistic) regression models were used to identify predictors.

RESULTS

Patients who were more disabled and patients with more pain benefitted more from the rehabilitation treatment than less disabled patients or those with less pain. Age, work status, vitality, depression and coping style also predicted outcomes significantly. The models explained between 27 and 80% of the outcomes. There was an interaction between type of treatment, work status and the baseline pain score as regards the outcome in terms of pain.

CONCLUSIONS

No strong predictors of treatment outcome were found other than the baseline scores of the respective outcome variables. More disabled patients and patients with more pain benefitted more from the rehabilitation program. Other predictors improved the prediction models slightly. Implications for Rehabilitation It remains challenging to correctly predict the outcome of treatment from patients' baseline sociodemographic and psychological characteristics; predictors other than baseline scores of the outcome variables are only slightly associated with treatment outcome. Patients with chronic musculoskeletal pain and poor physical functioning or mental health benefit most from pain rehabilitation. Older patients benefit less from a pain rehabilitation program than younger patients in terms of physical functioning. Pain reduction during a pain rehabilitation program is greatest in patients with high pain intensity who are not at work at the start of the rehabilitation program. Coping style influences the outcome of rehabilitation of patients with chronic musculoskeletal pain.

Short- and long-term changes in perceived work ability after interdisciplinary rehabilitation of chronic musculoskeletal disorders: prospective cohort study among 854 rehabilitants

OBJECTIVE

To investigate the changes in rehabilitants' perceived work ability after rehabilitation for chronic musculoskeletal disorders with respect to the baseline characteristics.

DESIGN

Prospective cohort study based on register and repeated survey data.

SETTING

Public sector employees in ten towns and five hospital districts.

SUBJECTS

A total of 854 employees who participated in the rehabilitation programme owing to common chronic musculoskeletal disorders between 1997 and 2009.

INTERVENTIONS

Interdisciplinary, biopsychosocial, inpatient rehabilitation programme targeting people of working age with common chronic musculoskeletal disorders. The programme was executed in different rehabilitation centres across the country and funded by the Social Insurance Institution of Finland.

MAIN MEASURES

Differences in perceived work ability level before and after rehabilitation. Data were derived from repeated surveys on average 2.1 years before rehabilitation, and 1.5 years (short-term follow-up) and 6.0 years (long-term follow-up) after rehabilitation.

RESULTS

Before the rehabilitation, perceived work ability was 7.13 (SD 1.84) among the rehabilitants and 7.27 (SD 1.72) in the matched reference population. Among rehabilitants, this figure decreased by 0.82 (95% confidence interval -0.98 to -0.67) in the short-term and by 1.26 (95% confidence interval -1.45 to -1.07) in the long-term follow-up. Only slight differences in steepness of this deterioration were observed between subgroups, created based on the participants' baseline characteristics.

CONCLUSIONS

Perceived work ability of participants, in an interdisciplinary biopsychosocial rehabilitation programme for common musculoskeletal disorders, deteriorated regardless of any studied pretreatment characteristics. The improvement of work ability may be an unrealistic goal for participants in this type of rehabilitation.

Multidisciplinary treatment in patients with persistent pain following total hip and knee arthroplasty

In a retrospective study, we evaluated the clinical outcome of multidisciplinary pain therapy (MPT) in a consecutive series of 40 patients with persistent unexplained pain following THA or TKA. Pain intensity, physical capability and psychological status were assessed before MPT (t1), after 3 weeks (t2) and at a mean follow-up of 32 months (t3). At t2, all scores demonstrated a significant improvement compared to the baseline value. At t3, pain intensity, physical capability, and depression levels deteriorated slightly but were still significantly better compared to baseline values. Anxiety scores deteriorated between t2 and t3 and showed no difference in the baseline value. The present study suggests that MPT has beneficial short-term and mid-term effects in this subgroup of patients and may avoid exploratory revision surgery.

The effects of integrative in-patient treatment on patients' quality of life: a meta-analysis

Background. In the last decades, several hospitals have adopted this concept of integrative medicine for the treatment of chronic and acute states of illnesses in in-patient treatment. The aim of this paper was to summarize the current evidence for a possible effectiveness of integrative on-patient treatment in patients' quality of life by means of a meta-analysis. Material and Methods. The databases MEDLINE, EMBASE, AMED, PsycInfo, PsycLit CCMED, and CAMbase were screened to find articles. We also screened publisher databases to find relevant information. Articles were included if patients were treated in a hospital. To guarantee comparability SF-36 was the predefined outcome measure for patients' quality of life. Data of pre/posteffects on the mental and physical scores of the SF-36 were extracted and effect sizes were calculated and entered into a random effect meta-analysis. Results. Eight articles published between 2003 and 2010 were included in the final meta-analysis. Random effect meta-analysis of the eight studies revealed an overall effect size of 0.37 (95% CI: [0.28; 0.45]) in the physical score and 0.38 (95% CI: [0.30; 0.45]) in the mental score of the SF-36. I² statistics indicate a high heterogeneity in the effects in both the physical and mental scores of the SF-36 (I² = 91.8%, P < 0.001, resp.; I² = 86.7%, P < 0.001). Discussion. This meta-analysis might help to rediscover the importance of integrative in-patient treatment for patients, physicians, and stakeholders.

Patient age is related to the types of physical therapy interventions provided for chronic low back pain: an observational study

STUDY DESIGN

Retrospective analysis of a longitudinal cohort of patients treated for chronic low back pain (CLBP).

OBJECTIVES

To determine whether patient age is associated with types of physical therapy interventions received for CLBP.

BACKGROUND

Advancing age is associated with less positive treatment outcomes in patients with CLBP. If patient age influences a therapist's choice of interventions, it may partially explain the difference in treatment outcomes.

METHODS

Data were examined in a sample of 7392 patients (62% women, 38% men; mean ± SD age, 56.7 ± 16.5 years) with CLBP. We used a generalized estimating equation to examine the probability of each subject receiving each of the individual intervention categories in the presence of the other intervention categories.

RESULTS

A significant interaction between intervention category and age existed after controlling for gender, duration of symptoms, comorbidities, payer source, and functional status at initial intake (χ(2) = 130.27, df = 8, P<.0001). The changes in probability of receiving an intervention category averaged 10% as patient age increased. The probability of receiving exercise or task-specific training did not change with advancing age. The probability of receiving postural exercises, pain modalities, joint mobility techniques, ice, or McKenzie exercises decreased with advancing age. The probability of receiving augmented soft tissue mobilization and balance/mobility training increased as age increased.

CONCLUSION

The impact of age on physical therapist treatment choices varies depending on the type of intervention. Other variables in addition to age may have an impact on treatment choice. Further research is needed to determine how therapists incorporate age into their clinical decision making.

Utilization and clinical outcomes of outpatient physical therapy for medicare beneficiaries with musculoskeletal conditions

BACKGROUND

Medicare beneficiaries frequently receive physical therapy for musculoskeletal conditions. Little information is available about this care.

OBJECTIVE

The purposes of this study were: (1) to describe characteristics, clinical outcomes, and utilization for Medicare beneficiaries receiving physical therapy in outpatient clinics within one integrated health care system; (2) to compare characteristics, outcomes, and utilization based on the body region affected; and (3) to examine factors predictive of outcomes and utilization.

DESIGN

This was a prospective, longitudinal study.

METHODS

Medicare beneficiaries aged 65 years or older (n=1,840 episodes of care) participated in the study. Descriptive statistics were calculated for patient characteristics and outcomes. Comparisons were made based on body region. Regression models evaluated factors associated with change in pain, improved outcome, and utilization.

RESULTS

The patients' mean age was 74.2 years (SD=6.3), and 65.3% were female. The most common body regions were the lumbar spine, shoulder, and knee, collectively accounting for 71.3% of the episodes of care. Patients attended a mean of 6.8 visits (SD=4.7), and 63.9% experienced an improved outcome. Episodes of care for lumbar spine conditions had less reduction in pain, whereas shoulder conditions and foot/ankle conditions showed the greatest improvement. Care for hip conditions was least likely to result in an improved outcome. Knee conditions were most likely to have an improved outcome. Care for shoulder and knee conditions had the highest number of visits. Factors associated with greater reduction in pain and improved outcomes included greater initial pain or disability and attending more visits. Factors associated with greater utilization included a postsurgical condition and higher initial pain rating. Limitations The study was performed in one geographic region within a single health care delivery system.

CONCLUSION

The results provide information on outcomes of physical therapy for Medicare beneficiaries in one health care system. Further research is needed to examine optimal utilization and care for these patients.

Pregnancy-related pelvic girdle pain: an update

A large number of scientists from a wide range of medical and surgical disciplines have reported on the existence and characteristics of the clinical syndrome of pelvic girdle pain during or after pregnancy. This syndrome refers to a musculoskeletal type of persistent pain localised at the anterior and/or posterior aspect of the pelvic ring. The pain may radiate across the hip joint and the thigh bones. The symptoms may begin either during the first trimester of pregnancy, at labour or even during the postpartum period. The physiological processes characterising this clinical entity remain obscure. In this review, the definition and epidemiology, as well as a proposed diagnostic algorithm and treatment options, are presented. Ongoing research is desirable to establish clear management strategies that are based on the pathophysiologic mechanisms responsible for the escalation of the syndrome's symptoms to a fraction of the population of pregnant women.

Prognostic factors for recovery from postpartum pelvic girdle pain

Pelvic girdle pain (PGP) has a high incidence during pregnancy and in some women pain will persist for years. Most studies have used pain as the outcome measure, and little attention is given to functioning or disability. A better understanding of prognostic factors for recovery seems important for clinical care and treatment. The aim of the present paper was to identify prognostic factors for recovery from postpartum PGP and disability, and to determine the impacts of prognostic factors when pain intensity and disability are used as outcome measures. Seventy-eight women with diagnosed PGP were included 6-16 weeks postpartum. Possible prognostic factors were obtained through clinical tests and questionnaires at baseline. The clinical tests were posterior pelvic pain provocation (P4) test, active straight leg raise (ASLR) test and pain provocation of long dorsal sacroiliac ligament (LDL). One year postpartum outcome measures were obtained by Oswestry disability index (ODI ver 2.0) and worst evening pain (VAS 0-100). Multiple linear regression and logistic regression analyses were used to identify significant prognostic factors. At baseline 60% believed they would recover and 40% were uncertain or believed they would not recover. Fifty per cent had a history of low back pain (LBP), and 20% had high emotional distress (HSCL25-item > or =1.75). About 75% had positive LDL and P4 at both sides and 24% had pain located to all three pelvic joints. Forty per cent had ASLR scores of at least 4 (sum score range 0-10). Multivariate analyses showed consistently that ASLR and belief in improvement were statistical significant predictors for both disability and pain as outcome measures. ASLR score <4 predicted 10 points lower ODI and 19 points lower evening pain compared with having ASLR score of at least 4. Pain location was a statistical significant predictor in only one analysis. History of LBP or high psychological distress was not prognostic for recovery. ASLR test and belief in improvement are predictors of clinical significance in women having PGP postpartum.

Gait analysis does not correlate with clinical and MR imaging parameters in patients with symptomatic lumbar spinal stenosis

Background

Parameters of MR imaging play a pivotal role in diagnosing lumbar spinal stenosis (LSS), and serve as an important tool in clinical decision-making. Despite the importance of MR imaging, little is known about the correlation between MRI parameters, objective gait analysis, and clinical presentation of patients with lumbar spinal stenosis.

Methods

Sixty-three patients from our clinic with symptomatic lumbar spinal stenosis leading to neurogenic claudication were included in this study in accordance with clearly defined inclusion and exclusion criteria. Clinical parameters, the depression status (CES-D), the subjective functional back capacity (FFbH-R), and the absolute walking distance (treadmill gait analysis) were quantitatively evaluated in correlation with morphological data from radiographs and MRI scans, in order to determine the coherence of spinal canal narrowing and clinical affliction.

Results

Sixty-three consecutive paents with a median age of 68 years and a mean Body Mass Index (BMI) of 28 were included in the study. The mean FFbH-R score displayed a value of 44 percent. The depression status scored an average of 13.6. Objectively measured walking distances showed a mean value of 172 m until patients stopped due to leg pain. A significant difference was found between the objectively measured and the subjectively estimated walking distance. The mean cross-sectional area of the dural tube at L1/2 was 113 mm², at L2/3 94 mm², at L3/4 73 mm², at L4/5 65 mm², and at L5/S1 93 mm². The mean overall cross sectional area of the dural tube of all segments did not correlate with the objectively measured walking distance. However, bivariate analysis found that the BMI (tau b = -0.194), functional back capacity (tau b = -0.225), and the cross sectional area of the dural tube at L1/2 (tau b = -0.188) correlated significantly with the objectively measured walking distance.

Conclusion

According to the results of this study MRI findings failed to show a major clinical relevance when evaluating the walking distance in patients with lumbar spinal stenosis and, therefore, should be treated with some caution as a predictor of walking distance. In determining the disease pattern of spinal stenosis functional back capacity and BMI might play a more active role than previously thought.

The role of TNF-alpha in patients with chronic low back pain-a prospective comparative longitudinal study

OBJECTIVES

In this prospective longitudinal clinical study with a matched-pair design, we evaluated the role of tumor necrosis factor-alpha (TNF-alpha) and its clinical relevance in patients with chronic low back pain.

METHODS

One hundred twenty patients with chronic low back pain were matched to a healthy control group. Patients and controls were prospectively followed for 6 months. At 4 fixed time points (day 0, day 10, day 20, and 6 mo) blood samples were taken and TNF-alpha levels compared in the 2 groups, and correlations with pain level and clinical function were analyzed.

RESULTS

At the beginning and at all other time points, there was a significantly higher proportion of TNF-alpha positive participants in the patients group than in the control group. The proportion of TNF-alpha positive patients decreased during the first 10 days of a multidisciplinary therapy in the patient group, but after this initial period, TNF-alpha levels remained constantly high with no further change until the final follow-up. In the healthy control group, the proportion of participants with positive TNF-alpha levels remained constant throughout the entire period. No significant correlation between TNF-alpha levels and pain or clinical function was detected.

DISCUSSION

TNF-alpha seems to have a significant role in patients with chronic low back pain. However, the pathophysiology of this process, the clinical relevance of TNF-alpha and, especially, its part in a potential therapy regimen in these patients need to be more closely examined and defined in additional studies.